Step 2

Endocrine 3

A 36-year-old woman is brought to the emergency department by emergency medical services after being found on the ground in an alley with altered mentation. Initials vital signs are temperature 36.8°C (98.4°F), blood pressure 106/50 mmHg, heart rate 131 beats/min, respirations 31/min, and oxygen saturation 95% on room air. She appears to be somnolent, and she responds minimally to name calling. She mumbles to the emergency department physician that she has been feeling nauseated and her “belly hurts.” The patient’s medical history is unknown. Her physical examination is grossly unremarkable. Her initial laboratory findings are shown below:

CBC
  • WBC: 12.0 x 103/mm3
  • Hemoglobin: 15.0 g/dL
  • MCV: 89 fl
  • Platelets: 307 x 103/mm3
BMP
  • Sodium: 136 mmol/L
  • Potassium: 5.6 mmol/L
  • Chloride: 98 mmol/L
  • CO2: 15 mmol/L
  • Glucose: 612 mg/dL
  • BUN: 16 mg/dL
  • Creatinine: 1.3 mg/dL

Her urinalysis is positive for 3+ ketones, 3+ glucose, trace blood, Specific gravity is >= 1.030. Her initial ABG shows pH 7.23, PCO2 30.9, PO2 55.8, HCO3 15.6 on room air. Her ECG shows sinus tachycardia without significant ST/T wave changes. Chest x-ray shows no acute findings. CT scan of the abdomen and pelvis shows no acute processes.

After a bolus of 1.5 liters of IV fluids and administering an intravenous insulin push, the patient’s mentation improves. The patient reports she has a history of type I diabetes, but she has lost access to her insulin as she recently became homeless.

Considering the most likely diagnosis, which of the following would be the most appropriate next step in management?

  • A) Continue to administer fluids
  • B) Give bicarbonate to raise the patient’s pH
  • C) Give sodium polystyrene sulfonate to decrease the patient’s potassium
  • D) Order antibiotics as laboratory findings show leukocytosis
  • E) Prepare for intubation as patient’s respiratory rate is high

Authors

Yunjia Shen

Editor

Dr. Raj Dasgupta

Last updated

Jan 08, 2023

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