View source for WBR0828

 {{WBRQuestion
|QuestionAuthor=Vendhan Ramanujam
|ExamType=USMLE Step 3
|MainCategory=Emergency Room
|SubCategory=Endocrine, Electrolytes
|MainCategory=Emergency Room
|SubCategory=Endocrine, Electrolytes
|MainCategory=Emergency Room
|SubCategory=Endocrine, Electrolytes
|MainCategory=Emergency Room
|MainCategory=Emergency Room
|SubCategory=Endocrine, Electrolytes
|MainCategory=Emergency Room
|SubCategory=Endocrine, Electrolytes
|MainCategory=Emergency Room
|SubCategory=Endocrine, Electrolytes
|MainCategory=Emergency Room
|SubCategory=Endocrine, Electrolytes
|MainCategory=Emergency Room
|MainCategory=Emergency Room
|SubCategory=Endocrine, Electrolytes
|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 revealed playing 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.  Pulseoximetry read as 94%.  Which is the next best step in the management of this patient?
|Explanation=The patient is most likely suffering from [[diabetic ketoacidosis]] (DKA) following his gastrointestinal disturbance and skipping of insulin doses.  DKA is a medical emergency.  Symptoms like vomiting, lethargy, confusion and rapid breathing typical of Kussmaul’s respiration along with signs like dehydration, hypotension, tachycardia and tachypnea are suggestive of DKA.  The next best step in management of a suspected DKA patient will be a rapid fingerstick glucose test that will confirm the suspicion immediately.  [[Arterial blood gas]] (ABG) measurement will follow.  While waiting for ABG and other serum biochemistry, empirical treatment with fluids can be started in the emergency department.

'''Educational Objective:'''
Patients suspected with diabetic ketoacidosis need to be confirmed with a rapid fingerstick glucose test, which will take only few minutes before proceeding with other blood tests and medical therapy.
 
|AnswerA=Administer nasal oxygen
	

|AnswerAExp='''Incorrect'''-Saturation is normal in this patient and nasal oxygen need not be the next best step in the line of management.
|AnswerB=Do a fingerstick glucose test
|AnswerBExp='''Correct'''-Patients suspected with diabetic ketoacidosis need to be confirmed with a rapid fingerstick glucose test, which will take only few minutes before proceeding with other blood tests and medical therapy.
|AnswerC=Obtain arterial blood gas
|AnswerCExp='''Incorrect'''-Arterial blood gas test will follow the rapid fingerstick glucose test.
|AnswerD=Immediately administer 0.9% normal saline
|AnswerDExp='''Incorrect'''-After confirming the suspected DKA with fingerstick glucose test and before the arrival of arterial blood gas and other serum biochemistry, empirical treatment with isotonic 0.9% normal saline is recommended.
|AnswerE=Immediately administer a bolus of 15 grams of 50% dextrose
|AnswerEExp='''Incorrect'''-In this patient, only isotonic 0.9% normal saline is recommended as an empirical treatment to replenish the lost fluids after a rapid fingerstick glucose test and not a bolus of 15 grams of 50% dextrose.
|RightAnswer=B
|WBRKeyword=Diabetic ketoacidosis
|Approved=Yes
}}