Question

1)

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

Answer 1

1

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)

2

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

• assesement of clinical condition
• identify and treat underlying cause (airway/ oxygen/ cqardia monitoring/ vital signs/ BP/ IV access/ 12 lead ECG)
• IV Atropine 0.5 mg bolus, repeat Q 3-5 minutes , maximum 3 mg OR Dopamine or Epinephrine infusion
• If ineffective expert consulattion and trans venous pacing