Eric Young

SOAPM Jimmy Wilkinson

Subjective:
CC: “I’ve been vomiting for 2 days.”
HPI: 20-year old Caucasian male university student with known T1DM comes into the emergency epartment with a
2-day history of N/V.
PMH: T1DM, major depressive disorder, seasonal allergic rhinitis, tonsillectomy (at age 4)
SH: Currently a junior in college and has a part-time job at a bookstore.
T/E/D: Admits to occasional alcohol and marijuana use at social gathering/denies use of tobacco and other illicit
drugs.
Allergies: NKDA
Medications: Loratadine 10mg PO QD
Diphenhydramine 50mg PO QD Q6-8H PRN allergies
Fluticasone one spray each nostril daily
Escitalopram 10mg PO QD
Insulin glargine 20U SC at bedtime
Insulin lispro 5U SC with meals (TID)
ROS: Tachypnea, polydipsia, N/V, urinary frequency, urgency, polyuria, fatigue

Objective:
VS: BP 87/62 mmHg, P 124 bpm, RR 27, T 37.2°C, Wt 139 lb (63.2kg), Ht 68 in (173cm), BMI 21kg/m2
Skin: Mild acne on face and back.
Chest: Breathing unlabored; mild tachypnea; breath sounds equal bilaterally; no wheezes, crackles, or rhonchi.

Na: 130 mEq/L Alk phos: 516 IU/L pH: 7.17

K: 3.0 mEq/L T bili: 2 mg/dL pCO2: 25 mmHg
HCO3: 11 mEq/L HbA1c: 10.3% pO2: 58 mmHg
BUN: 40 mg/Dl Anion gap: 15 Calculated HCO3: 9.1 mEq/L
SCr: 1.5 mg/Dl
Fasting glu: 550 mg/dL Glucose: 890 mg/dL pH: 5
Phos: 2.0 mg/dL Ketone: 150 mg/dL

Assessment: Diabetic ketoacidosis (DKA)

Type 1 Diabetes Mellitus
Major depressive disorder
Seasonal allergic rhinitis
Immunizations

Plan:
DKA: Initiate fluid therapy; initiate fluid replacement 15-20mL NS/kg/hr or ~1L NS/hr. Reassess fluid needs.
Transition to fluid maintenance of 0.45% NaCl 250-500mL/hr. Transition to oral fluid if possible.
Since K is 3.0 mEq/L, hold insulin therapy and infuse 20-30mEq of K with each liter of IV fluid until K>3.3mEq/L
and patient is stable.
Once K > 3.3 mEq/L, initiate insulin infusion therapy: 9U/hour (0.14U/kg) of regular insulin IV continuous
infusion.
Initiate SC insulin therapy if the patient is eating by mouth. DC IV insulin 1 hour after first SC insulin dose. (TDD =
36U insulin)
Schedule basal insulin (Glargine 18U SC HS; 0.3U/kg/d); schedule bolus insulin lispro 6U SC (0.1U/kg/meal)-
given 0-15 minutes before 3 regular sized meals.
Recommend noninvasive ventilation of oxygen 2L/hr via nasal cannula.

Type 1 diabetes mellitus: Increase home insulin regimen to lower A1c and get better glucose control (TDD =
44U/day)
Insulin glargine 29U SC at bedtime; insulin lispro 5U SC with meals
Eric Young
SOAPM Jimmy Wilkinson

Major depressive disorder: Seek counseling on top of medication therapy; follow up with patient in a month.
Recommend psychiatric evaluation if mental health status does not improve.

Seasonal allergic rhinitis: Take patient off loratadine 10mg and diphenhydramine 50 mg PO and put him on
cetirizine 10mg PO daily during allergy season. Continue fluticasone one spray each nostril daily (100mcg/daily)
during allergy season.

Immunizations: If no vaccination history is provided, he should receive annual influenza, Tdap/Td, varicella, MMR,
and PPSV23. Based on risk factors, can also receive PCV 13, hepatitis A, hepatitis B, MenACWY or MPSV4,
MenB, and Hib

Monitor:
DKA:
Continue fluid maintenance if SBP < 100 mmHg, P > 120 bpm, RR > 20, capillary refill > 3 sec, UO <
0.5 mL/kg/hr, poor skin turgor, peripheral cold to touch, or altered mental status.
Serum glucose should be measured every hour until stable (< 200 mg/dL)
Blood should be drawn every 2–4 hours for serum electrolytes, blood urea nitrogen, creatinine,
osmolality, and venous pH
If available, use bedside ketone meters to measure capillary blood beta-hydroxybutyrate to monitor
response to treatment
Monitor for symptoms of hypoglycemia such as tremors, confusion, palpitations and sweating
Carefully monitor serum potassium during administration of insulin, symptoms of hypokalemia, and EKG
Monitor for symptoms of cerebral edema such as headache, lethargy, and decreased arousal

Type 1 diabetes mellitus:

Monitor blood glucose daily
Goals: FBG 80-130 and postprandial glucose <180
Goal A1c is <7%
Check A1c every 3 months and BG levels at every office visit

Major depressive disorder:

Signs and symptoms of depression such as lethargy, loss of interest, suicidal ideation, changes in appetite,
and changes in sleep

Seasonal allergic rhinitis:

Monitor for symptoms of allergic rhinitis such as sneezing, runny nose, and itchy eyes.
Monitor for side effects of cetirizine, which includes sedation, dry mouth, and headache.
Counsel patient on side effects of fluticasone, such as nose bleeds

Immunizations: Allergic reaction after administering vaccination.

Monitor for any allergic reactions after administering vaccinations.