Esposado, Princess Anne

Mugas, April Anne Joyce

Nakan, Sittie Fatima
3,721,900
GENERAL PROFILE
• A.R.
• 18 years old/male
• Single
• Matina, Davao City
• Roman Catholic
• 10/09/19 3:17 AM
DYSPNEA
VITAL SIGNS
• BLOOD PRESSURE: 120/70 mmHg
• HEART RATE: 120 bpm
• RESPIRATION RATE: 35 cpm
• TEMPERATURE: 37.0 degrees celsius
• OXYGEN SATURATION: 99%

BMI: 20.4

ESI CATEGORY 2
PRIMARY SURVEY
OBJECTIVE FINDINGS
A patent
B spontaneous
deep
labored
respiratory rate of 35 cpm
oxygen saturation of 99%
C 120/70 mmHg
pulse rate of 120 bpm
full pulses
capillary refill time of <2 seconds
D GCS14 (E3V5M6)
E Afebrile, (-) rashes
COURSE IN THE ED
10/09/19 3:17 AM
> Hook to cardiac monitor
> Give oxygen supplement at 4 lpm via nasal cannula
> Start IVF no. 1: PNSS 1L, FD = 500cc
> Start IVF no. 2: PNSS 1L, FD = 500cc
> ABG, 12L ECG, CBG
> Labs: CBC with PC, S. Na, K, Ca, Mg, Cl, crea, BUN,
SGPT, albumin, U/A, ketones, chest xray-PA
ECG
ABG
RESULTS REFERENCE RANGE
pH 6.86 7.35-7.45
PCO2 9 35-45
PO2 138 80-100
HCO3 3 21-27
Temp 37
BEecf
BE (E)

UNCOMPENSATED RESPIRATORY ACIDOSIS

CBG
• 432 mg/dL

BLOOD PRESSURE
• 120/60 mmHg

OXYGEN SATURATION
• 99%
SECONDARY SURVEY
OBJECTIVE FINDINGS
S dyspnea
A no known food and drug allergy
M regular insulin - poor compliance
P diabetes mellitus type 1
L 6PM 10/08/19
E at rest
HISTORY OF PRESENT ILLNESS
Nine hours prior to consult, the patient had a sudden onset of
undocumented fever associated with epigastric pain, cramping in
character with a pain scale of 5/10 and 3 episodes of postprandial
vomiting about 100 mL in volume per episode which he initially
tolerated with no medications taken. Persistence of symptoms now
associated with generalized body weakness and dyspnea prompted this
consult.
PHYSICAL EXAMINATION
> awake, conscious, deep and labored breathing, tachypneic at 35 cpm
> atraumatic head, anicteric sclerae, pink palpebral conjunctivae, pupils
equally reactive to light
> adynamic precordium, distinct heart sounds, regular rhythm
(tachycardia)
> equal chest expansion, clear breath sounds
> flat, soft, non-tender abdomen, (+) kidney punch sign, left
> capillary refill time <2 seconds
10/09/19 4:30AM
• HCO3: 3 mmol/L
• Bicarbonate deficit: 300 mmol/L

Pertinent PE findings:
(+) tachypnea
(+) lethargy
CBG of 402 mg/dL
MANAGEMENT
10/09/19 4:30AM

> Repeat CBG

> Give NaHCO3 150 mEqs IV bolus
> Give ceftriaxone 2 grams IVTT as loading dose
COMPLETE BLOOD COUNT
RESULT REFERENCE
Hemoglobin 139 135-175
Hematocrit 0.40 0.40-0.52
RBC Count 4.58 4.20-6.10
WBC Count 26.26 5.0-10.0
Neutrophil 70 55.0-75.0
Lymphocytes 20 20-35
Monocytes 10 2-10
Eosinophils 0 1-8
Basophils 0
Platelet Count 312 150-400
MCV 87.80 79.0-92.0
MCH 30.3 25.70-32.00
MCHC 34.6 32.30-36.50
URINALYSIS
RESULTS REFERENCE
PHYSICAL EXAM
Appearance Clear
Color Yellow
URINE CHEMISTRY
Protein 2+
pH 5.5
Specific Gravity 1.027
Glucose 3+
Micro-Albumin 3+
Urine Bilirubin Negative
Urine Urobilinogen 3.4 3.4-3.17
Nitrite Negative
 RESULTS REFERENCES
Leukocyte Esterase Negative
Urine Ketone 7.8 0-0.4
URINE FLOWCYTOMETRY
RBC 3 0-28
WBC 1.000 0-27
Epithelial Cells 2 0-7
Cast 0 0-2
Bacteria 3 0-111
CRYSTAL
Amorphous Urates 0
Calcium Oxalates 0
Uric Acid 0
Amorphous Phosphates 0
OTHERS
Mucus Threads 0 35.0-50
 RESULTS REFERENCE
Creatinine 44.93 57-113
Potassium 2.96 3.5-4.5
Sodium 133.7 136-144
Magnesium 0.94 0.74-1.03
HBA1c 18.1 4.0-6.5
SGPT 16.3 17-63
CHEST X-RAY
10/10/19 5:30AM
• Serum Potassium: 2.96 mmol/L
• Potassium Deficit: 200 mmol/L

> Start KCl drip 40mEqs + 500 cc PNSS to run at 130 cc/hr
> Give Kalium Durule tab 10 mEqs/tab, 3 tabs now
> Give Omeprazole 40 mg IVTT now
> Give Regular Insulin 6 units IV
SALIENT FEATURES
• undocumented fever
• epigastric pain
• vomiting
• generalized body weakness
• dyspnea
• diagnosed DM Type 1
SUPPLEMENTARY
• hyperglycemia of 432 mg/dL
• bicarbonate level of 3 mmol/L
• blood pH of 6.86
• ketonuria of 7.8
• HBA1c of 18.1%
• hypokalemia of 2.96 mmol/L
• hyponatremia of 133.7
ASSESSMENT

DIABETIC
KETOACIDOSIS
Primary consideration

DIABETIC KETOACIDOSIS, DIABETES MELLITUS TYPE 1

DIFFERENTIAL DIAGNOSIS
Hyperosmolar Hyperglycemic State
DIABETIC KETOACIDOSIS
HISTORY LABORATORY
• Labored breathing
• Elevated RBS (432 mg/dL)
• vomiting
• Diagnosed with Type I DM (July • Acidosis (pH of 6.36)
2019) • Ketonuria (3+)
• Poor compliance with insulin

PHYSICAL EXAM
• Tachycardia (120bpm)
• Tachypnea (35cpm)
• Lethargy
• Epigastric pain
TREATMENT & MANAGEMENT
 GOAL OF THERAPY
VOLUME POTASSIUM INSULIN

• (1) volume repletion

• (2) reversal of the metabolic consequences of insulin
insufficiency
• (3) correction of electrolyte and acid-base imbalances
• (4) recognition treatment of precipitating causes
• (5) avoidance of complications
 VOLUME

• VOLUME REPLETION:
• restore intravascular volume, normal tonicity, perfusion of vital
organs, improve GFR,  serum glucose and ketone levels.
• -  response to low-dose insulin therapy
• -NSS  change to 0.45 % NS once eunatremia/ hypernatremia
• initial fluid bolus rat: 15-20 ml/kg/h during the 1st hr
 POTASSIUM

• K deficit: 3-5meq/kg due to insulin deficiency, metabolic acidosis,

osmotic diuresis and frequent vomiting
• Replacement of K: first 24-36 hrs
• 0.1 pH= s.K (0.5mEq/L)
• Hypokalemia cardiac arrhythmias, respiratory paralysis, paralytic
ileus, rhabdomyolysis.
• Severe Hypokalemia- potentially most life-threatening electrolyte
derangement during tx of DKA
• Hyperkalemia
 INSULIN

• Half –life: 4-5 mins, biologic half life: 20-30mins

• IV insulin: rate: 0.1 to 0.14 unit/kg/h with no insulin bolus once
hypokalmeia is excluded
• Glucose: 200mg/dl add Dextrose to IV fluids and insulin drip to
0.02-0.05 unit/kg/h
• Continue insulin infusion until resolution of DKA:
• GLUCOSE <200mg/dL and (2) of the following:
• S.Bicarbonate >15mEq/L
• Venous pH >7.3
• Normal calculated anion gap
THANK YOU!