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Endgames Case Report

A woman with ketoacidosis but not diabetes

BMJ 2012; 344 doi: (Published 01 March 2012) Cite this as: BMJ 2012;344:e1535
  1. H U Rehman, clinical associate professor
  1. 1Department of Medicine, Regina Qu’Appelle Health Region, Regina General Hospital, Regina, SK, Canada S4P 0W5
  1. Correspondence: H U Rehman habib31{at}

A 41 year old woman presented with a one day history of abdominal pain and vomiting. She had been drinking alcohol and three to four bottles of Iso-Gel (isopropanol) a day for the past two weeks. She was positive for hepatitis C and was known to have used injecting drugs and alcohol in the past.

On admission, her blood pressure was 119/72 mm Hg, pulse rate was 110 beats/min, respiratory rate was 28 breaths/min, and temperature was 36.6°C. She was dehydrated but seemed well nourished. She was alert and oriented in time and place. Her abdomen was tender in the epigastric and left upper quadrant regions, without guarding or rigidity. The rest of the physical examination was unremarkable.

Laboratory tests showed the following results: haemoglobin 154 g/L (normal range 120-160), white blood cell count 7.6×109/L (4.0-10.0), platelets 82×109/L (150-400), glucose 4.8 mmol/L (3.6-11.0), sodium 139 mmol/L (135-145), potassium 4.9 mmol/L (3.5-5.0), chloride 104 mmol/L (98-110), bicarbonate 12 mmol/L (22-26), anion gap 28 mmol/L (10-20), urea 4.6 mmol/L (3.0-7.1), creatinine 89 µmol/L (60-130), alkaline phosphatase 152 U/L (40-135), alanine aminotransferase 68 U/L (4-55), total bilirubin 33 µmol/L (2-20), albumin 42 g/L (35-50), amylase 276 U/L (20-110), and lactate 1.4 mmol/L (0.7-2.1). Arterial blood pH was 7.27 (7.35-7.45); her partial pressure of carbon dioxide was 22 mm Hg (33-45) and partial pressure of oxygen was 126 mm Hg (75-100) while inhaling 1 L of oxygen per minute.

A pregnancy test was negative. Small amounts of ketones were found in the venous blood. Plasma β-hydroxybutyric acid was 7.9 mmol/L (0.02-0.29). Serum osmolality was 304 mmol/kg (280-305). Ethanol …

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