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 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.
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
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 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.
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
