1) While working as a scribe a


While working as a scribe at a local hospital, you are witness to a48-year-old male who arrived in the emergency suite who wasunresponsive. Prior to becoming comatose, he reported to a friendhe was experiencing mental confusion, nausea, abdominal pain andwas breathing rapidly. Upon examination, he demonstrates he isbreathing rapidly and has a blood pressure of 150/95. Lab testsshow 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, firstattempt to diagnose this patient. Then explain each of the reportedsymptoms and clinical findings. You must account for all thereported symptoms and blood values for full credit.

2)A72-year-old woman is brought into the emergency suite with severechest pain. Upon questioning by the admitting physician, she alsoreports a shortness of breath and dizziness. Her heart rate is 40beats per minute. You order an EKG. Based on the limitedinformation, what would you expect the EKG to show with respect toher heart activity? What condition would you diagnose this patientwith and what is the likely cause of this condition? Suggest apossible treatment



Diagnosis: Diabetic Keto Acidosis (DKA)

It is acute life threatening complication of diabetes

Symptom/ Clinical finding



If DKA is untreated it progresses and eventually lead tounconsciousness

History of mental confusion

Electrolyte imbalances, acidosis


Electrolyte imbalances, elevated ketones

Abdominal pain

Secondary to acidosis and electrolyte imbalances

Rapid breathing

Compensatory mechanism to combat acidosis by enabling removal ofcarbon dioxide

BP 150/95 mmHg

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

Blood glucose: 450 mg/dL

Glucose cannot be utilised in the body because of insulindeficiency

Elevated serum potassium

Increased blood glucose and acidosis leads to efflux ofpotassium 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 upbecause of non-availability of insulin. Fat break down releasesketones, 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 toher heart activity?

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

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

She has symptomatic Bradyarrhythmia, may be heart block iscausing bradycardia

Suggest a possible treatment

Follow AHA Bradycardia with pulse algorithm

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

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