A 40-year-old female presents to the emergency department with complaints of lower back pain, fever, nausea, vomiting, malaise, chills, syncope (brief loss of consciousness), dizziness and shortness of breath. Patient states that she has had some burning with urination (dysuria). Her fever was as high as 39.40C (1030F) at home earlier in the day. She has a history of non-insulin dependent diabetes mellitus (NIDDM) but denies any other medical problems. On exam, she is in moderate distress with a temperature of 38.90C (1020F), pulse of 110 beats per minute (nl: 60-100 beats/min), respiratory rate of 30 breathes per minute and blood pressure of 70/30 mmHg (nl: ~120/70 mmHg). Her extremities are cool to the touch with thready pulses. Her chest is clear and heart is tachycardic (beating fast) but with regular rhythm. She has significant tenderness on the right side of her back. Her white blood cell (WBC) count was elevated at 20,000/mL (nl: 5,000-10,000/mL). The hemoglobin and hematocrit were normal. Her glucose was moderately elevated at 200 mg/dL (nl: 65-110 mg/dL) and her serum bicarbonate level is low. An arterial blood gas has demonstrated a pH of 7.28 (nl: 7.35-7.45).
1. Is she in acidosis or alkalosis?? And is it metabolic or respiratory??
Acidosis, pH is below normal, 7.28
Serum HCO3- decreased indicating Respiratory Alkalosis (compensation)
2. What is the most likely diagnosis??
Increased Lactic Acid from increased Anaerobic metabolism
Pyruvate is converted to Lactic Acid by Lactate Dehydrogenase
Lactate is then metabolized to CO2, H2O or
Glucose via Gluconeogenesis
Reduced oxygenation of cells halts these pathways thus leading to a Lactic Acid build-up
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