Emergency Medicine

Case DiscussionExt. Nuchsarang Udomkaewkanjana4802050

Patient Profile: 70 Chief Compliant: 1 PTA

Brief History Symptoms Trauma Medication Underlying disease

Primary SurveyAirway clearBreathing & Ventilation RR 30 /min O2 sat 97%Circulation BP 130/70 mmHg PR 162 bpm, full & regularDisability E3V2M5, no evidence of head trauma, no focal neurodeficit6.00 PM

DTX STAT = 388 mg%O2 Sat = 97%-OH butyrate- positiveUrine ketone dipstick- positive

Initial management? DKA ?6.05 PM

O2 canula 3 LPMIV Fluid- 0.9%NSS 1000 ml/hrRetained foleys cathMeropenem 2 g IV STATCBC, BUN, Cr, Electrolyte, Ca, Mg, P, LFTUA, U/G, U/C, CXREKG 12 leads, ABG room air, LactateF/U DTX q1h , Elyte at 8 PM6.10 PM

Present Illness: 1 wk PTA ER UA WBC 15-20 dx UTI Ceftriaxone IV OD *3 d. F/U U/C, H/C NG Ciprofloxacin PO *14 d.1 d PTA / .Past Illness: Underlying DM, HT, DLP, distal CBD stricture with obstructive jaundice S/P stentNo drug or food allergy, no smoking and alcoholic drinkingSecondary Survey6.20 PM

Physical ExaminationVital Signs: BP 130/70 mmHg RR 30/min PR 162 bpm T 40.1 CGA: A Thai old woman, drowsiness, tachypnea, mild jaundiceHEENT: no bruise or petechiae, marked pale conjunctivae, icteric scleraeCVS: tachycardia, full and regular pulse, normal s1 s2, no murmurRS: normal breath sound, no wheezing, no crepitationGI: soft, no mass, no guardingCNS: E4V5M6, drowiness, pupils 2 MM RTLBE, motor tone- normal, power gr III at leastExt: no pitting edema

Differential DiagnosisIntracranialExtracranial

DTX = 390 mg% 0.9% NSS 1000ml + KCl 40 mEq IV 100 ml/hr0.9% NSS 1000ml IV 400 ml/hr RI 10 u IV push RI 10 u IMAG = 19.3EKG 12 LEADS Sinus tachycardia rate 160 bpmCXR no cardiomegaly, no infiltrationUrine 150 ml clearUA pH 5.0 spec. 1.019 glucose 4+ protein2+ ketone marked + WBC 0-1 RBC 2-3 ELECTROLYTE 129 3.16 24 89 20.7 1.07.20 PM

DTX = 302 mg%IV RI IV drip 0.1 u/kg/hrF/U elyteRespiratory alkalosis with metabolic acidosisHCO3-Consult MED 7NWCBC10.3 17,550 N 9131.1 229,000 L 5UG- no organism seenABG pH 7.505 pO2 71.3 pCO2 23.8 HCO3- 18.9Lactate 0.6 mmol/L (5 mg/dl)8.20 PM

MED noteDiagnosis : Sepsis with hyperglycemiaDTX = 252 mg%IV 5%DN/2 + KCl 40 mEq

9.20 PMELECTROLYTE 135 2.25 24 100 22.9 1.0

Diagnostic criteria: serum glucose >250 mg/dlarterial pH 7.3 serum bicarbonate >15 mEq/l minimal ketonuria and ketonemia

D K ADiabetic KetoacidosisInsulin DeficiencyWith counteregulatory hormone responseProtein BreakdownLipolysisHepatic gluconeogenesisCellular underutilization of glucoseLoss of nitrogenMuscle wastingOsmotic diuresisHyperglycemiaKetoacidDehydrationSHOCKCompensatory tachypneaN/VWide AG acidosisKetonuria

I VK & RI

Monitoring Treatment OutcomeOut Of DKA ?DTXpHSerum ketoneUrine ketoneUrine betahydroxybutyrateAGHCO3-

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