1) While working as a scribe at a local hospital, you are witness to a 48-year-o

ID: 136825 • Letter: 1

Question

While working as a scribe at a local hospital, you are witness to a 48-year-old male who arrived in the emergency suite who was unresponsive. Prior to becoming comatose, he reported to a friend he was experiencing mental confusion, nausea, abdominal pain and was breathing rapidly. Upon examination, he demonstrates he is breathing rapidly and has a blood pressure of 150/95. Lab tests show his blood glucose to be 450 mg/dL, he also has elevated serum potassium, magnesium and ketone levels. His blood pH is 7.28. Using your understanding of physiology, first attempt to diagnose this patient. Then explain each of the reported symptoms and clinical findings. You must account for all the reported symptoms and blood values for full credit.

2)A 72-year-old woman is brought into the emergency suite with severe chest pain. Upon questioning by the admitting physician, she also reports a shortness of breath and dizziness. Her heart rate is 40 beats per minute. You order an EKG. Based on the limited information, what would you expect the EKG to show with respect to her heart activity? What condition would you diagnose this patient with and what is the likely cause of this condition? Suggest a possible treatment

Explanation / Answer

Diagnosis: Diabetic Keto Acidosis (DKA)

It is acute life threatening complication of diabetes

Symptom/ Clinical finding

Explanation

unresponsive

If DKA is untreated it progresses and eventually lead to unconsciousness

History of mental confusion

Electrolyte imbalances, acidosis

nausea

Electrolyte imbalances, elevated ketones

Abdominal pain

Secondary to acidosis and electrolyte imbalances

Rapid breathing

Compensatory mechanism to combat acidosis by enabling removal of carbon dioxide

BP 150/95 mmHg

Hypotension usually occurs in DKA due to dehydration secondary to glycosuria. But, Dehydration and cerebral edema may co-exist in DKA. Cerebral Edema or increased intracranial pressure may be responsible for elevated BP

Blood glucose: 450 mg/dL

Glucose cannot be utilised in the body because of insulin deficiency

Elevated serum potassium

Increased blood glucose and acidosis leads to efflux of potassium from cells to blood circulation creating high levels

Elevated serum magnesium

May be due to changes in magnesium metabolism due to DKA , Insulin has role for transportation of magnesium into cells

Elevated ketones

Fats are broken down for energy when glucose cannot be used up because of non-availability of insulin. Fat break down releases ketones, increasing their levels

Blood pH 7.28

Increasing level of ketones make blood more acidotic (pH< 7.35)

What would you expect the EKG to show with respect to her heart activity?

Answer: ECG may show Sinus bradycardia OR heart block- First, second or third

What condition would you diagnose this patient with and what is the likely cause of this condition?

She has symptomatic Bradyarrhythmia, may be heart block is causing bradycardia

Suggest a possible treatment

Follow AHA Bradycardia with pulse algorithm