Here’s Dr. Aldokhi with today’s Morning Report!
AG Acidosis
Case 1
| HX | 29 YOM no PMH , sent from CPEP for abnormal labs, patient has unspecified psychosis, no etoh, no drugs |
| Px | Vitals normal, dry MM, flat affect rest of exam within normal. |
| labs | CBC 12.5>15.5/46<318 CMP 142/4/99/18/39/1.2<73
AG 25 pH 7.3 UA ketones , serum Osm 312, calculated lactate 1.4 methyl -ve |
| Dx | Starvation ketoacidosis |
| Rx | Hydration with glucose |
Case 2
| HX | 80 YOF with AMS, has crohn disease, arthritis , take Tylenol for pain, hypothyroidism, Afib, take mesalamine, PPI, levothyroxine. |
| Px | Vitals normal, dry MM, cachectic, does not follow command , rest of exam within normal |
| labs | CMP 138/4.7/108/11.3/30/1<78 serum albumin 1.5
AG 19 Corrected AG 25, pH 7.3, serum Osm 309, lactate 13 , urine positive for 5-Oxoproline |
| Dx | Tylenol with malnutriention (depleted cysteine) resulted in 5-Oxoproline acidosis |
| Rx | D/C acetaminophen and give NAC |
Anion gap (AG), representing the difference in concentration between measured cations and anions
ED approach to AG acidosis:
- Correct AG to albumin (add 2.5 mEq/L for each 1 mEq/L decrease in albumin)
- Hx of diet, alcohol (ethanol, methanol, ethylene glycol), renal failure, medicine (metformin …)
- Labs (CMP, OSm, ketones, acidosis, lactate, ASA…)
- Relation of [HCO3–] to the AG.
- Remember MUDPILES
| Category | Examples |
| Renal failure | Uremia |
| Lactic acidosis | Sepsis, shock, liver disease, isoniazid, iron, carbon monoxide, methemoglobin, metformin, and cyanide |
| Ketoacidosis | Diabetic ketoacidosis, alcoholic ketoacidosis, starvation ketoacidosis |
| Ingestions | Methanol, ethylene glycol, salicylates |
M – Methanol
U – Uremia
D – DKA / AKA
P – Paraldehyde / paracetamol
I – Iron / INH
L – Lactic acidosis
E – Ethylene glycol
S – Salicylates
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Jay Khadpe MD
- Editor in Chief of "The Original Kings of County"
- Assistant Professor of Emergency Medicine
- Assistant Residency Director
- SUNY Downstate / Kings County Hospital
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