The Clinical Problem Solvers Episode 437 – RLR – An Abnormal Normal Gap Acidosis
Jan 5, 2026
A 65-year-old woman with fatigue presents an intriguing clinical puzzle for discussion. Hosts dive into differential diagnoses, exploring causes of tachycardia and hypokalemia. They emphasize the importance of magnesium levels and blood gas analyses to clarify metabolic acidosis. A surprising twist reveals ketosis despite a normal anion gap, leading to insights on renal function. The conversation explores fascinating mechanisms of non-gap acidosis and highlights the value of curiosity in clinical casework, showcasing learning from ordinary yet complex cases.
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Use Duration To Frame The Problem
- Acute onset (three days) narrows the differential toward acute processes rather than chronic disease.
- Reza Manesh uses duration early to set the diagnostic problem frame and prioritize likely causes.
Tachycardia Triggers To Prioritize
- Tachycardia with hypertension and tremulousness suggests sympathetic overactivity from pain, early sepsis, withdrawal, or thyrotoxicosis.
- Reza Manesh prioritizes quick focused exam and targeted labs (TSH, urine tox, lactate, electrolytes) to distinguish causes.
Approach Severe Hypokalemia
- When K <3.0 get an ECG and ask whether loss is GI, renal, or transcellular; prioritize history to distinguish these.
- Check prior labs to see chronicity and guide targeted testing rather than treating in isolation.