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y12 here. love this thread. Post some more scenarios when possible pleaseee!!
Reply 61
Original post by Etomidate
I don't think I've ever seen a case of alcoholic ketoacidosis. Alcoholics with ketones, high lactates and mild acidaemia, yes. But not really anything to be called an alcoholic ketoacidosis, I guess.

Vomiting commonly causes ketosis, and hypovolaemia can easily cause a metabolic acidosis, especially in the context of acute kidney injury. I would attribute that gas to this rather than the above.

A blood ketone value would also be useful - if it were particularly high I would still suspect DKA despite the blood glucose (especially if I had no further info on the patient). As the DKA guidelines state, a high blood glucose isn't required to diagnose DKA, but a previous history of diabetes will suffice. It's not unheard of for frequent flier DKAs to manipulate their insulin doses to avoid admissions, resulting in a low reading but ongoing ketoacidosis.

But I think the hypovolaemia explanation is far simpler and more likely.

Which is why we take a history - usually fit and well, vomiting and hypovolaemia; diabetic on insulin or a gliflozin, DKA; bottle of voddy a day and a binge last night, alcohol. Any of those 3 scenarios fit the biochemistry and physiology, which is, I think, what OP was trying to illustrate. The clinicians have just moved beyond pure science and cannot separate it from the clinical picture now (well, at least, I don't on a daily basis!) and hooves just tend to mean horses
I know it's not my thread and I don't want to interfere haha, but I could post some cases too if @HumblyBumbly is happy for me too, just let me know
Reply 63
Finding this thread very interesting
Original post by AortaStudyMore
I know it's not my thread and I don't want to interfere haha, but I could post some cases too if @HumblyBumbly is happy for me too, just let me know

yeah sure - we could take turns ! PM me if you want too and we can agree on some cases to discuss with these guys. I need to post one for today anyway :smile:
Original post by Etomidate
I don't think I've ever seen a case of alcoholic ketoacidosis. Alcoholics with ketones, high lactates and mild acidaemia, yes. But not really anything to be called an alcoholic ketoacidosis, I guess.

Vomiting commonly causes ketosis, and hypovolaemia can easily cause a metabolic acidosis, especially in the context of acute kidney injury. I would attribute that gas to this rather than the above.

A blood ketone value would also be useful - if it were particularly high I would still suspect DKA despite the blood glucose (especially if I had no further info on the patient). As the DKA guidelines state, a high blood glucose isn't required to diagnose DKA, but a previous history of diabetes will suffice. It's not unheard of for frequent flier DKAs to manipulate their insulin doses to avoid admissions, resulting in a low reading but ongoing ketoacidosis.

But I think the hypovolaemia explanation is far simpler and more likely.

I once 'saw' a patient (was only minimally involved) - 30, from US, confused, ataxic, pH 6.9-something on admission, BM normal. Only comorbidity crohn's, so ended up under gastro despite no actual gastro symptoms. They hadn't a clue what was going on, all MRIs and LPs and CRPs negative.

Anyway - long story short - after a few days the pH was better but still confused and ataxic, they suspected weird poisons, so sent the family home to hunt thoroughly for anything unusual (House-style, but without the break-in). They found... about 100 litre-bottles of vodka. Turned out she'd been still drinking on the ward somehow and she was just constantly hammered. Did ketones for the first time... very high.

Then all the complaints about why this person is under gastro... suddenly went away :tongue:

That is the only case of alcoholic ketoacidosis I've ever seen, and it took the gastro consultants (all of them, as they had been chatting about this weird case among themselves) a week to figure it out.
Original post by nexttime
I once 'saw' a patient (was only minimally involved) - 30, from US, confused, ataxic, pH 6.9-something on admission, BM normal. Only comorbidity crohn's, so ended up under gastro despite no actual gastro symptoms. They hadn't a clue what was going on, all MRIs and LPs and CRPs negative.

Anyway - long story short - after a few days the pH was better but still confused and ataxic, they suspected weird poisons, so sent the family home to hunt thoroughly for anything unusual (House-style, but without the break-in). They found... about 100 litre-bottles of vodka. Turned out she'd been still drinking on the ward somehow and she was just constantly hammered. Did ketones for the first time... very high.

Then all the complaints about why this person is under gastro... suddenly went away :tongue:

That is the only case of alcoholic ketoacidosis I've ever seen, and it took the gastro consultants (all of them, as they had been chatting about this weird case among themselves) a week to figure it out.

Wow - it's always the test that you never think of immediately. Recently read 'Shapeshifters' by Gavin Francis - great book, would recommend - and one of his accounts detailed a patient who always stayed indoors (appeared she was very sensitive to light. Presented with hallucinations. It turned out that the porphyrin count was too high - really interesting bit of physiology.
@forbearne@epicnm @Ksadanand @harryoke22 @Chemist123 @FlawlessChicken @shinypixel @Matthew Qurku


and anyone else I forgot to @ ... thought we could do something more basic. I will roll with whatever you guys say because more than one thing presents in this way. So you guys give me your thoughts:



A patient comes to see you saying they feel thirsty all the time, they are also waking up at night needing to pee and notice they need to pee more often.



Now what are your ideas on what could be causing the triad AND what questions would you want to ask to help direct you.



Try to think of 2/3 possibilities.
Diabetes was my first thought. Perhaps ask about family history of diabetes and would monitor bmi and lifestyle to see if this is a plausible diagnosis. Thinking of other possibilities too - will post later
Reply 69
Maybe a problem with the kidney ? Maybe the release of ADH from the pituitary glands is not sufficient enough at certain times in a day.
Original post by Exdoz
Maybe a problem with the kidney ? Maybe the release of ADH from the pituitary glands is not sufficient enough at certain times in a day.

Yeah urine issues could be separate from thirst (dry mouth). Also could be uti
I'm thinking diabetes insipidus. Is it?
(edited 4 years ago)
Could it be diabetes as the patient feels thirsty all the time? I would ask the patient for other symptoms too and whether they feel pain/discomfort whilst urinating to see if there is an infection involved.
Reply 73
Original post by kyotpanda
I'm thinking diabetes insipidus. Is it?

Right kinda similar to what I said. I guess we will ask them if they got in any recent accident (involving the head) and how long ago it was. Then deciding if they need a surgery or not. I suppose that would be the start of the treatment
mhmhmhm, the first thing which came into my brain was diabetes and as @kyotpanda said diabetes insidipdus (whatever that is, I'll research it later lol)
Original post by PastelColours
mhmhmhm, the first thing which came into my brain was diabetes and as @kyotpanda said diabetes insidipdus (whatever that is, I'll research it later lol)

diabetes insipidus isn't related to diabetes mellitus - shares symptoms - but is to do with ADH response from the kidney.
perhaps its a nocturnal issue, the person did say they are waking up more often in the night to pee since ADH causes you to pee less in the night etc etc, but maybe im over analysing it
Original post by forbearne
diabetes insipidus isn't related to diabetes mellitus - shares symptoms - but is to do with ADH response from the kidney.

oh ok I hadn't searched up the insipidus one anyway and yh based on my very vague GCSE biology knowledge I realised it was to do with the ADH and the kidney thanks x
perhaps ask what colour their urine is and some questions concerning lifestyle.
Original post by Exdoz
Maybe a problem with the kidney ? Maybe the release of ADH from the pituitary glands is not sufficient enough at certain times in a day.

^this.
Maybe they're just taking in a lot more diuretics? so you could ask them whether anything noticeable in their diet has changed? or maybe they're taking some other sort of medication that might effect urine production?

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