History of Present Illness:

50 y/o M, with a history of T2DM and alcohol abuse, who presents to the ED c/o generalized weakness and dizziness for three days. He describes the dizziness as his eyes “shifting.” Patient reports he is on insulin lispro and glargine but has not taken either in two weeks because he has been busy, but states he has the medication. He also states that while he has a glucometer, he has not checked his glucose in one week. He states he took his insulin this morning because he did not feel well. He reports diffuse, nonradiating, crampy 7/10 abdominal pain for three days and bowel urgency but denies fever, chills, chest pain, shortness of breath, nausea, vomiting, diarrhea, constipation, dysuria, hematuria or headache. Patient has been drinking Pedialyte but denies eating food because of the bowel urgency. He states he has had similar symptoms in the past and was given IV fluids, which helped with the symptoms.  

PMHx: T2DM, alcohol abuse, hyperparathyroidism

Medications: Insulin glargine 0.25 mL under skin nightly. Insulin lispro 0.1 under skin 3 times a day before meals.

PSHx: parathyroidectomy, umbilical hernia repair

FMHx: Sister T2DM, otherwise non-contributory

Social History: Current everyday smoker 0.5 ppd x 35 years, 1 beer per day – states he has decreased his alcohol usage, admits to marijuana use but denies heroin or cocaine use

Allergies: NKDA

Review of Systems:

Gen: Admits to weakness. Denies fever, chills, fatigue.

Resp: Denies cough, wheezing, hemoptysis, shortness of breath.

CV: Denies chest pain, palpitations, leg swelling.

GI: Admits to diffuse abdominal pain and bowel urgency. Denies distention, nausea, vomiting, diarrhea, constipation.

GU: Denies polyuria, difficulty urinating, dysuria, flank pain, hematuria

MSK: Denies muscle or joint pain.

Skin: Denies any rashes

Neuro: Admits to dizziness. Denies headaches

Physical Exam:

VS: T 98.5 F, BP 122/77, HR 72, RR 12, O2 sat 100%, Wt 170 lb, Ht 5’11”, BMI 23.71

Gen: Alert and oriented, in no acute distress. Resting comfortably on stretcher

Skin: Warm and dry

HEENT: Normocephalic, atraumatic. PERRL. EOMIs, no nystagmus.

Resp: Clear to auscultation bilaterally

CV: Tachycardic. Regular rhythm

Abd: Soft, nondistended. Mild epigastric tenderness. Normoactive bowel sounds. No rebound or guarding.

MSK: Decreased strength on LLE compared to RLE, which patient states is his baseline. Full range of motion of bilateral upper extremities and 5/5 strength.

Neuro: No focal neuro deficits. Gait at patient’s baseline.

Differentials: Dehydration, DKA, pancreatitis

Assessment:

50 y/o M, with a PMHx of DM, who presents to the ED c/o generalized weakness and dizziness x 3 days. Patient has not been compliant with his insulin for 2 weeks and has not checked his glucose in one week. In no acute distress, tachycardia and mild epigastric tenderness on exam.

Plan:

CBC to rule out anemia and infection

BMP, Mg to rule out electrolyte abnormality and anion gap

VBG to r/o acidosis

Ketones to r/o DKA

LFTs

Lipase

EKG

1000mL LR

Addendum:

CBC 10.3 with no sign of infection. Sodium 132, potassium 4.4, chloride 94, CO2 17, BUN 10, creatinine 1.1, glucose 177, calcium 9.3, anion gap 21, osmolality 277.

Magnesium 2.2. Lipase 8

Albumin 4.9, total protein 8.0, total bilirubin 1.3. direct bilirubin 0.2, alk phos 126, ALT 14, AST 18

VBG: pH 7.27, PCO2 41, PO2 16, sodium 131, potassium 4.8, chloride 99, calcium ionized 1.21, HCT 44, glucose 191, lactate 1.5, HCO3 19

Large number of ketones in blood

Disposition:

Patient in DKA. pH 7.27, anion gap of 21, lactate 1.5, large number of ketones in blood.

Patient receiving insulin regular 100 units in sodium chloride 0.9% 100 mL at 0.1 units/kg/hr x 77.1 kg IV

D5%-NaCl 0.45% infusion at 125 mL/hr IV infusion

Insulin regular injection 8 units IV push

D50W 50% injection 25g IV push given

Will admit to MICU for further evaluation, insulin drip and DKA management.

Patient Education:

You are being treated for diabetic ketoacidosis. This can occur when you do not take your insulin, as has been the case the last two weeks. It is a life-threatening condition where your body is breaking down fat very quickly into ketones, which causes your blood to be acidic. The fat is being broken down instead of your glucose, because there is not enough insulin in your body for the glucose to get from your blood into your cells. We have to treat this with fluids and insulin through an IV in the hospital. You will be admitted for a few days until the DKA is managed properly.