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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Recognize signs and symptoms of diabetic ketoacidosis (DKA).

  • Determine laboratory parameters for the diagnosis and monitoring of DKA.

  • Identify anticipated fluid and electrolyte abnormalities associated with DKA and their treatment.

  • Recommend appropriate insulin therapy for treating DKA.

  • Identify therapeutic decision points in DKA treatment and provide parameters for altering therapy at those points.

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PATIENT PRESENTATION

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Chief Complaint

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“I felt weak and nauseated during softball practice. I checked my blood glucose and it read ‘HI.’”

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HPI

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Mary McGee is a 21-year-old woman with a history of type 1 diabetes, diagnosed 3 years ago. She is a college senior at the local university where she also plays softball. She started using an insulin pump approximately 6 months ago.

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She noticed she was unusually tired and short of breath at the beginning of her practice and then began feeling weak and nauseated. She was also very thirsty during practice. Her softball coach said she seemed “a little confused.” He advised her to check her blood glucose and it read (HI). She checked her insulin pump and noticed the pump had become disconnected. She is unsure how long she has been without insulin. She vomited two times since shortly thereafter and was transported via EMS to the ED.

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PMH

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Type 1 DM diagnosed 3 years ago

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FH

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Parents are alive and healthy. One twin sister who also has type 1 DM.

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SH

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College student; no tobacco, alcohol, or illicit drug use

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Meds

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  • NovoLog 100 U/mL, per insulin pump

  • Basal rates:

  •   0.6 units/hour 0000–0300

  •   0.9 units/hour 0300–0700

  •   0.8 units/hour 0700–1100

  •   0.7 units/hour 1100–1730

  •   0.8 units/hour 1730–0000

  • Correction factor: 1 U:40 mg/dL >120 mg/dL

  • Insulin:carbohydrate ratios:

  •   1:10 insulin:carbohydrate before breakfast

  •   1:15 insulin:carbohydrate before lunch and dinner

  • Glucagon injection kit, as needed

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Allergies

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NKDA

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ROS

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Complains of blurry vision, lethargy, shortness of breath, nausea, polyuria, and polydipsia. Denies constipation, diarrhea, and headache.

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Physical Examination

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Gen
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WDWN Caucasian female appearing her stated age, with deep respirations, ketones on her breath, and slurred speech; slightly confused, but responds appropriately to questions

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VS
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BP 101/72 mm Hg, P 123 bpm, RR 32, T 37.0°C; Wt 56 kg, Ht 5′6″

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Skin
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Unremarkable

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HEENT
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PERRLA, EOMI; mucous membranes are dry

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Neck/Lymph Nodes
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Supple without lymphadenopathy or thyromegaly

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