1. Case VII – Metabolic.
Dr. A. Pemberton-Gaskin.
Vasha Ramgobin.
Neil Roopchan.
Valmiki Seecheran.
Year V MBBS.

2. Case summary.
• A family reports that their 5 year old son has
been increasingly confused over the last several
hours. His emergency department vital signs
show tachycardia, hypotension, mild
hypothermia, and slow, deep respirations. He has
poor capillary refill, skin tenting, and altered
mental status. His mother reports that he has
had a several-pound weight loss over the last few
weeks, and has been increasingly tired for several
days, and that she has been concerned about his
2 or 3 day history of thirst, frequent daytime
urination, and new onset of nocturnal enuresis.

3. Objectives.
• What is likely differential diagnosis?
• How would you evaluate this child?
• Describe the initial treatment strategies in this
case.
• What are the likely ongoing modalities of
treatment?

4. Patient history.
• Demographics.
– Name – John Doe.
– Age – 5 years.
– Gender – Male.
• Presenting complaint.
– Increasingly confused over the last several hours.
– Disinterested in reaching for toys.
• History of presenting complaint.
– Several pound weight loss over the last few weeks.
– Increasingly tired for several of days.
• Review of systems.
– 2-3 days history of thirst.
– Frequent urination.
– New onset nocturnal enuresis.

5. Patient history.
• Vitals.
– Tachycardia. (95-140).
– Hypotensive. (80-100mmHg systole).
– Mild hypothermia.
– Slow deep respiration.
• Other findings.
– Poor capillary refill (<2secs).
– Skin tenting .
– Altered mental status.

6. Differential diagnosis.
• Diabetic ketoacidosis.
• Metabolic acidosis.
• Respiratory acidosis.
• Shock.

7. Initial evaluation.
• More detailed history.
– Nausea, vomiting, abdominal pain, fruity scent
breath, malaise, recent illness – UTI &
pneumonia, history of diabetes, family
history, stressors, change in diet, physical
trauma, emotional stress, recent surgery.
• Physical examination.
– Cardiovascular, respiratory, abdominal, neurologic
al, peripheral.

8. Initial evaluation.
• Investigations.
– Blood sugar level. (Highly positive for glucose)
– Blood culture. (Signs of infection).
– Ketone level. (>2mmol/L).
– ABG. (Acidotic, bicarbonate levels less than 15mmol/L).
– U&E’s. (Potassium elevated then low, Sodium decreased).
– Amylase. (Elevated).
– Serum osmolarity. (Elevated).
– Urinalysis. (Glucose + Ketones).
– CXR. (Pneumonia).
– ECG.(MI)
– CT scan. (Cerebral edema).

9. Treatment.
Managing diabetic ketoacidosis (DKA) in an intensive care
unit during the first 24-48 hours always is advisable.
When treating patients with DKA, the following points
must be considered and closely monitored:
• Correction of fluid loss with intravenous fluids.
• Correction of hyperglycemia with insulin.
• Correction of electrolyte disturbances, particularly
potassium loss.
• Correction of acid-base balance.
• Treatment of concurrent infection, if present.

10. Treatment.
• Inpatient care.
– ABCs.
– Closely monitored.
– Fluid, insulin and electrolyte replacement.
– Treat underlying cause.
• Outpatient care.
– Manage via outpatient department.
– Endocrinologist.
– Dietician.

11. Prevention.
• Education of signs, symptoms and potential
risks.
• Education of diabetes & management.
• Urine test – glycosuria – easy to perform.
• Diascan testing.
• Dietary caution & encouragement of exercise.

12. Thank you.