2. case study :
25-year-old African-American man with type 2 diabetes presented with a 5-day
history of nausea and vomiting.
He also reported a 2-week history of polyuria and polydipsia and a 10-lb weight
loss.
A review of symptoms was positive for a 5-day history of persistent lower back
pain.
The patient was diagnosed with type 2 diabetes 5 years ago when he presented to
a different hospital with symptoms of polyuria, polydipsia, and weight loss.
He was given a prescription for a sulfonylurea, which he says he took until his
initial prescription ran out 1 month later. He had not taken any other medication
since that time.
3. Physical examination revealed an afebrile, obese man (BMI 40 kg/m2) with prominent
acanthosis nigricans, no retinopathy by direct funduscopic exam, and a normal neurological exam,
including motor function and sensation.
The patient had no tenderness to palpation over the lumbrosacral spine or paraspinous muscles despite
his complaint of lower back pain.
The laboratory data showed an anion gap, metabolic acidosis, and hyperglycemia
(pH of 7.14, anion gap of 24, bicarbonate 6 mmol/l, urinary ketones 150 mg/dl, glucose 314 mg/dl)
consistent with the diagnosis of DKA.
His white blood count was 20,400/μl. Urinalysis demonstrated no evidence of infection. The patient's hemog
The patient was admitted and treated aggressively with intravenous fluid and an insulin-glucose infusion. A
Neurology was consulted, and during their assessment, the patient became incontinent and was found to ha
4. . Diabetic ketoacidosis in adults (DKA)
Diabetic ketoacidosis (DKA) is characterised by the triad of hyperglycaemia, high
anion gap metabolic acidosis and the presence of ketone bodies. It is common in type-1
DM, although it may also occur in type-2 DM during stressful situations.
Ketoacidosis is a potentially lethal condition and should be suspected and treated
promptly
Check for ketone bodies if glucose ≥14 mmol/l in type-1 DM or when you suspect
DKA
Send all diabetic patients with positive ketones to the emergency department for
further management
5. . Precipitating factors:
Poor compliance/Insulin withdrawal/inadequate treatment.
Infection, especially urinary, respiratory tract, and soft tissue infections
Myocardial infarction and cerebrovascular accident.
Trauma and surgery.
Unrecognised type-1 DM.
6. . Signs and symptoms of DKA:
Polydipsia
Polyuria
Nausea and vomiting
Dehydration (most obvious sign)
Abdominal pain and muscle cramps
Drowsiness (and, rarely, coma)
8. . Management of DKA in adults:
(For the management of DKA, please refer to the following chart)
Arrange for urgent referral for admission to the nearest regional hospital.
Until referral is being arranged, commence the patient on normal saline and insulin as given
below:
1. Rehydration/ I.V uid:
1000 ml of 0.9% normal saline given over one hour, then 1000ml over two hours, then 500
ml over four hours (80-100ml/hour)
2. Insulin: Give 0.1units/kg of regular short acting insulin subcutaneously 3. A nurse should
accompany the patient during transfer to the hospital
9.
10. . Hyperglycaemic Hyperosmolar State (HHS) /Hyperglycaemic
hyperosmolar non ketotic state/coma (HONK)
. Suspect this condition if the patient has signs and symptoms of severe hyperglycaemia (blood glucose 33
mmol/l or more), drowsiness, severe dehydration and with negative or mild positive test for ketones
Management
Arrange for urgent referral for admission to the nearest regional hospital. Until referral is being arranged, commence
I.V uids and insulin as given below:
1.Rehydration/ I.V uid:
Saline infusion using 1000 ml of 0.45% or 0.9% normal saline given over one hour, then 1000ml over two
hours, then 500 ml over four hours (80-100 ml/hour)
2.Insulin: Give 0.1units/kg of regular short acting insulin subcutaneously
3.A nurse should accompany the patient during transfer to the hospital
