Location: Emergency room

Vital signs: BP:90/60 mmHg, HR:128/min regular, Temp:100.0° F, R.R:30/min rapid and shallow  

C.C: Vomitings and abdominal pain.

HPI:

A 20-yr-old woman presents to E.R 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 relieving factors. Vomiting is non-bloody. She has no other medical problems. She has no known drug allergies. She is not on any prescription or over the counter medications. She is not a smoker or alcoholic, and denies IV drug abuse. She has a family history positive for Type 1 Diabetes Mellitus.  Her father, and paternal uncle and grandfather are all diabetics.

Review of systems:

She 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, bloody stools, burning on urination, recent travel, ill contacts, vaginal discharge or itch, pregnancy, heat or cold intolerance, drug or alcohol use.  Last menstrual period ended four weeks ago, was normal in flow and duration.

How do you approach this case?

First quickly examine the patient

General

HEENT

Neck
Heart

Lungs

Abdomen

Extremities

Here are the results of the exam:

General: Patient is in mild to moderate abdominal pain and appears very distressed.

HEENT: Very dry mucus membranes, no JVD, EOM are intact. Rest is unremarkable.

Lungs: Clear to auscultation B/L.

Heart: Completely normal except tachycardia.

Abdomen: Soft, non tender, normal bowel sounds and no guarding or rigidity.

Extremities: No edema, calf tenderness, but week peripheral pulses.

Discussion:

Now, make a mental checklist of differential diagnosis, i.e.

1.      Abdominal pathology like appendicitis, gastroenteritis, pancreatitis, acute intestinal obstruction etc.

2.      Menstrual symptoms or pregnancy related complications

3.      DKA (Based on the family history and presenting clinical features)

4.      Nonketotic Hyperosmolar state

5.      Alcoholic ketoacidosis

6.      Drug intoxication

Order the following stat:

Pulse oximetry, stat and continuous

Oxygen, inhalation, continuous
IV access, stat
Cardiac monitor, stat

Normal saline, 0.9% NaCl, continuous, stat (This patient is severely dehydrated. She is hypotensive and tachycardic. So, she needs IV fluids.)

Finger stick glucose, stat

Results:
Pulse oxymetry showed 96% on room air

Finger stick glucose shows 600mg/dL  

Order:

Urine pregnancy test, stat

CBC with differential, stat

BMP, stat
Calcium, serum, stat

EKG, 12 lead, stat

Serum amylase, stat

Serum lipase, stat

UA, stat

ABG, stat

Serum osmolality, stat

Serum ketones, qualitative, stat  

Regular insulin, IV, continuous
Phenergan, IV, one time (for nausea)
Discontinue oxygen

Ok here are the results:

Urine pregnancy test is negative

WBC 10,000/µL and normal differential

Sodium is 129, Potassium is 5.0, Chloride is 90, Co₂ is 14, calcium is 8.0, and a blood sugar of 600mg/dL

EKG sinus tachycardia, nothing concerning

Serum Amylase - mildly elevated

Serum Lipase WNL

UA showed 4+sugar, 2+ ketones but no evidence of infection

Serum Osmolality 305

Serum Ketones - high

ABG showed metabolic acidosis, compensated by respiratory alkalosis (pH of 7.3)  

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