Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are currently a Foundation Year 1 doctor working in the Emergency Department. You have been asked to review a patient who came in due to drowsiness. The patient has been brought to the emergency department by a relative. You have been asked to take a history from the relative and perform a relevant examination on the patient.
Patient History:
Your name is Susan Smith. You bought your brother, a 45-year-old called Jordan Smith, who was increasingly drowsy a few hours ago.
You have noticed in the past few days that your brother has been having diarrhoea and has generally been unwell lately. No nausea/vomiting. No abdominal Pain. There's a sweet smell from the breath. You do not know if he has been feeling dizzy or had any tremors/seizures lately. Your brother does feel a little cold when you touch him.
You noticed your brother has been drinking more water and emptying his bladder more often than usual. You are not sure if he has lost any weight. You have taken his blood sugar level today, which is around 20, on the monitor. You are also not sure if your brother has taken his insulin today.
Ideas, Concerns, Expectations:
You think this is related to his diabetes, but you are not so sure about it. Generally, he has high blood sugar levels but is usually doing just fine. You are worried that he is not his usual self, and you want a solution to fix this. You have no idea how to inject his insulin as your brother normally does it himself.
Past Medical History:
Type 1 DM, heart failure, atrial fibrillation, arthritis (newly diagnosed but do not know which type). No recent surgeries/ trauma.
Drug History:
Furosemide, insulin (Novorapid + Lantus), recently been started on prednisolone for arthritis, omeprazole, apixaban, bisoprolol.
NKDA.
Family History:
Diabetes in mother (doesn't remember why type)
Social History:
You drink a lot, but you do not know how much.
Smoker- 10 cigarettes/day since a teenager.
Work part-time as an accountant.
Examination Findings:
Might involve: ABCDE examination / abdominal examination/ neurological examination (diabetic neuropathy) / mental status assessment
Signs might include dry mucous membrane. Decreased skin turgor/ skin wrinkling, sunken eyes. CRP >2 seconds, acetone smell (like pear drops) from breath. Tachycardia. Weak pulse. Hypotension. Poor orientation to time, place and time. Warm, dry skin. No Kussmaul breathing (deep hyperventilation).
Differentials:
Hyperglycaemia / poorly controlled diabetes possibly leading up to DKA / secondary to steroid use / ?missing insulin doses
Dehydration
Hyperosmolar hyperglycaemic state
Excessive alcohol intake
To rule out infection e.g. gastroenteritis/ UTI/ LRTI
Investigations:
Bedside:
Observations
ECG (electrolyte imbalance can cause changes in ECG)
Urine Dip (rule out UTI as cause for confusion) + may show glycosuria + ketonuria +/- MSU
Monitor BM + ketones
Fluid input and output monitoring (background of HF & possible infection/ dehydration)
Urine albumin /creatinine ratio (?diabetic nephropathy)
Bloods:
Blood Gas – to monitor pH
Bloods: U&Es (potassium/Na imbalance secondary to dehydration/ interference of glucose/ketones/acidosis) + Mg, glucose, HbA1C + baseline routine: FBC, LFT, bone profile + CRP.
Blood culture & lactate if suspecting infection (part of sepsis 6)
Plasma osmolality (HHS)
Imaging:
CXR: rule out infection
AXR if indicated
Consider CT/MRI head for confusion (if continued unexplained drowsiness)
Special Test:
Consider lumbar puncture (if continued unexplained drowsiness)
Management: