DKA

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍day history of ‍hyperglycemialethargyfatigue

Blood glucose level: ‍

Recent HbA1c level: ‍ %



Associated symptoms: *Try using right-click for negatives*

‍fatigue

‍increased thirst

‍increased hunger

‍increased urination

‍blurred vision

‍headache, ‍diffuse, ‍persistentintermittent, ‍pressurethrobbing, ‍mild

‍dry mouth

‍nausea

‍vomiting, ‍ episodes ‍per day, ‍, ‍hematemesis

‍shortness of breath

‍chest pain, ‍retrosternal, ‍aching, ‍on exertionat restwith deep breath, ‍mild

‍fruity breath odor

‍lethargy

‍confusion



Contributing factors:

‍non-adherence to low-sugar diet

‍alcohol abuse

‍recent infection

no history of: ‍diabetes, ‍pancreatitis

no use of: ‍insulin, ‍oral hypoglycemics, ‍steroids, ‍new medication

‍low adherence to medication

‍recent medication changes





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍guarding, bowel sounds ‍normal, ‍, ‍CVA tenderness ‍

Skin: ‍rashlesions on ‍

Extremities: ‍warm, ‍dry, cap refill ‍< 3> 3 sec, pulses ‍intact, ‍edema ‍bilaterally, ‍

Neurologic: cranial nerves ‍intact, strength ‍intact 5/5, sensation ‍intact, reflexes ‍intact 2+, cerebellar function ‍intact, gait ‍steady

Mental status: ‍alert, ‍oriented, speech ‍clear, mood ‍normal, thought ‍organized, ‍suicidal ideation, judgment ‍good





ASSESSMENT:

‍Diabetic ketoacidosis ‍likelysuspectedpossible, ‍well-controlled

DDx: diabetic ketoacidosis, type 1 diabetes mellitus, type 2 diabetes mellitus, drug-induced diabetes, pancreatic disease-related diabetes, starvation ketosis, alcoholic ketoacidosis, lactic acidosis, uremic acidosis, thyrotoxicosis, adrenal insufficiency, sepsis, acute pancreatitis, ischemic bowel, cerebral edema, pulmonary edema, myocardial infarction, stroke, infection, non-compliance with insulin therapy, insulin pump failure, extreme stress, substance abuse





PLAN:

Investigations:

- Blood work: ‍CBC, ‍lytes, ‍creatinine, ‍glucose, ‍HbA1c, ‍blood gas

- Urinalysis

- ECG

- Chest X-ray

Treatments:

- Follow protocol

- Normal saline 1L bolus, then 500cc/h x2h, then 250cc/h x4h

- KC 20 meq/L at 150cc/h if K less than 5.5 (must have urine output)

- ‍Insulin RGlargine 0.1 units/kg/h (stop when pH normalized)

- Bicarbonate infusion if pH < 7.0-7.1

- Urine output monitoring

Further care:

- Referral to ER

- Monitor glucose level every 1 hour

- Monitor electrolytes and blood gas every 2 hours

- Monitor vital signs every 15 minutes

- Admission to intensive care unit

- Referral to endocrinologist

- Follow-up in ‍ ‍daysweeks