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The question
A 55-year-old woman with a BMI of 49 kg/m2 has daytime sleepiness and morning headaches. She has no lung disease, vomiting or diuretic use. Her chemistry panel shows total CO2 32 mmol/L (reference 22-29) and chloride 96 mmol/L, and the ward asks whether she has a metabolic alkalosis. Arterial results: pH 7.36 (reference 7.35-7.45), pCO2 7.6 kPa (57 mm Hg), HCO3- 31 mmol/L. For every 10 mm Hg rise in pCO2, HCO3- rises by about 1 mmol/L in acute and about 3.5 mmol/L in chronic respiratory acidosis (±2 mmol/L). Which interpretation fits best?
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