2. An 18-year-old Hispanic woman with a 10 year history of type one DM and reactive airway disease presented to the hospital emergency department with a 5-day history of weakness, tactile fever, productive cough, nausea, and vomiting. Patient report and chart review confirmed that 2 years before this presentation, her diabetes had been managed Well with basal / bolus inulin regemin , However noted a 4 day history of decreased oral intake , nausea , vomiting and diarrhea , following a barbeque party were raw meat was served ,

3. On examination, her temperature was 99
On examination, her temperature was 99.1° F, blood pressure was 98/64 mmHg, pulse was 136, and respirations were 36. There was a strong smell of ketones in the exam room. The patient was drowsy but concious.
Her lung sounds were clear without wheezes or rhonchi. Her heart sounds were normal. The abdominal exam revealed mild epigastric tenderness to deep palpation but no rebound tenderness or guarding. Extremities were well perfused with symmetric pulse

4. Laboratory results were remarkable for a room air arterial blood gas with pH of 7.12, pCO2 of 17 mmHg, and bicarbonate of 5.6 mEq/l. Urinalysis revealed 4+ glucose and 3+ ketones. Chemistry panel revealed a glucose of 420 mg/dl, BUN of 16 mg/dl, creatinine of 1.3 mg/dl, sodium of 139 mEq/l, chloride of 112 mEq/l, CO2of mmol/l, and potassium of 5.0 mEq/l. Chest X-ray revealed no infiltrate
What is the diagnosis ? And how will you manage this case ?

5. DKA is defined as a plasma glucose level >250 mg/dl,
plasma bicarbonate <15 mEq/l,
pH <7.3
ketonemia,
and an elevation in the anion gap.
This patient clearly meets the criteria for DKA based on her blood glucose of 420 mg/dl, CO2 of 11.2, pH of 7.12, anion gap of 15.8, and obvious ketonemia

6. How does ketonemia develop ??

7. How does ketonemia develop ??
Unable to rely on carbohydrate metabolism, cells switch to fat metabolism and oxidise fatty acids to release acetyl coenzyme A (CoA) in concentrations that saturate the Kreb’s cycle
Excess acetyl CoA is converted to the ketone bodies acetone, acetoacetate and beta-hydroxybutyrate, which are released into the blood causing a raised anion gap metabolic acidosis

8. What causes the dehydration ,and electrolyte disturbance ?

9. What causes dehydration ?
Insulin deficiency renders cells unable to take up and metabolize glucose
Glucose remains trapped in the blood from where it is filtered by the kidneys in concentrations that exceed renal reabsorption capacity
Glycosuria causes a profound osmotic diuresis leading to severe dehydration

10. What are the causes , signs and symptoms of DKA ?

11. How is it managed ? Fluid resuscitation Potassium replacement
Fixed rate insulin IV infusion at 0.1 unit/kg/hour

12. How is the fluid deficit replaced ?
0.9% saline 1 L IV over 1 hour
0.9% saline 1 L IV over 2 hours
0.9% saline 1 L IV over 4 hours
0.9% saline 1 L IV over 6 hours

13. When should potassium be replaced ?
When should regular potassium be added to the iv fluid regimen ?

14. A patient is admitted with Diabetic Ketoacidosis
A patient is admitted with Diabetic Ketoacidosis. The junior resident orders intravenous fluids of 0.9% Normal Saline and 10 units of intravenous regular insulin IV bolus and then to start an insulin drip per protocol. The patient’s labs are the following: pH 7.25, Glucose 455, potassium Which of the following is the most appropriate to do next ?
Start the IV fluids and administer the insulin bolus and drip as ordered by resident
Hold IV fluids and administer insulin as ordered
Recheck the glucose level
Hold previous order and give potassium iv via central line

15. What are the possible complications of DKA ?

16. A 42-year-old female presented unresponsive to the emergency department. Upon arrival, the patient’s examination was consistent with hypovolemia and tachycardia. Review of systems included a one- week history of nausea and vomiting. The patient had stopped all of her medications one year prior, only restarting metformin one week prior to admission. Her presenting systolic blood pressure was 119 mmHg with a poor mental state. The presenting blood sugar level was 1263 mg/dL, and ketones were not detected in her urine , serum PH is 7.37 , creatinine is 1.3 , sodium is 153 , BUN IS 24 , How will you approach this patient ?

17. Hyperosmolar non-ketotic diabetic coma
DIAGNOSTIC CRITERIA
1. Severe hyperglycaemia (blood glucose usually > 540 mg/dl).
2. Total osmolality > 320mOsm/kg.
3. Serum bicarbonate >15mmol/l (not acidotic).
4. Urinary ketones < 3.0 mmol/l or <++ plus (if urine test).
5. altered consciousness
CLINICAL FEATURES
1. Insidious onset.
2. Severe dehydration.
3. Impaired level of consciousness (degree correlates with plasma osmolality).
4. May have concurrent illness e.g. MI, stroke or pneumonia.

18. An 80 y old male patient who lives with his wife was brought by the ambulance after an emergency call noting the patient was unresponsive ,
His wife noted he had been complaining of reduced eye sight during the last few months associated with difficulty taking his insulin ,
On arrival to ER the patient was drowsy and unresponsive ,Sweating, hr 130 bpm sinus , RR 12 /min , bp 95/50
His wife noted he had been complaining of
Irritability or moodiness ,Anxiety or nervousness , and Headache earlier that day
Glucocheck taken in ER revealed a glucose level of 15 mg/dl, how will you approach this case ?
What could have the patients wife done till arrival of the ambulance to manage this case promptly ?