CCS Practice Case 1 Flashcards
Location: ER
Vital signs: BP 90/60, HR 128 and regular, Temp 100F, RR 30/min, rapid and shallow
CC - vomiting and abdominal pain
HPI: 20 y/o F presents with 5 episodes of vomiting, abdominal pain, weakness, and increasing drowsiness of one-day duration. During the last 2 months she has noticed increased thirst and increased urination. The abdominal pain is diffuse, 4-5/10 in severity, constant, non-radiating and there are no aggravating or alleviating factors. Vomiting is non-bloody. She has no other medical problems. She has no known drug allergies. She is not on any prescription or OTC medications. She is not a smoker or alcoholic and denies IVDU. She has a family history + for Type 1 DM. Her father and paternal uncle and grandfather are all diabetics.
ROS: denies weight changes, fever, chills, night sweats, diarrhea, constipation, skin, hair, or nail changes, blurry vision, acute bleeding, easy bruising, indigestion, dysphagia, changes in bowel movements, blood stools, burning on urination, recent travel, ill contacts, vaginal discharge or itch, pregnancy, heat or cold intolerance, drug or alcohol use. LMP ended 4 weeks ago, normal in flow and duration
How do you approach this case? (Step 1)
- Quickly examine the patient (General, HEENT, Neck, Heart, Lungs, Abdomen, Extremities)
Results of the exam:
General: mild to moderate abdominal pain, appears very distressed
HEENT: very dry mucus membranes, no JVD, EOMI.
Lungs; CTAB
Heart: normal except tachycardia
Abd: soft, non-tender, +BS, no guarding or rigidity
Ext: no edema, calf tenderness, but weak peripheral pulses
DDx?
Abdominal pathology - appendicitis, gastroenteritis, acute intestinal obstruction, etc.
Menstrual symptoms or pregnancy related complications
DKA
Non-ketotic hyperosmolar state
Alcohol ketoacidosis
Drug intoxication
What do you order STAT?
Pulse ox +: stat, continuous Oxygen, inhalation, continuous IV access state NS, continuous, stat Finger stick glucose stat
Results:
Pulse ox shows 96% on RA
Finger stick glucose shows 600 mg/dL
Now what do you order?
Urine pregnancy test CBC with diff BMP Calcium EKG Amylase Lipase UA ABG Serum osmolality Serum ketones qualitative Regular insulin IV continuous Phenergan IV x1 for nausea D/C oxygen
Results:
Negative pregnancy test WBC 10,000, normal differential Sodium 129 Potassium 5.0 Chloride 90 CO2 14 Calcium 8 Blood sugar of 600 EKG sinus tachycardia, nothing concerning Serum amylase - mildly elevated Serum lipase - WNL UA - 4+ sugar, 2+ ketones, no infection Serum osm - 305 Serum ketones - high ABG - metabolic acidosis, compensated by respiratory alkalosis (pH) 7.3
Most likely diagnosis, admitting orders
Most likely diagnosis - DKA
Admit to ICU NPO Bed rest Vitals as per ICU protocol Urine output KCl IV, continuous HbA1C level, routine Phosphorus, serum stat (optional) Follow with BMP Q2-4 hours, then Q8-12 hours, then Qday ABG Q2hours x2
After 4 hours, stop 0.9% NS and give 1/2 NS IV continuous
Monitor potassium deficiency and add IV KCl as needed
Consider ABX if precipitating cause is an infection - get a CXR, BCx, UA, UCx
Once nausea is decreased, start oral fluids
Once stabilized, transfer to ward/floor
To do at discharge?
DC IV insulin, IV fluids, cardiac monitor
NPH insulin, subcutaneous (continuous)
Regular insulin, subcutaneous, continuous
Diabetic diet
Advance diet
Counseling?
Diabetic teaching Patient education, diabetes Diabetic foot care Home glucose monitoring, instruct patient No alcohol No smoking Safe sex No illegal drug use Regular exercise Seat belt use Follow-up in 10 days
Dx of DKA?
Elevated BG (usually above 250), low serum bicarb (usually below 15), elevated AG, demonstrable ketonemia
Both amylase and lipase are often elevated in DKA by an unknown mechanism
Dx of HHS?
Serum glucose levels in excess of 600, serum osmolality greater than 330, absent or minimal ketonemia, pH >7.3, serum bicarb >20
Severe fluid and electrolyte depletion due to the osmotic diuresis produced by the extreme levels of glucose in the serum (often >1000)
Hydration management in DKA
Patients are profoundly dehydrated, must restore intravascular volume
Estimates of fluid deficits in the decompensated diabetic is 4 to 10 L (usually 5-6L).
Initially, 1 or 2 L NS is given as a bolus, followed by 500 mL/hr for the first 4 hours, followed by 250 mL/h for the next several hours
This should be guided by the patient’s general condition
After the first 3-4 hours, as the clinical condition improves, with stable BP and good urine output, fluids should be changed to 1/2 NS at 250-500 cc/hour for 3-4 hours
Insulin dose?
Standard is an initial bolus of 0.1 U/kg body weight followed by a continuous infusion at a rate of 0.1 U/kg per hour
When glucose levels begin to approach 250 mg/dL, insulin infusions continue, but the fluid composition is changed to include 5-10% dextrose in water to avoid hypoglycemia
Potassium?
Regardless of the K level at the start of therapy, during treatment of DKA, there is usually a rapid decline in the K concentration in the patient with normal kidney function
Replacement is indicated in all patients with the following features: K <5.3, no EKG changes, normal renal function
Bicarb treatment?
Highly controversial. Current recs - unnecessary when pH is >7.1
Phosphate?
Dragged out of the cell during DKA; level may be normal high or low at presentation while total body supply is depleted. Despite this, replacement has not been shown to affect patient outcome, routine replacement is not recommended
