An elderly male is brought to the emergency department by the police when he was found wandering on the street in the night. He is confused, disoriented, and intermittently complaining of generalized abdominal pain and thirst. Any further history is unobtainable. His blood pressure is 110/80 mmHg, pulse is 98/min, temperature is 36.7C (98 F) and respirations are 22/min. There is no abdominal rigidity or rebound tenderness. Laboratory examination shows that his urine is positive for ketones. His plasma glucose level is 167 mg/dL. Other laboratory results are pending.
What is the most likely cause of this patient's condition?

Question

An elderly male is brought to the emergency department by the police when he was found wandering on the street in the night.  He is confused, disoriented, and intermittently complaining of generalized abdominal pain and thirst.  Any further history is unobtainable.  His blood pressure is 110/80 mmHg, pulse is 98/min, temperature is 36.7C (98 F) and respirations are 22/min.  There is no abdominal rigidity or rebound tenderness.  Laboratory examination shows that his urine is positive for ketones.  His plasma glucose level is 167 mg/dL.  Other laboratory results are pending.
What is the most likely cause of this patient's condition?

Quizplus · Accepted Answer

Explanation: The patient most likely has alcoholic ketoacidosis, as suggested by his impaired mental function with ketonuria and mildly elevated plasma glucose levels. Plasma glucose levels can be low, high, or normal. High plasma glucose levels are speculated to be due to impaired insulin secretion combined with increased insulin resistance. Biochemically, the patients with alcoholic ketoacidosis will have increased anion and osmolal gap. (Choice A) The patient is unlikely to have acute appendicitis, as he does not have tenderness in his right lower quadrant; however, appendicitis can be associated with starvation ketoacidosis. (Choice B)Similarly, the patient does not have cholecystitis because his pain is not localized to the right upper quadrant. (Choice D)Henoch-Schonlein purpura is mainly seen in the pediatric age group. It is characterized by abdominal pain, skin rashes and joint inflammation. Mental status change is not a feature of Henoch-Schonlein purpura. (Choice E)The patient is unlikely to have diabetic ketoacidosis in the presence of mild hyperglycemia. Blood glucose levels are generally higher than 250 mg/dL in patients with diabetic ketoacidosis. Educational Objective: Alcoholic ketoacidosis is characterized by anion gap acidosis, increased osmolal gap, ketonemia or ketonuria and variable blood glucose levels. Blood glucose levels are generally higher than 250 mg/dL in patients with diabetic ketoacidosis.

An Elderly Male Is Brought to the Emergency Department by the Police