AccessMedicine's Case of the Week: Diabetic Ketoacidosis

From: Resident Readiness: Internal Medicine
AccessMedicine's Case of the Week: Diabetic Ketoacidosis


A 36-year-old woman presents to the emergency department for evaluation and management of refractory nausea, vomiting, and abdominal pain. Symptoms have persisted for 2 days, and the patient has felt somewhat short of breath and light-headed when standing for the past 12 hours. She was diagnosed with gestational diabetes mellitus 3 years ago and then type 2 diabetes when hyperglycemia persisted after delivery. The patient's only medication is metformin. Examination is notable for resting tachycardia, mild tachypnea, dry mucous membranes, and modest, diffuse pain on palpation of the abdomen. Capillary blood glucose (CBG) is >500 mg/dL. 

Initial electrolyte panel revealed sodium 132 mEq/L, potassium 4.6 mEq/L, chloride 92 mEq/L, bicarbonate 12 mEq/L, blood urea nitrogen (BUN) 20 mg/dL, creatinine (Cr) 0.7 mg/dL, and glucose 520 mg/dL. Anion gap was computed to be 28. Arterial blood gas was notable for pH 7.21, pCO2 34 mm Hg, pO2 80 mm Hg, and calculated bicarbonate 14 mEq/L. Urinalysis was remarkable for large glucose and ketones, but nitrites and leukocyte esterase were undetectable. Complete blood count (CBC) showed modest leukocytosis and elevation of neutrophil count. Markers of liver function, amylase, lipase, EKG, and chest plain films were unremarkable.


1: How is diabetic ketoacidosis (DKA) diagnosed?

2: How should DKA patients be evaluated?

3: What are the appropriate steps in DKA management?

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