question: Q:A 64-year-old man presents to the emergency department with the complaints of nausea and muscle weakness for the past 24 hours. He further adds that he is significantly aware of his heartbeat. He was diagnosed with type II diabetes mellitus 20 years ago and hypertension 15 years ago for which he is taking metformin and captopril. He occasionally takes naproxen for his knee pain. He does not smoke but drinks alcohol occasionally. His father and sister also have diabetes. His vitals include a temperature of 37.1°C (98.8°F), blood pressure of 145/92 mm Hg, and a regular pulse of 87/min. His body mass index (BMI) is 32.5 kg/m2. Physical examination is insignificant except for grade 4 weakness in both lower limbs. Fingerstick blood glucose is 200 mg/dL. An ECG is ordered and shows peaked T waves.
  Lab studies show:
  Blood pH 7.32
  Serum bicarbonate 19 mEq/L
  Serum sodium 135 mEq/L
  Serum chloride 107 mEq/L
  Serum potassium 6.5 mEq/L
  Urine anion gap 20 meq/L
  Which of the following is the primary defect responsible for this patient’s condition?? 
  {'A': 'Increased ketogenesis', 'B': 'Decreased aldosterone secretion', 'C': 'Impaired distal tubule acidification in the kidneys', 'D': 'Decreased bicarbonate reabsorption in the proximal tubules', 'E': 'Metformin overdose'},