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Vomiting & Drunk

History of Present Illness:

A man in his early 30’s is brought to the ED for vomiting after his wife called 911.  Medics state she said he has been drinking and often forgetting to take his insulin and his Jardiance.  Over the past few hours  he vomited multiple times and she saw some blood so called 911.  The patient is alert but a bit giddy.  He denies any fever, pain, melena or other complaints.

Vital Signs & Physical Exam:

Vital signs are normal except for a pulse of 110

Physical exam is otherwise normal except for the odor of alcohol and a bit of non-bloody emesis on his shirt

Initial Diagnostic Testing:

  • CBC: normal except for a hemoglobin of 10.2 with macrocytic indices
  • Chem-7: normal except for a gap of 20 and a glucose of 193
  • Imaging: none

What is the most likely diagnosis?

  • A) euglycemic DKA
  • B) eubicarbic DKA
  • C) AKA
  • D) GI bleed
  • E) 3/4 of the above

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ANSWER:

  • A) euglycemic DKA:  this patient has an anion gap but a glucose under 250.  He has multiple reasons he could have euglycemic DKA including possible recent insulin, alcohol and use of Jardiance.
  • B) eubicarbic DKA: unlikely if he has AKA, but if vomiting has been excessive enough to cause a contraction alkalosis he could have this as well.
  • C) AKA: alcoholic ketoacidosis is common and could certainly be present in this case
  • D) GI bleed: probably has underlying macrocytic anemia from chronic EtOH but could certainly have a concomitant GI bleed
  • E) 3/4 of the above: unlikely to have both B & C but could have 3 of the above

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