An 87-Year-Old Nursing Home Resident Is Brought to the Emergency

An 87-year-old nursing home resident is brought to the emergency department with a 2-day history of fever, vomiting, and progressive lethargy.  The patient's past medical history is significant for advanced dementia and stroke.  Temperature is 38.3 C (101 F) , blood pressure is 88/62 mm Hg, and pulse is 120/min and regular.  On examination, he is lethargic but arousable.  Coarse rhonchi are heard over the right midlung.  Laboratory results are as follows: Which of the following is the most likely cause of this patient's increased anion gap?

A) Decreased oxidative phosphorylation
B) Impaired hepatic gluconeogenesis
C) Impaired renal tubular bicarbonate reabsorption
D) Increased lipolysis and ketogenesis
E) Increased protein breakdown

Correct Answer:

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