i-Human Case : Melissa Stewart – Pediatrics CC – Confusion – reported by patient’s mother. Diagnosis – DKA – DKA, substance use disorder, diabetes insipidus, dehydration, DM Type 1 Tests - BMP, UA, Drug tox, arterial blood gas, 12lead ECG, beta -hydroxybutyric acid (BOH) Problem Statement: ( Demographic description – chief complaint – Hx and PE key findings – risk factors ) Melissa Stewart is a 12 year old child brought in by her mother with complaint of confusion since morning. Melissa i s obtunded and only responsive to verbal commands. Her mother states that she recently has been losing weight and eating more and experiencing polyuria and polydipsia as well as blurred vision. Today she is tachypneic, tachycardia, lethargic and confused with continued blurry vision. PE shows decreased skin tugor, delayed capillary refill and fruity breath. Risk factors include a family history of a “sugar problem”. CC: Melissa Stewart is a 12 year old child brought in by her mother with complaint of confusion since morning.. HPI: . Melissa is obtunded and only responsive to verbal commands. Her mother states that she recently has been losing weight and eating more and experiencing polyuria and polydipsia as well as blurred vision. Today she is tachypneic, tachycardia, lethargic and confused with continued blurry vision. Meds: None PMH: noncontributory FH: Paternal grandfather diabetes. SH: Mother states child does not smoke, drink alcohol, or take recreational drugs. ROS: Only positive findings are seen in HPI Physical Exam: VS: Pulse – 85; BP – 88/56 RR – 20; T – 98.6F; SpO2 – 99% Skin: Shows decreased skin tugor Cardiovascular: Delayed capillary refill seen in fingers +3 seconds, and toes +3 seconds. HEENT: breath smells fruity. ASSESSMENT/PLAN Test Results: • BMP: Hyponatremia, Hyperkalemia, Hyperglycemia (574), Elevated BUN/Cr, Metabolic acidosis w/ elevated anion gap. • UA: glycosuria, ketonuria w/ high osmolarity (no evidence of UTI) • Drug Toxicology: Negative. • Arterial Blood Gas: Partially compensated metabolic acidosis. • Beta -hydroxybutyric acid: Elevated – indicating insulin deficiency • 12 lead ECG: Sinus tachycardia Management Plan • IV access • Fluid resuscitation • Electrolyte replacement (Potassium) • Insulin Therapy • IV Bicarbonate • Once stable – consult parents on DM 1 Questions 1. Metabolic acidosis 2. Decreased Bicarbonate 3. Decreased intravascular volume 4. Increased lipolysis 5. Metabolic acidosis
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