FACULTY OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE,

NATIONAL UNIVERSITY OF MALAYSIA

MEDICINE POSTING CASE REPORT:

DIABETIC KETOACIDOSIS

SUPERVISOR: DR. ADAWIYAH JAMIL

NURUL HASHIMAH BINTI ABD RASHID A117037
YEAR 5
SESSION 2011/2012

DIABETIC KETOACIDOSIS
Faculty of medicine, Department of internal medicine, National University of Malaysia,
Kuala Lumpur
Nurul Hashimah Abd Rashid.

ABSTRACT
A 32 years old Malay lady with background history of type I diabetes mellitus
presented to casualty complained of sudden onset shortness of breath
associated with vomiting and polyuria 1 day prior. On examination, she was alert
and conscious with Glasgow coma scale of 15/15, she was tachypnoiec, in
Kussmaul breathing, with rate of 32 breaths/minute. She was in metabolic
acidosis and was partially compensated with kussmaul breathing. Random blood
glucose showed 40 mmol/L and urine ketones showed 4+. She was diagnosed to
have diabetic ketoacidosis and recovered with fluid therapy and insulin. She will
continue her follow up at medical clinic in Hospital Teluk Intan.
KEYWORDS: diabetic ketoacidosis, type I diabetis mellitus, Kussmaul breathing.
INTRODUCTION:
Diabetic ketoacidosis (DKA) is acute,

infection, missed insulin injections,

major

life-threatening

undiagnosed diabetes, medical or

complication of diabetes. It mainly

surgical or emotional stress, and

occurs in diabetes type I patient but

sometimes

it is not uncommon in some patients

identified.

and

no

cause

can

be

with type II diabetes. DKA is a state

of

absolute

deficiency

or
that

hyperglycaemic,

relative
will
acidosis

insulin

CASE REPORT:

produce
and

HN,

32

years

old

lady

with

dehydration state to the patient.

background history of type I diabetes

Clinically defined, it is an acute state

mellitus, complained of sudden onset

of uncontrolled diabetes associated

shortness of breath associated with

with

requires

vomiting and polyuria for 1 day

emergency treatment with insulin

duration. The shortness of breath

and intravenous fluids. The common

was sudden in onset, occur when she

triggers to DKA includes underlying

was lying down and doesnt relieve

ketoacidosis

that

by

changing

posture.

It

was

increased her insulin dose by 2u as

progressively worsened in just 1 hour

advised

duration and this is the first time she

dextrostix

experienced

this

mmol/L

However there

is no paroxysmal

nocturnal

symptoms.

dypsnoea,

by

the

doctor

reading

that

when

showed

morning.

She

20
was

diagnosed to have diabetes mellitus

orthopnea,

type I when she was 15 years old

pedal edema, abdominal distension

after she had a coma for 2 days and

to suggest heart failure. There is also

currently she was under hospital

no

suggest

teluk intan follow up 3 monthly.

infective causes. it was also not

Currently, she was on Actrapid 10u

associated with noisy breathing to

tds and Insulatard 10u on. She had

suggest asthmatic. She also denies

home

history of prolong immobilisation or

ranging from 6-12 mmol/L but lately

frequent

she

fever

or

cough

long

to

travel

to

suggest

glucose
claimed

monitoring

that

her

which

dextrostix

pulmonary embolism. The shortness

reading has been more than 20 for

of breath was associated with 10

more than 2 weeks. She had her eye

episodes of vomiting. The vomitus

follow-up annually and was told that

contained mainly clear fluids and

her eyes are normal. Otherwise, she

undigested food. There is no blood

has

tinge or bilious. However patient

healing, skin infections, peripheral

denies abdominal pain and no other

numbness, chest pain, blurring of

family

member

vision

same

symptom.

lethargy

experienced
She

however

the

became

there

is

no

no

history

or

of

frothy

poor

urine.

wound

She

had

multiple admission due to diabetes in

the early diagnosis for blood glucose

drowsiness. She also complained of

stabilisation.

polyuria, which she passed urine

admission up until past 2 weeks,

more

day

where she was admitted to hospital

compared to previously which only 5-

because of fever and vomiting for 1

6 times/day. There is no dysuria.

day

Patient

admitted

than

also

10

times

denies

that

history

of

There

duration,
for

is

which
5

days

no

recent

she

was

duration,

nocturia, polydipsia or polyphagia.

completed a course of antibiotic and

Regarding the diabetes, she claimed

discharged

to be compliant to her medication

menarche at the age of 13 years old

and

insulin

with menses of 3-4 days with cycle of

denies taking

28 days. There is no dysmenorrhea,

never

injection.

misses

She also

her

sugary food. She admit that she has

well.

intermenstrual

She

attained

bleeding

or

menorrhagia. She delivered her first

beats /minute however it is regular

child, a baby boy with weighted of

rhythm but weak volume. Her blood

4.1 kg via caesarean

pressure

section in

is

96/53

which

is

hospital Ipoh in 2006. While in 2007,

hypotensive and she is not fever.

she delivered her second son, at 32

Examinations of the lungs, heart and

weeks of period of amenorrhea with

abdomen is normal. There is also no

weighted of 2.25 kg via emergency

abnormality

caesarean section due to bleeding

examinations. Random blood glucose

placenta accreta and hysterectomy

was taken during admission was 40.5

was also done. She is the 2nd child

mmol/L

out of 5 sibling, her father has

hyperglycemia. Venous blood gases

diabetes mellitus type II and is on

showed that the patient has severe

oral hypoglycaemic agent while her

metabolic acidosis with pH of 6.856

mother is well. There is no family

which is acidotic, pCO of 27.4 which

history of sudden death, malignancy,

is hypocapnoiec, pO 41.2 which is

stroke

hypoxic,

or

heart

disease.

She

is

in

the

which

and

neurological

was

severe

bicarbonate

of 4.7.

married, and blessed with 2 sons.

Urine ketone showed 4+. The patient

She is a housewife while her husband

was

owns a welding workshop in Tronoh.

ketoacidosis

They live in a Kampung house with

bicarbonate was given immediately

her parents in laws in Ipoh. She does

because

not smoke or consume any alcohol.

metabolic

However, her husband is a chronic

saturation

smoker

smokes

patient is hypoxic and was put on

examination,

oxygen supplementation with nasal

that

20cigarettes/day.
she

is

alert

On

and

with

diabetic

IV

sodium

and

she

was

having

acidosis.
also

severe
Oxygen

showed

that

the

with

prong 3 L/minute. Then she was put

Glasgow coma scale of 15/15. There

on IV drip 8 pint normal saline in the

is no onicomycosis, the capillary refill

first

time is less than 2 seconds, the

injection was replaced with insulin

insulin

not

sliding scale. She was discharged

no

well after 5 days of admission and

acanthosis nigricans. There is no

will be follow-up in the hospital Teluk

pallor

Intan.

injection

lipodystrophic
or

conscious

diagnosed

sites

and

jaundice.

are

there
Her

is

mucous

24

hours

membrane is dry and there is no

fetor

breath

noted.

She

is

tachycardic with pulse rate of 109

DISCUSSION:

and

her

insulin

Diabetic ketoacidosis (DKA) can be

respiration,

the first presentation of diabetes.

breathing

The main feature of DKA includes

presented. The mouth, tongue and

hyperglycaemia, metabolic acidosis

lips are dry. The majority of doctors

with

heavy

can smell ketones on the patients

ketonuria. This feature is contrasted

breath. However, this is an unreliable

with

sign as the sign would depends on

high

anion

the

other

gap

and

hyperglycaemic

called
as

what

the

patient

diabetic emergency of hyperosmolar

the

non-ketotic

detecting the ketotic smell. Other

there

is

hyperglycaemia
acidosis,

in

signs of dehydration also should be

minimal ketonuria but often very

sought. Although this patient is not

high glucose level. Actually there is

feverish but we must not exclude

no specific clinical sign that can

infection as the triggering factor

confirm or exclude the diagnosis of

because infection can occur without

DKA. The diagnosis typically when

causing

there is clear history that the patient

significant reduction in total body

has diabetes but can cause serious

potassium, the serum concentration

diagnostic difficulty in the situation

is

where the patient is unconscious or

presentation because of a shift into

this was the first presentation of the

the extracellular compartment. The

diabetes.

DKA

steepest decline of potassium occurs

whenever

in the first few hours of treatment.

The
be

absent

experience

or

should

no

where

examiners

Kussmaul

possibility

considered

assessing

patient

of

usually

normal

Despite

or

high

at

is

The patient also was experiencing

hyperventilating and it is always

decline of potassium level after few

essential

to measure the blood

hours of initiating the treatment. She

glucose early in the resuscitation of

was given potassium replacement

any unconscious patient. The usual

together with the fluids and tapered

symptoms are polyuria, polydipsia,

down accordingly based on the renal

and

weakness . Other features of

profile

DKA

that

management of DKA includes; fluid,

can

present

who

fever

includes

results.

The

principle

nausea, vomiting or abdominal pain

insulin,

as what this patient presented to the

Early venous access is essential.

casualty 1. There may also history of

Urinary catheter is needed if patients

omitted

On

are haemodynamically unstable and

has

an

need accurate measurement of urine

rate

of

output.

insulin

examination,
increased

the

depth

dose.
patient
and

potassium and

of

regimen

education.

suitable

for

patients who are not shocked/oliguric

diabetes.

is 500ml/hour of 0.9% saline for 4

Diabetes

Care.

2004;27(suppl 1):S94102.

hours followed by 250 ml/hour for

the next 4 hours

. This is associated

3.

Harden,

Quinn,

with as rapid a correction of acidosis

Department of Accident and

and hyperglycemia as a regimen

Emergency

using

General

twice

Unnecessarily

these
large

rates.

volumes

Medicine,
Infirmary,

The
Leeds.

Emerg Med J 2003;20:210-213.

of

intravenous fluids should be avoided

because of the high case fatality rate
4

of cerebral oedema

. Volume status

4.

David

Trachtenbarg

M.D,

University of Illinois College of

can be assess on the basis of clinical

Medicine,

assessment

Diabetic Ketoacidosis. Am Fam

pressure,

(heart
state

rate,
of

blood

hydration),

assessment of renal function by urea

measurement,

and

urine

output.

Once glucose has fallen to around 14

mmol/L, 5% dextrose is given rather
than saline. Administering hypertonic
dextrose

rather

dextrose

may

than

isotonic

accelerate

the

clearance of ketone bodies but also

causes a rise in glucose without an
additional improvement on blood pH
or bicarbonate.
REFERENCES:
1.

Siperstein

MD.

Diabetic

ketoacidosis and hyperosmolar

coma. Endocrinol Metab Clin
North Am. 1992;21:41532
2.

Kitabchi
Murphy

AE, Umpierrez
MB,

Barrett

GE,
EJ,

Kreisberg RA, Malone JI, et al.

Hyperglycemic

crises

in

Peoria,

Illinois.

Physician. 2005 May 1;71(9):1

705-1714.