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Question: Diabetic patient

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You are seeing a 16 year old obese teen with no previous history of diabetes who presents with recent viral URI symptoms and increasing altered mental status over the last 8 hours. Her temperature is 37.9, heart rate 140, resp rate 22, and BP 90/35.  Blood glucose is 950, Na 130, K 3.4, and urine negative for ketones. The teen is confused and has a GCS of 13.

What is your management priority?

pemsou5_wp • October 2, 2018

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  1. Kelly October 4, 2018 - 1:45 am Reply

    C. IV fluids for dehydration. Given that there are no urinary ketones, pH > 7.3, and a very high blood sugar, this patient likely has hyperosmolar hyperglycemic state associated with previously unrecognized diabetes mellitus, not diabetic ketoacidosis. These patients are severely dehydrated, and intravenous fluid rehydration is the management priority. Insulin will also be needed, but attention to shock (this patient is tachycardic and hypotensive) first is key. In DKA patients, insulin should not be started until hypokalemia < 3.3 is corrected as cellular shifts in K+ with correction of the acidosis could result in life-threatening hypokalemia. Intubation is indicated if a patient is not protecting their airway, which is not likely to be the case at a GCS of 13. Extreme caution would be indicated if performing RSI in a patient with DKA as taking away the patient’s compensatory hyperventilation could result in life-threatening worsening of acidosis.

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