A 28-year-old female presented with lightheadedness, nausea, vomiting, and worsening thirst over the past two days. Her vital signs showed low blood pressure and high pulse. She reported diarrhea after a family BBQ three days prior. Her medical history included type 2 diabetes and obesity. A physical exam found high blood glucose, darkened skin on her neck, and delayed capillary refill. Lab tests confirmed hyperglycemia. The symptoms began after a gastrointestinal illness and suggest diabetic ketoacidosis given her history of diabetes and hyperglycemia.

1. The case
Lesson 1

2. The case!
● 28 year old female
● Chief concern: lightheadedness
● She is also concerned about worsening nausea and vomiting for past two
days
● Medical history: unsure
● Vitals:
○ Blood pressure: 88/60 mmHg (low)
○ Pulse: 110 beats per minute (high)
○ Respiratory rate: 18 breaths per minute (normal)
○ Oxygen saturation: 98% on room air (this measures how much oxygen is found in blood)
(normal)
○ Weight: 195 lbs (88kg)
○ height : 5 feet, 2 inches (157.5 cm)
○ BMI: 35.7 kg/m2 (obese)

3. History of Present Illness
Patient went to a BBQ with her family, fun right?
Well afterwards the whole family had diarrhea for a day.
For the past 2 days, the patient has been dizzy, nauseous, thirsty, urinating
frequently, and vomiting.
Even though she is drinking enough fluids, she is still thirsty!
She says this is the first time this has happened.

4. Let’s find out more information…
When getting a patient history, it is important to ask questions to get a good idea
of what’s going on.
We use the mnemonic “OLDCARTS” to help remember what to ask:
● Onset - when did the symptoms start and what was happening when it started
● Location - where is the pain/symptoms
● Duration - how long have the symptoms lasted?
● Character - what the pain or symptoms feel like
● Aggravating/Alleviating factors - does anything make the pain/symptoms better or worse?
● Radiation - does the pain spread to anywhere else in the body?
● Temporal - Timing of pain/symptoms (does it come and go? Is it constant?)
● Severity - how bad is the pain? Usually rate on scale of 1-10 (with 10 being the worst)

5. Our patient...
● Onset: 3 days ago (the problems after the BBQ)
● Location: none (sometimes this doesn’t apply, like here - the patient doesn’t
have any pain)
● Duration: 1 day of diarrhea, 2 days of dizziness, nausea, vomiting &
excessive thirst/urination
● Character: she feels like she’s going to faint
● Aggravating/Alleviating: gets better on standing, and worse on lying down
● Radiation: again, doesn’t work here because no pain
● Temporal: constant symptoms
● Severity: again, doesn’t work here because no pain

6. Other important information
We ask the patient more questions to see if anything else has been going on.
Some important findings:
● Patient HAS had: lightheaded when she stands, blurry vision, excess thirst
and urination, history of Type 2 diabetes, coronary artery disease, obesity
● Patient does NOT have: fever, chills, sweats. No chest, abdominal, or flank
pain. No shortness of breath. No blood or pain when using the bathroom.
○ Sometimes it’s important to know symptoms the patient doesn’t have as we can rule out some
diseases this way

7. Patient’s history
Past Medical history: none (patient doesn’t tell us about any other problems she’s had)
Past Surgical History: none (no past surgeries)
Medications: none
Allergies: none
Social History:
● Poor diet, no exercise
● Denies any alcohol, tobacco or intravenous drug use
Family History
● Brother - Type 2 diabetes and had heart attack @ 43 years old
● Sister - type 2 diabetes
● Mother - on dialysis
● Father - healthy
OB/GYN: last menstrual period was 4 weeks ago

8. On physical exam
General: Patient was resting comfortably, and did not look to be in any distress. She was alert and
oriented with normal speech and understanding.
Skin: Area with velvety, brownish black discoloration on posterior neck. (Acanthosis nigricans - will
be explained later!)
Head, eyes, ears, nose, and throat: no jaundice/yellowing (if there had been, this might be due to liver
problems)
Cardiac: Regular rate and rhythm
Abdomen: Obese II. Abdomen is soft, nontender and nondistended (normal). There are mildly hyperactive
bowel sounds. There is no enlargement of spleen or liver.
Extremities: No edema (swelling). Delayed capillary refill (more will come later! But this is a sign that
blood is not getting to the extremities)
Blood glucose: high (done via finger stick glucose test)

9. Lab values
Blood glucose (sugar): 765 (high) (normal = 42.5 mmol/L)
Sodium: 135 mEq/L (low) (normal = 135 mmol/L)
Potassium: 4 mEq/L
Chloride: 100 mEq/L
Bicarbonate: 24 mEq/L
BUN: 30 mg/dL
Creatinine: 1.0 mg/mL
Don’t worry about the lab values too much: the main takeaway is that high blood
glucose is associated with diabetes

10. More labs
Urinalysis: No nitrites or WBCs (normal)
Urine ketones: negative
Serum ketones: negative
Urine HCG (pregnancy test): negative → patient is not pregnant
Again - don’t worry too much about these!