WBR0912
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| Author | PageAuthor::Vendhan Ramanujam |
|---|---|
| Exam Type | ExamType::USMLE Step 3 |
| Main Category | MainCategory::Inpatient Facilities |
| Sub Category | SubCategory::Endocrine, SubCategory::Electrolytes |
| Prompt | [[Prompt::A 28 year old African-American male presented to the emergency department with complaints of lethargy and vomiting for the past one day. He is a known type 1 diabetes mellitus patient. He had a gastrointestinal disturbance before two days following which he restricted his food intake and skipped his insulin doses. He also played soccer with his friends last evening. Physical examination revealed a confused, dehydrated, tachypneic male with vital signs like heart rate of 120 beats/min, blood pressure of 98/58 mmHg, respiratory rate of 35/minute and oral temperature of 37.2 C. A rapid finger glucose test revealed plasma glucose of 638 mg/dL, thus confirming diabetic ketoacidosis. He was started on 0.9% normal saline while waiting for his lab results, which revealed a high anion gap metabolic acidosis with serum potassium below 5.3 mEq/L. He was admitted in the intensive care unit and started on a continuous infusion of intravenous regular insulin, isotonic 0.9% normal saline and potassium. He was continuously monitored with hourly blood glucose and fourth hourly basic chemistry profile, pH and plasma osmolality until he clinically became stable. The most recent lab tests revealed the following
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| Answer A | AnswerA::Continue the continuous infusion of intravenous regular insulin, isotonic 0.9% normal saline and potassium |
| Answer A Explanation | AnswerAExp::'''Incorrect'''-Since the patients blood glucose has gone below 200 mg/dL and anion gap returned to normal, this regimen is not required. |
| Answer B | AnswerB::Continuous intravenous infusion of half the previous dosage of regular insulin, hypertonic D5 normal saline and potassium |
| Answer B Explanation | AnswerBExp::'''Incorrect'''-Since the patients blood glucose has gone below 200 mg/dL and anion gap returned to normal, this regimen is not required. |
| Answer C | AnswerC::Switch to subcutaneous insulin immediately |
| Answer C Explanation | AnswerCExp::'''Incorrect'''-Switching to subcutaneous insulin alone will loose the control over blood glucose and make the patient unstable again. |
| Answer D | AnswerD::Continue the insulin drip while switching over to subcutaneous insulin for the next 2 hours |
| Answer D Explanation | [[AnswerDExp::Correct-Diabetic ketoacidosis patient on treatment when becomes stable and hungry without any nausea and vomiting, returning to parameters like blood glucose <200 mg/dL, serum bicarbonate >18 mEq/L and anion gap <12 mEq/L, should be switched to subcutaneous insulin while maintain the insulin drip since it takes 2 hours for the subcutaneous insulin to reach therapeutic level.]] |
| Answer E | AnswerE::Stop all his medications and begin oral feeding |
| Answer E Explanation | AnswerEExp::'''Incorrect'''-Oral feeding can be started once the patient becomes stable without nausea and vomiting. It also gives a chance to shift to subcutaneous insulin. Stopping all medications will be inappropriate to this patient. |
| Right Answer | RightAnswer::D |
| Explanation | [[Explanation::Any diabetic ketoacidosis patient on treatment when becomes stable and hungry without any nausea and vomiting, returning to parameters like blood glucose <200 mg/dL, serum bicarbonate >18 mEq/L and anion gap <12 mEq/L, should be switched to subcutaneous insulin. Since it takes 2 hours for the subcutaneous insulin to reach therapeutic level, the insulin drip must be allowed to continue over that period in order to maintain the stable blood parameters.
Educational Objective:
Any diabetic ketoacidosis patient on treatment when becomes stable and hungry without any nausea and vomiting, returning to parameters like blood glucose <200 mg/dL, serum bicarbonate >18 mEq/L and anion gap <12 mEq/L, should be switched to subcutaneous insulin while maintain the insulin drip since it takes 2 hours for the subcutaneous insulin to reach therapeutic level. |
| Approved | Approved::Yes |
| Keyword | WBRKeyword::Diabetic ketoacidosis |
| Linked Question | Linked:: |
| Order in Linked Questions | LinkedOrder:: |