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CaseStudy2:TypeIDiabetesMellituswithDiabeticKetoacidosis

SamBallard
KNH413
2.18.2016

1. Thereareprecipitatingfactorsfordiabeticketoacidosis.Listatleastsevenpossible
factors.

1.
2.
3.
4.
5.
6.
7.
8.

Lackofbloodglucoseselfmonitoring
Severeillnessorinfection
Insulinomitted
Increasedinsulinneedswithgrowthspurts
Pumpmalfunction
Physicaloremotionaltrauma
Alcoholordrugabuse
Strokeorheartattack

2. DescribethemetaboliceventsthatledtothesymptomsassociatedwithDKA.

ThesymptomsofDKAmayincludenauseaand/orvomiting,stomachpain,fruityor
acetonebreath,Kussmaulrespirations,dehydration,andmentalstatuschanges
(Nelms,Sucher,&Lacey,2014).Withoutadequateinsulin,thebodybreaksdown
lipidsasanalternativefuelsource.Ketonesareaproductofthisincreasedrateof
lipolysisandtheseacidicketonebodieslowerserumpH.Thisaciditycancause
nausea,vomiting,andstomachpainasitinterfereswiththenormalfunctionof
multipleorgans.Theproductionofketonebodiescausesacetone,orfruity,breath.
InordertocompensateforthisdropinpH,respiratoryventilationchangesto
accommodatetheneedtoreducepCO2.Thesedeep,laboredbreathsareknownas

Kussmaulrespirations.Dehydrationandelectrolyteimbalanceareoftenaresultof
glucoseandketonesaccumulatinginthebloodstream.Glucosecanaccumulatein
thebloodwhenthereisinsufficientinsulintomoveglucoseintothecells
(Drugs.com,2016).Asthebloodlosesfluidandbecomesfurtherconcentrated,
hyperglycemiaisexacerbated(Nelms,Sucher,&Lacey,2014).

3. AssessSusansphysicalexamination.Whatisconsistentwithdiabeticketoacidosis?
Givethephysiologicalrationaleforeachthatyouidentify.

Susansphysicalexamindicatedthatsheistiredlookingandisexperiencingnausea
andvomiting.Shealsohastachycardia;drymucousmembranes;dry,flushedskin
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withpoorturgor;deep,rapidKussmaulsrespirations;atenderabdomen;andsheis
feelingirritableandlethargic.Allofthesesymptomsareconsistentwithdiabetic
ketoacidosis.Asnotedinquestion2,Susansbodyhasinsufficientinsulinandhas
begunbreakingdownlipidstouseasfuel.Thishascausedtheproductionof
ketones,makingherbloodacidicbyloweringitspH.ThisacidityiscausingSusans
nausea,vomiting,andabdominalpainasitinterfereswiththefunctionofmultiple
organs.Asglucoseandketonesaccumulateintheblood,electrolyteimbalanceand
dehydrationoccur.DehydrationisthereasonforSusansdrymucousmembranes
anddry,flushedskinwithpoorturgor.Thethicker,moreconcentratedbloodmay
alsobethereasonforSusanstachycardiaifthebloodhastoworkhardertopump
herblood.Lastly,thedeep,rapidKussmaulrespirationsarethebodysresponseto
theincreasedacidity.ThesebreathscompensateforthedropinpHbyreducing
pCO2throughchangesinrespiratoryventilation.

4. ExamineSusansbiochemicalindicesbothinthechemistrysectionandinherABG
report.WhichareconsistentwithDKA?Why?

LabValue

Normal

Admit

Day2

Chemistry
Potassium

3.55.5

5.8H

5.1

Chloride

98108

110H

102

PO4

2.54.5

4.9H

4.0

Osmolality

275295

336H

298H

TotalCO2

2430

22L

24

Glucose

70120

475H

200H

BUN

826

29H

21

Creatinine

0.61.3

1.8H

1.2

CHOL

140199

201H

200H

HbA1c

4.87.8

12.0H

ArterialBloodGases(ABGs)
pH

7.357.45

7.31L

7.35
2

CO2content

2330

22L

23

HCO3

2428

21L

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Susanspotassium,osmolality,glucose,BUN,creatinine,andlowCO2levelsaresome
ofthemostimportantindicatorsofdiabeticketoacidosis.Potassiumlevelsmaybe
highduetotheextracellularshiftofpotassiuminexchangeofhydrogen,whichis
accumulatedinacidosis,inspiteofseverelydepletedtotalbodypotassium
(Medscape,2015).Highbloodosmolalityisaconsequenceoftheconcentrated,
acidicblood,whichalsocausesdehydration.HighbloodglucoseisaresultofSusans
lackofinsulin.Withoutinsulin,sugarwasnottakenupbythecellsanditstayedin
thebloodstream,alsolendingtotheincreasedbloodosmolality.BUNandcreatinine
mayalsobeelevatedifSusanskidneysareworkingtorebalanceherbodyspH
levels.LowCO2levelsmaybeduetohyperventilation,whichisoneofthebodys
waystocompensateforbeinginanacidicstate.BlowingoffCO2alsoeliminates

excesshydrogenionsandhelpsmaintainthepHofbodyfluids.Thismayimpair
theirabilitytoefficientlyfilterthebodyswasteproducts.WhenlookingatSusans
ABGs,herlowpHandlowHCO3indicatethatherbodyisinanacidicstate.

5. IfSusanssymptomswereleftuntreated,whatwouldhappen?

IfSusanssymptomswereleftuntreated,herbodysdisturbedacidbasebalance
wouldbecomeexacerbatedandlifethreatening.UntreatedDKAcancauselossof
consciousness,coma,orevendeath.Thebodywouldcontinuetobreakdownlipids
touseasfuel,whichwouldproducemoreandmoreketonebodiesandfurther
drivingdownthebodyspHlevel.DKAcancauseothercomplications,suchas
cerebraledema,cardiacarrest,andkidneyfailure(MedlinePlus,2015).Theheart
mayhavedifficultypumpingthickenedorconcentratedbloodthroughthebodyand
thekidneyswouldworktocounteracttheacidbaseimbalancebyconserving
bicarbonateandexcretingincreasedsodium,potassium,andammonium(Nelms,
Sucher,&Lacey,2014).

6. AssumingSusansSMBGrecordsarecorrect,whateventsseemtohaveprecipitatedthe
developmentofDKA?

ThreeeventsseemtohaveprecipitatedSusansdevelopmentofDKA.Susanstarted
herperiodon9/20,hadavolleyballtournamenton9/24,andcelebratedher
birthdayon9/25.Changesinhormonelevelsthatareassociatedwithmenstrual
periodscanhaveasignificanteffectonthefluctuationofbloodsugarlevels(.A
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volleyballtournamentcouldhaveaffectedSusansbloodsugarinmanyways.Her
increasedphysicalactivitywouldhavemadeherbloodglucosemonitoringmuch
moredifficultandvariable.Susanwouldhavehadtocoordinateherphysicalactivity
withinsulin,snacks,andproperhydration.BecauseSusansperiodhadalready
increasedherbloodglucoselevels,shewasalreadyhyperglycemic.Herinsulinwas
deficientandtheriseincounterregulatoryhormonesthattakesplaceduring
exercisecausesanincreaseinhepaticglucoseproductionandfreefatty
acids(Nelms,Sucher,&Lacey,2014).Hercellularuptakeofglucosewasminimal,
whichresultedinincreasedbloodglucoselevelsandanincreasedproductionof
ketones.Inadditiontothis,Susansbirthdaycelebrationritualsmayhavenegatively
affectedherhyperglycemiaevenmore.Eatingsweets,drinkingalcohol(although
illegalforherage,butnotunheardofforthispatient),andbeinggenerally
distractedbyfunandfriendswouldhavemadeitevenmoredifficulttomonitorher
bloodglucoselevels.Susansrisingbloodglucoselevelsthroughoutthesethree
eventsmostlikelywouldhavecausedherbodytoretrieveinsulinfromalternative
sources,causingherDKA.

7. What,ifanything,couldSusanhavedonetoavoidDKA?

TherearemanythingsthatcanbedonetopreventDKA.Commonprevention
techniquesincluderegularselfmonitoring,testingforketones,monitoringany
effectsofillnessonbloodglucoseclosely,takingmedicationsevenwheneatingless,
havingasickdaymanagementplan,andprobingrationaleforomittinginsulin.
Susancouldhavemorecloselymonitoredherbloodglucoseknowingthatshewas
onherperiod.Duringhervolleyballtournamentandbirthday,Susanwouldhave
benefitedfromcloserbloodglucosemonitoringaswellascarbohydratecounting
andmealmanagement.

8. WhileSusanisbeingstabilized,TagametisbeinggivenIVpiggyback.WhatdoesIV
piggybackmean?WhatisTagamet,andwhyhasitbeenprescribed?

ThetermIVpiggybackdescribesanIVbagthatishungsecondarytoaprimaryIV
bag.ThissecondaryIVisattachedtotheprimaryIVatinjectionports.SecondaryIVs
areprimarilyusedtoinfusemedsorotherIVfluidsonanintermittentbasisif
compatiblewithfluidontheprimaryline.TagametisthemedicationinSusansIV
piggyback.TagametisanH2(histamine)blockerthatworksbyblockinghistamine,

whichstimulatesthereleaseofacidintothestomach.Tagametisusedtotreatand
preventulcers,gastroesophagealrefluxdisease,andotherconditionsthatcauseor
arecausedbyincreasedacidsecretion.BecauseSusansbodyisalreadyinanacidic
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state,Tagametwasprescribedtoblockhistamineandpreventfurtheracidsecretion
(Drugs.com,2016).

9. TheDiabetesControlandComplicationsTrialwasalandmarkmulticentertrial
designedtotestthepropositionthatcomplicationsofdiabetesmellitusarerelatedto
elevationofplasmaglucose.Itisthelongestandlargestprospectivestudyshowing
thatloweringbloodglucoseconcentrationslowsorpreventsdevelopmentof
complicationscommontoindividualswithdiabetes.Thetrialcomparedintensive
insulintherapy(tightcontrol)withconventionalinsulintherapy.Defineintensive
insulintherapy.Defineconventionalinsulintherapy.

Intensiveinsulintherapyrequiresmultipledailyinjections(MDIs)ofrapidacting
insulinbeforemealsinadditiontobasalinsulinoncedaily(Nelms,Sucher,&Lacey,
2014).Thistypeofinsulintherapycanusesyringes,pens,orapumptodeliver
insulin,whichisadjustedaccordingtofoodintake.Thisreplicatesinsulinsecretion
inanormalpersonandallowsforadjustmentofinsulininresponseto
hyperglycemia,carbohydrateintake,andphysicalactivity.Intensiveinsulin
therapy(whencomparedtoconventionaltherapy)delaysonsetandslowthe
progressionofcomplicationssuchasretinopathy,nephropathy,andneuropathyin
patientswithT1DM(Nelms,Sucher,&Lacey,2014).Conventionalinsulintherapy
isapremixedorfixedinsulinplan.Aprescribeddoseofbasalorintermediateacting
insuliniscombinedwithshortorrapidacting(orbolus)insulin.Individualsusing
conventionalinsulintherapymayusepremixedinsulinsandmustcoordinate
administrationoftheirinsulinandfoodintaketoavoidhypoglycemia.Thisregimen
requiresconsistentinsulindosesandmealtimesfromdaytoday.Mealscannotbe
skippedandphysicalactivitycanleadtohypoglycemia(Nelms,Sucher,&Lacey,
2014).

10. Listthemicrovascularandneurologiccomplicationsassociatedwithtype1diabetes.

CardiovascularDisease(Nelms,Sucher,&Lacey,507)
Hyperglycemiamakesbloodvesselspronetoendothelialdamage,
causingthickeninganddecreasedflexibilityofthevesselsand
increasedhighbloodpressure.
Hypertensionisariskfactorforcardiovasculardiseaseaswellasa
complicationformicrovascularcomplicationssuchasretinopathyand
nephropathy.
Nephropathy(Nelms,Sucher,&Lacey,507)
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Leadingcauseofchronickidneydisease(CKD)kidneyfailurethat
mustbetreatedwithdialysisortransplantation
Hyperglycemiachangesthestructureofthebloodvesselsofthe
glomerulus.Changesincapillarystructureresultinincreased
permeabilityanddecreasedfilteringability.
Earlystageofnephropathyispersistentalbuminuria(albumininthe
urine).
Retinopathy(Nelms,Sucher,&Lacey,507)
Mostfrequentcauseofnewcasesofblindnessinadults.
PrevalenceisstronglyassociatedwithdurationofDM.
Eyedamagedirectlyrelatedtohyperglycemicdamagetoitsblood
vessels.
Othereyeailmentsincludeglaucomaandcataracts.
Hypertensionisalsoassociatedwithretinopathy.
Neuropathy(Nelms,Sucher,&Lacey,507)
Nervoussystemdamage(duetohyperglycemia)causesimpaired
sensationofpaininthefeetorhands,sloweddigestionoffoodinthe
stomach,carpaltunnelsyndrome,impairedwoundhealing,motor
dysfunction,and/orbonefracture.
Accumulationofabnormalsubstances,suchassorbitolandglycated
proteins,resultsincellulardamage,whichdisruptsnormalnervous
systempathways.
Peripheralneuropathypainandlossofsensationinfeetandhands,
whichleadsinjuriestolimbstogounrecognizedandcause
ulcerations,infection,andtheneedforamputation.
Autonomicneuropathyaffectsmanyorgansystems,suchasthe
gastrointestinaltract,genitourinarytract,andthecardiovascular
system.
Gastrointestinal:damagetovagusnervecausesdelayedgastric
emptyingandcancauseanorexia,nausea,vomiting,early
satiety,postprandialbloating,anderraticglycemiccontrol;
constipationanddiarrhea.
Genitourinary:bladderand/orsexualdysfunctionthatmay
manifestasrecurrenturinarytractinfections,pyelonephritis,
orincontinence.
Cardiovascular:maymanifestthroughrestingtachycardia,
orthostatichypotension,orincreasedriskofsilentheart
disease.

11. Whataretheadvantagesofintensiveinsulintherapy?

Intensiveinsulintherapycanpreventorslowtheprogressionoflongtermdiabetes
complications,boostyourenergy,andhelpyoufeelbetteringeneral.Several
studieshaveindicatedthatintensiveinsulintherapycanalsoreducetheriskofeye
damagebymorethan75percent,reducetheriskofnervedamageby60percent,
andpreventorslowtheprogressionofkidneydiseaseby50percent(MayoClinic,
2014).

12. Whataretherisksofintensiveinsulintherapy(tightcontrol)?

Intensiveinsulintherapyhasariskoflowbloodsugarandweightgain.Because
bloodsugarissotightlycontrolledinthistypeofinsulintherapy,anyfluctuationsin
dailyroutinecancauselowbloodsugar.Lowbloodsugarcancausesignsand
symptomssuchasanxiety,sweating,andshaking.Theseshouldbedealtwith
immediatelyusingitemssuchasfruitjuices,hardcandies,orglucosetablets.Weight
gainisapossibleriskbecauseinsulinallowssugarinyourbloodstreamtoenter
yourcellsinsteadofbeingexcretedasurine.Anysugaryourcellsdontusefor
energyisstoredasfat,whichcanleadtoweightgain(MayoClinic,2014).

13. Dr.Greenconsultswithyou,andthetwoofyoudecidethatSusanwouldbenefitfrom
insulinpumptherapycombinedwithCHOcountingforintensiveinsulintherapy.This
willgiveSusanbetterglycemiccontrolandmoreflexibility.Whataresomeofthekey
characteristicsofcandidatesforintensiveinsulintherapy?

AccordingtotheAACEinsulinpumptaskforce,thebestcandidatesforinsulin
pumptherapyhaveeitherType1diabetesorinsulindeficientType2diabetes,
performfourormorebloodglucosechecksandfourormoreinsulininjectionsdaily,
aremotivatedtoachievetighterbloodglucosecontrol,andarewillingand
intellectuallyandphysicallyabletoundergotherigorsofinsulinpumptherapy
initiationandmaintenance(DiabetesSelfManagement,2010).

14. Explainhowaninsulinpumpworks.IsSusanacandidateforaninsulinpump?

Insulinpumpsareusedtodelivercontinuoussubcutaneousinsulininfusion(CSII).
Theydeliverregularorrapidactinginsulinata24hourprogrammablebasalrate
andindividualsareabletobolusadditionalinsulinformealsandsnacks.Useofan
insulinpumpallowscreationofvariableandadjustableinsulindosingtomeet
specific,individualinsulinneeds(Nelms,Sucher,&Lacey,2014).Pumpscandeliver
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assmallas0.001unitsofinsulin,whichcanallowmoreprecisedosing.Therateof
insulindeliverycanbeindividualizedforchangesininsulinsensitivity,sleep,and
physicalactivity.SusanisacandidateforaninsulinpumpbecauseofherT1DM.
AccordingtotheAACEinsulinpumptaskforce,thebestcandidatesforinsulin
pumptherapyhaveeitherType1diabetesorinsulindeficientType2diabetes,
performfourormorebloodglucosechecksandfourormoreinsulininjectionsdaily,
aremotivatedtoachievetighterbloodglucosecontrol,andarewillingand
intellectuallyandphysicallyabletoundergotherigorsofinsulinpumptherapy
initiationandmaintenance(DiabetesSelfManagement,2010).Thistypeofinsulin
therapycouldbenefitherandherparticipationinvolleyball.Itmayalsoencourage
hertomoretightlycontrolherinsulinregimenandteachheradditionalinsulin
controlskills.

15. HowwouldyoudescribeCHOcountingtoSusanandherfamily?

Carbohydratecountingisthemostsuccessfulmealplanningapproachusedfor
diabetesmanagement.Carbohydratesarethemajormacronutrientinfluencing
postprandialglucosevariations,whichinfluencespremealinsulinrequirements
morethanproteinandfat.Thefocusofcarbohydratecountingisthetotalamountof
dailycarbohydrateintake,notwherethecarbohydratesarecomingfrom.Asimple
methodofcarbohydratecountingformealplanningistoeataconsistentamountof
carbohydrateatmealsandsnacks.Therearetwowaystocountcarbohydrates:
1. Theamountoffoodcontaining15gramscarbohydratecountsasone
carbohydratechoice.
2. Totalgramsofcarbohydrateinamealorsnackcanbecountedbyuseoffood
labelinformationorothersourcesofnutrientanalysisinformation.
Carbohydratefoodsourcesincludestarches,fruits,milk/yogurt,andsweets.
Nonstarchyvegetablesdonotneedtobecountedunlessmorethan15gramsof
carbohydratesareconsumedfromthesesources.Theamountofcarbohydrate
necessaryisdifferentforeachindividualandamountscanbeadjustedbasedon
bloodglucosemonitoringresultsandtheindividualslifestyle.Carbohydrate
countingisusefulindetermininghowmanyunitsofglucosearenecessarywithfood
consumption(Nelms,Sucher,&Lacey,2014).IwouldalsoprovideSusanandher
familywithhandoutsdescribingtheamountofcarbohydratesincommonfoods.

16. HowisCHOcountingusedwithintensiveinsulintherapy?

Theinsulintocarbohydrateratioisusedindetermininginsulindosagebasedon
carbohydrateintake.Ingeneral,1unitofrapidactinginsulinistakenforevery
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1015gramsofcarbohydrateconsumed.Thisstartingpointisthenadjustedbased
onselfmonitoringbloodglucoserecords.Tocalculatetheinitial
insulintocarbohydrateratio,the500ruleisusedbydividing500bythe
individualstotaldailydoseofrapidactinginsulin.450isusedforregularinsulin
(Nelms,Sucher,&Lacey,2014).Intensiveinsulintherapyrequiresclosemonitoring
ofglucoseandinsulinlevels.Thisrequiresaccuratecarbohydratecountingto
determineproperinsulindosesandclosemaintenanceofbloodglucose.

17. EstimateSusansdailyenergyneedsusingtheHarrisBenedictequation.

[655+(9.56xwt(kg))+(1.85xht(cm))(4.68xage(yrs))]xPAL
[655+(9.56x50kg)+(1.85x160cm)(4.68x16yrs)]x2.0
[655+478+29674.88]x2.0
1,354.12x2.0=2,708.24kcal/day2,6502,750kcal/day

18. Usingthe1weekfooddiaryfromSusan,calculatetheaverageamountofCHOusually
consumedeachmealandsnack.
a. ~100gmCHObreakfast
b. ~87gmCHOlunch
c. ~32gmCHOsnack
d. ~103gmCHOdinner
e. ~21gmCHOHS
(USDASupertracker)

19. AfteryouhavecalculatedSusansusualCHOintakefromherfoodrecord(Question
18),developaCHOcountingmealplanthatshecoulduse.Includemenuideas.
a. DailyTotal: CHO:338g(2,700kcalx0.5=1,350kcal/4kcal/g=338g)
protein:135g(2,700kcalx0.2=540/4kcal/g=135g)
fat:90g(2,700kcalx0.3=810kcal/9kcal/g=90g)
kcalories:2,6502,750kcal

Time
AM

CHOChoiceorGramsCHO

SampleDayMenuIdeas

5CHOchoicesor75gCHO

1ccereal,1c1%milk,1corange
juice,1slicewholewheattoast

45ozmeat/meatsubstitutes

2ozsausageorbacon,2eggs

4servingfat

2tspbutterontoast,fatfrommeat

Lunch

Snack

Dinner

HS

5CHOchoicesor75gCHO

cfreshfruit,1cmashedpotatoes,c
mixedvegetables,1c1%milk

45ozmeat/meatsubstitutes

4ozbakedchickenorpork

4servingfat

fatfrommeat,2tspbutter(mashed
potatoes)

3CHOchoicesor45gCHO

6saltines,cfreshfruit,craw
carrots

23ozmeat/meatsubstitutes

2ozcheesecubes

23servingfat

2tbsppeanutbutter

5CHOchoicesor75gCHO

2cpasta,1breadstick,1ccooked
vegetables,1c1%milk

45ozmeat/meatsubstitutes

2ozgroundbeef,cheeseforpasta
and/orvegetables

4servingfat

fatfrommeat,butterforpasta,
breadstick,&cookedvegetables

3CHOchoicesor45gCHO

3cpopcorn,1medfruit,1c1%milk

23ozmeat/meatsubstitutes

1cheesestick

23servingfat

butteronpopcorn,fatfromdairy

20. JustbeforeSusanisdischarged,hermotherasksyou,Myfriendwhoownsahealth
foodstoretoldmethatSusanshouldusesteviainsteadofartificialsweetenersor
sugar.Whatdoyouthink?WhatwillyoutellSusanandhermother?

Stevia,alsoknownasRebaudiosideAorrebiana,isgenerallyrecognizedassafeby
theFoodandDrugAdministrationasafoodadditiveandatabletopsweetener.
Steviaisanoncaloricplantbasedsweetenerthatishundredsoftimessweeterthan
sugar.Thisallowsindividualstousemuchlesssweetener,butSteviamayaffect
differentindividualsinvariousways.Therearemanydifferentopinionsonthe
effectSteviamayhaveonindividualswithdiabetes,sotheonlywaytodecideif
Steviaisrightforyouistotryitout!WhentryingStevia,itisimportantto
constantlymonitoryourbloodglucoselevelstoensurethatitdoesnotnegatively
affectthesevalues.Itisalsoimportanttonoteanyphysicalchanges,suchas
lightheadedness,nausea,oranyothersymptomsthatmayindicateachangein
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bloodsugar.ThismaymeanyouhavetoadjusttheamountofSteviayouareusing,
orthatyoushoulddiscontinuetheuseofSteviaaltogether.Artificialsweeteners
havemoreresearchontheirsafetyandsideeffectssoitmaybeeasiertodecideto
usetheseproducts.

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References

DiabetesSelfManagement.(2010).AACEissuesrecommendationsonCGMandinsulinpump
use.Retrievedfrom
http://www.diabetesselfmanagement.com/blog/aaceissuesrecommendationson
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Drugs.com.(2016).Diabeticketoacidosis.Retrievedfrom
http://www.drugs.com/healthguide/diabeticketoacidosis.html

Drugs.com.(2016).Tagamet.Retrievedfromhttp://www.drugs.com/cdi/tagamet.html

MayoClinic.(2014).Diabetes.Retrievedfrom
http://www.mayoclinic.org/diseasesconditions/diabetes/indepth/diabetesmana
gement/art20047963?pg=2

MayoClinic.(2014).Intensiveinsulintherapy:Tightbloodsugarcontrol.Retrievedfrom
http://www.mayoclinic.org/diseasesconditions/diabetes/indepth/intensiveinsul
intherapy/art20043866?pg=1

MayoClinic.(2015).Diabeticketoacidosis.Retrievedfrom
http://www.mayoclinic.org/diseasesconditions/diabeticketoacidosis/basics/caus
es/con20026470

MedlinePlus.(2015).Diabeticketoacidosis.Retrievedfrom
https://www.nlm.nih.gov/medlineplus/ency/article/000320.htm

Medscape.(2015).Diabeticketoacidosisworkup.Retrievedfrom
http://emedicine.medscape.com/article/118361workup#c13

Nelms,M.,Sucher,K.P.,&Lacey,K.(2014).Nutritiontherapyandpathophysiology.Boston,
MA:CengageLearning.

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