Question

A 72-year-old man with severe congestive heart failure is brought to the emergency department because of a 5-day history of malaise and vomiting. He takes no medications. His pulse is 104/min, respirations are 35/min, and blood pressure is 90/64 mm Hg. Physical examination shows dusky-colored skin, peripheral cyanosis, and 10-cm jugular venous distention. Crackles are heard over the lung bases bilaterally. Cardiac examination shows an S3. There is 2+ pitting edema to the knees bilaterally. Laboratory studies show: Serum Na+: 127 mEq/L K+: 5.2 mEq/L CI-: 79 mEq/L HCO3-: 17 mEq/L Urea nitrogen: 100 mg/dl Glucose: 171 Mg/dl Creatinine: 8.4 mg/dl Urine Glucose 1+ Ketones absent Arterial blood gas analysis on 28% oxygen pH: 7.35 Pco2: 32 mmHg Po2: 154 mmHg HCO3- :17 mEq/L Which of the following is the most likely cause of the anion gap in this patient? A) Alcoholic ketoacidosis B) Diabetic ketoacidosis C) Hyperperfusion D) Hypoalbuminemia E) Metabolic alkalosis F) Milk-alkali syndrome G) Renal failure H) Respiratory alkalosis

          A 72-year-old man with severe congestive heart failure is brought to the emergency department because of a 5-day history of malaise and vomiting. He takes no medications. His pulse is 104/min, respirations are 35/min, and blood pressure is 90/64 mm Hg. Physical examination shows dusky-colored skin, peripheral cyanosis, and 10-cm jugular venous distention. Crackles are heard over the lung bases bilaterally. Cardiac examination shows an S3. There is 2+ pitting edema to the knees bilaterally. Laboratory studies show:
 
Serum
Na+: 127 mEq/L
K+: 5.2 mEq/L
CI-: 79 mEq/L
HCO3-: 17 mEq/L
Urea nitrogen: 100 mg/dl
Glucose: 171 Mg/dl
Creatinine: 8.4 mg/dl

Urine
Glucose 1+
Ketones absent

Arterial blood gas analysis on 28% oxygen
pH: 7.35
Pco2: 32 mmHg
Po2: 154 mmHg
HCO3- :17 mEq/L

Which of the following is the most likely cause of the anion gap in this patient?
A) Alcoholic ketoacidosis
B) Diabetic ketoacidosis
C) Hyperperfusion
D) Hypoalbuminemia
E) Metabolic alkalosis
F) Milk-alkali syndrome 
G) Renal failure
H) Respiratory alkalosis

Added by The Real E.

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