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ACCP-SEEK Board Review Question of the Month |

A 27-Year-Old Homeless Man With Mental Obtundation and a Metabolic Acidosis*

Harold M. Szerlip, MD, FCCP
Author and Funding Information

*From the ACCP-SEEK program, reprinted with permission. Items are selected by Department Editors Richard S. Irwin, MD, FCCP, and John G. Weg, MD, FCCP. For additional information about the ACCP-SEEK program, phone 1-847-498-1400.



Chest. 1999;115(5):1447-1448. doi:10.1378/chest.115.5.1447
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A 27-year-old homeless man with a history of alcohol abuse is brought to the emergency department obtunded. On examination, he is a disheveled male with rapid deep respirations. His blood pressure is 120/70 mm Hg, pulse 120 beats/min, and respiratory rate 36 breaths/min. His sclerae are anicteric. His pupils are 5 mm and responsive. Disc margins are sharp. Chest and cardiovascular examination are without abnormalities. An arterial blood gas measurement demonstrates a Po2 120 mm Hg, Pco2 18 mm Hg, and pH 7.1. Laboratory tests reveal the following: sodium 138 mEq/L (138 mmol/L), potassium 4.0 mEq/L (4.0 mmol/L), chloride 96 mEq/L (96 mmol/L), bicarbonate 10 mEq/L (10 mmol/L), glucose 80 mg/dL (4.4 mmol/L), and blood urea nitrogen 4 mg/dL (1.1 mmol/L). Serum osmolality is 346 mOsm/kg (346 mmol/kg). Urinalysis shows numerous calcium oxalate crystals. This patient’s acidosis is probably secondary to which of the following?

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