MRCP2-1194

MRCP2-1194

A 54-year-old man with type 1 diabetes presents to the hospital with a day of vomiting and diarrhea. He experienced indigestion earlier in the day, which he treated with antacids, but the burning pain in his chest and throat persisted for four hours. Despite several insulin boluses, his blood glucose continued to rise. He denies any missed doses of insulin, changes in exercise, or skipped meals. He smokes 20 cigarettes a day and manages his diabetes with a basal bolus regimen and correction doses based on carbohydrate counting.

During the examination, the patient appears sweaty with dry mucosa. His heart rate is 125/min, respiratory rate is 28/min with prolonged expiration phases, blood pressure is 110/90 mmHg, and temperature is 37ºC. The nurse measures his blood glucose, which is 27 mmol/l, and his blood ketones, which are 4 mmol/l.

Lab results show Hb 130 g/l, Na+ 133 mmol/l, Platelets 356 * 109/l, K+ 4.5 mmol/l, WBC 9.8 * 109/l, Neuts 7.5 * 109/l, Lymphs 1.0 * 109/l, Eosin 0.1 * 109/l, Urea 6.2 mmol/l, Creatinine 98 µmol/l, CRP 34 mg/l, and HbA1c 48 mmol/mol (normal range <42). The ECG shows deep T-wave inversion in V1-V4, and the chest x-ray shows no acute abnormalities. What is the most likely cause of this patient’s presentation?