A 49 year old man with confusion, hypothermia and shock requiring urgent resuscitation has blood results which show

The patient has a large osmolar gap which is probably caused by toxic alcohol ingestion.

He required intensive resuscitation

Intubation

Temp control

The cure lay in dialysing the toxic alcohol

Bloods for ethylene glycol and methanol were negative but the history obtained the next day from a friend was that the patient was concocting some unusual home brew alcohol.

The blood gas in this patient gave the clue to his diagnosis if it was carefully looked at. He was a diabetic and DKA was a reasonable first thought but was not supported as the only cause based on his lactate, ketones, pH and HCO3