For Examiner Only
Case Diabetic Ketoacidosis
Author: Chris Kyriakedes, MD
Reviewer: Michael Bohrn, MD
Approved: 1/10/06
ORAL CASE SUMMARY
CONTENT AREA
Endocrine Emergencies
SYNOPSIS OF CASE
Patient presents with clinical signs and symptoms of DKA. Early recognition and aggressive
treatment with fluids and insulin while monitoring the patient's electrolytes, acid-base status and
vitals will successfully resusitate this patient.
SYNOPSIS OF HISTORY
Patient brought in by family with weakness and confusion. Patient is oriented to person, place
and time but cannot give any other history. Family relates patient drank ETOH up to one month
ago and stopped to lose weight. Since then has had intermittent blurry vision. In the past week
has had flu like symptoms of anorexia but no vomiting or diarrhea. Denies fever or chills. ROS:
no cardiopulmonary or neurological complaints. Denies known drug use or trauma. Found this
am in this condition.
SYNOPSIS OF PHYSICAL
A&Ox3 but confused and barely cooperative. Parched mucous membranes. Lungs clear but
Kussmaul respirations. Heart tachycardic. Obese, soft abdomen with bowel sounds present.
Poor skin turgor, good skin tone and color. No focal findings on neurological exam'
CRITICAL ACTIONS
1. Fluid Hydration and labs drawn
2. Monitor & EKG for hyperkalemia
3. IV Insulin Therapy
4. Finger stick glucose
5. Admission to ICU
6. ABG or venous pH
7.
SCORING GUIDELINES
(Critical Action No.)
Number 4 & 6 should be ordered while fluid hydration is started and labs are drawn(1). Monitor
and EKG should follow shortly thereafter(2). Labs confirm DKA, insulin drip(3) is initiated and
close monitoring of electrolytes(2) and finally admission to ICU(5).
FOR EXAMINER ONLY
For Examiner Only
PLAY OF CASE GUIDELINES
(Critical Action No.)
Aggressive fluid hydration with Normal Saline initially
IV insulin: (bolus optional) insulin drip: 0.1 units/kg/hr
Repeat glucose and K+ one hour after therapy was initiated
Bicarbonate therapy: usually withheld for pH > 7.1 Acidosis will correct with hydration and insulin
therapy. Use of bicarbonate would be indicated if hyperkalemia is clinically symptomatic
..not in this case - EKG has no peaked T-waves.
Patients should be placed on a monitor, a large-bore IV should be established. A second line of
½ N/S should be at a keep open rate. Labs sent should include: electrolytes, CBC, phosphorous,
calcium, magnesium, consider blood/urine cultures, and a ABG in critically ill patient or venous
pH. Use the second line to adjust for potassium therapy: if < 3.3 hold insulin for 30 minutes and
infuse K+, if 3.3-5.0 start insulin drip, if > 5.0 start fluids and insulin drip and stat recheck K+.
Potassium should be held until there is adequate urine output. Give 3-4 liters (70kg) over first 4
hours of treatment.
Discussion: The importance of early treatment with fluids in very important. Recognition of DKA
and subsequent rule out of hyperkalemia is also critical. The ability of the resident to determine
that there is no need for treatment of hyperkalemia because it is asymptomatic is important.
FOR EXAMINER ONLY
For Examiner Only
Critical Actions
1.
This critical action is met by Fluid Hydration
Cueing Guideline: Parched mucosa, tachycardia
2.
This critical action is met by Monitor & EKG for hyperkalemia
Cueing Guideline: Tachycardia with DKA in diffdx think K+ imbalance
3.
This critical action is met by IV Insulin Therapy
Cueing Guideline: Kussmaul respirations and lab support
4.
This critical action is met by Finger Stick Glucose
Cueing Guideline: Kussmaul respirations
5.
This critical action is met by Admission to ICU
Cueing Guideline: Kussmaul respirations, tachycardia
6.
This critical action is met by ABG or venous pH
Cueing Guideline: Kussmaul respiration, tachycardia
7.
This critical action is met by
Cueing Guideline:
For Examiner Only
History Data Panel
Age: 44
Sex: Male
Name: Hodge Stone
Method of Transportation: Family
Presenting complaint: Weakness and confusion
Onset and Description of Complaint: this am
Past Medical History
Allergies: NKA
Medical: none
Surgical: none
Last Meal: not known
Habits
Smoking: none
Drugs: no
Alcohol: yes, up to one month ago, quit
Family Medical History
Father: hypertension, NIDDM
Mother: none
Siblings: none
Social History
Married: yes
Children: 2
Employed: yes
Education: high school
PMD: no
Person giving information: Patient, Family
For Examiner Only
Physical Data Panel
General Appearance: alert, but confused and barely cooperative
Vital Signs:
BP
:
P
:
R
:
T
:
O2Sat
:
Glucose :
150/80
120
24
37
98
finger stick > 500
Neurological: no focal findings, A & O x 3, moves all extremities
Mental Status: confused, but barely cooperative
Head: normocephalic, no trauma
Eyes: PERRL
Ears: TM clear, normal cone of light, normal external canal
Mouth: mucosa membranes parched
Neck: supple
Skin: warm and dry, poor skin turgor
Chest: lungs clear (Kussmaul respirations)
Heart: tachycardic, good S1, S2, no rub murmur or gallop
Abdomen: obese, soft with bowel sounds present, no mass or organomegaly
Extremities: full ROM, good skin color
Rectal: guiac negative, good tone
Pelvic: not done
Back: normal spinal alignment
Other exam findings: none
For Examiner Only
Lab Data Panel
Stimulus #2 – CBC
WBC
10.2
Hgb
13.1
Hct
39.4
Platelets
260
Differential
Segs
57
Lymphs
42
Monos
1
Eos
0
/mm3
g/dL
%
/mm3
%
%
%
%
Stimulus #3 – Chemistry
Na+
130 mEq/L
K+
5.6 mEq/L
HCO35
mEq/L
Cl98 mEq/L
Glucose
674 mg/dL
BUN
20 mg/dL
Creatinine
3.6 mg/dL
Stimulus #4 – Urinalysis
Color
Yellow
Sp Gravity
1.035
Glucose
>1000
Protein
Negative
Ketone
large
Leuk. Est.
Negative
Nitrite
Negative
WBC
1-5 /HPF
RBC
0-3 /HPF
pH
5
Bacteria
few
Stimulus #5 – Ca++ 8.3, PT/PTT 12.4/28 INR
1.0
Stimulus #6 – Thyroid Panel TSH 2.1 (nl
0.34-4.82), T4 8 (nl 5-11.4), T3 22 (nl 19-38)
Stimulus #7 – Hepatic ProfileHep Profile: Bili
0.9, ALT 22, AST 20, LDH 99, Alk Ph 30
Stimulus #8 – ABG: pH 7.005, PCO2 16,
PO2, 167, HCO3 40 O2 Sat 98.5%, Lactic
Acid 1.7 (nl 0.5-2.2)
Stimulus #9 – Tox Screen: Theo <0.1, ASA <
0.2, APAP 0 S. Acetone: Positive (1:32)
Stimulus #10 – Acetone: positive (1:32)
Stimulus #11 – ETOH negative
VERBAL REPORTS
Chest xray: normal without infiltrate
EKG: tachycardia, non ischemic
For Examiner Only
Stimulus Inventory
Stimulus #1 – Emergency Admitting Form
Stimulus #2 – CBC
Stimulus #3 – Chemistry
Stimulus #4 – Urinalysis
Stimulus #5 –
Stimulus #6 –
Stimulus #7 –
Stimulus #8 –
Stimulus #9 –
Stimulus #10 –
Stimulus #11 –
FOR EXAMINER ONLY
Mock Oral Feedback Form – ABEM model
Date:
Examiner:
Examinee:
Data acquisition
Worst
1
NOTES
2
3
4
5
6
7
8
Best
Problem solving
Worst
1
NOTES
2
3
4
5
6
7
8
Best
Patient management
Worst
1
2
NOTES
3
4
5
6
7
8
Best
Resource utilization
Worst
1
2
NOTES
3
4
5
6
7
8
Best
Health care provided
Worst
1
2
NOTES
3
4
5
6
7
8
Best
4
5
6
7
8
Best
Comprehension of path physiology
Worst
1
2
3
4
NOTES
5
6
7
8
Best
Clinical competence (overall)
Worst
1
2
3
NOTES
5
6
7
8
Best
Patient Interpersonal relations
Worst
1
2
3
NOTES
4
Critical Actions
Dangerous actions
1.
Fluid hydration and labs
 and omissions
2.
Monitor and ECG for hyperkalemia

3.
Insulin therapy

4.
Fingerstick glucose

5.
Admission to ICU

6.
ABG

7.
FOR EXAMINER ONLY

Mock Oral Feedback Form – Core Competencies
Date:
Examiner:
Does not meet
expectations
Examinee:
Meets
Expectations
Exceeds
Expectations
1. Patient care
2. Medical
knowledge
3. Interpersonal
skills and
communication
4. Professionalism
5. Practice-based
learning and
improvement
6. Systems-based
practice
Critical Actions
Dangerous actions
1.
Fluid hydration and labs
 and omissions
2.
Monitor and ECG for hyperkalemia

3.
Insulin therapy

4.
Fingerstick glucose

5.
Admission to ICU

6.
ABG

7.
FOR EXAMINER ONLY

Stimulus #1
ABEM General Hospital
Emergency Admitting Form
Name
:
Age
:
Sex
:
Method of Transportation :
Person giving information :
Presenting complaint
:
Background:
Chief Complaint:
“Weakness and confusion”
History: Patient brought in by family with weakness and confusion. Patient is
oriented to person, place and time but cannot give any other history. Family
relates patient drank ETOH up to one month ago and stopped to lose weight.
Since then has had intermittent blurry vision. In the past week has had flu like
symptoms of anorexia but no vomiting or diarrhea. Denies fever or chills. ROS:
no cardiopulmonary or neurological complaints. Denies known drug use or
trauma. Found this am in this condition.
Vital Signs
T 36
BP 150/80
P 120 R 24
Stimulus #2 – CBC
WBC
Hgb
Hct
Platelets
Differential
Segs
Lymphs
Monos
Eos
/mm3
g/dL
%
/mm3
%
%
%
%
Stimulus #3 – Chemistry
Na+
mEq/L
K+
mEq/L
HCO3mEq/L
ClmEq/L
Glucose
mg/dL
BUN
mg/dL
Creatinine
mg/dL
Stimulus #4 – Urinalysis
Color
Yellow
Sp Gravity
1.
Glucose
Negative
Protein
Negative
Ketone
Negative
Leuk. Est.
Negative
Nitrite
Negative
WBC
/HPF
RBC
/HPF
Stimulus #5 – Ca++ 8.3, PT/PTT 12.4/28 INR 1.0
Stimulus #6 – Thyroid Panel TSH 2.1 (nl 0.34-4.82), T4 8 (nl 5-11.4), T3 22 (nl 19-38)
Stimulus #7 – Hepatic ProfileHep Profile: Bili 0.9, ALT 22, AST 20, LDH 99, Alk Ph
30
Stimulus #8 – ABG: pH 7.005, PCO2 16, PO2, 167, HCO3 40 O2 Sat 98.5%, Lactic
Acid 1.7 (nl 0.5-2.2)
Stimulus #9 – Tox Screen: Theo <0.1, ASA < 0.2, APAP 0 S. Acetone: Positive
(1:32)
Stimulus #10 – Acetone: positive (1:32)
Stimulus #11 – ETOH negative
Stimulus #12 ECG
Stimulus #13 – Chest X Ray