1. DIABETIC KETOACIDOSIS

2. Case history

3. Clinical assessment  Observations:  BP 106/67  HR 90  RR 30  Temperature 36.8°C  O2 saturation 99% (air)  Examination:  Slightly drowsy (GCS 13)  Dry mucous membranes, slow capillary refill, cool peripheries  Ketotic breath  Generalised abdominal tenderness

4. Investigations  3+ ketones, 4+ glucose  -ve for blood, nitrites, leukocytes  -ve for bHCG  25 mmol/L

5. Investigations  pH 7.24  PaO2 14 kPa; PaCO2 3.5 kPa  HCO3- 12 mmol/L  WCC 14.5; sodium 130; potassium 5.6  urea 11.4; creatinine 150.3  ketones 5 mmol/L; glucose 25 mmol/L

6. Investigations  Sinus arrhythmia

7. Prescribing Elizabeth Austin 23/02/1996 X008156377 56 kg PMH  Type I diabetes  Asthma (mild) Sunderland Royal Hospital Emergency department Consultant: Dr Watanabe DH  NKDA  Levemir 16 units ON  NovoRapid 6-10 units with meals  Ventolin Evohaler 200 micrograms PRN  Clenil Modulite 200 micrograms BD  Microgynon 30 OD for 21 days, 7 pill-free days

8. Prescribing 1. Please prescribe appropriate initial fluids 2. Please prescribe the appropriate insulin infusion regimen

9. Prescribing Treatment is commenced and Liz is being continuously monitored. After five hours: ketones 3 mmol/L glucose 13 mmol/L The equipment is checked and is working correctly. 3. Please continue/modify the treatment as necessary

10. Prescribing Latest results of monitoring: K+ 3.5 mmol/L capillary glucose 11 mmol/L 4. Please continue/modify the treatment as necessary

11. Prescribing Liz is reviewed. She still feels nauseated but her blood results are steadily improving, with venous pH 7.28 and ketones 0.7 mmol/L. 4. A colleague suggests converting IV to subcutaneous insulin. Is this treatment appropriate?

12. Prescribing Her nausea has now resolved and she is requesting food. Blood results: glucose 4.8 mmol/L ketones 0.2 mmol/L pH 7.35 Bicarbonate and potassium normal 5. Please prescribe insulin and her regular medications as appropriate

13. Prescribing Following the resolution of her DKA, the patient is medically fit for discharge. 6. What further management should be arranged for her?