M_Wormwood_Oct_2_2021
H_James_Feb_10_2021
D_Beckham_May_2_2021
<Note>
<Section>Reason for referral
<p>Suspected Diabetic Ketoacidosis (DKA)</p>
</Section>
<Section>Chief complaint
<p>Vomiting.</p>
</Section>
<Section>History of Present Illness
<p>Diarrhoea and vomiting for last 4 days. Not eating much and so didn't think she needed to take insulin. Known type 1 diabetic since 2014.</p><br />
<p>Diarrhoea now settled but vomiting and abdominal pain ongoing. Feels very fatigued, drowsy and unwell.</p>
</Section>
<Section>Assessment
<p>Diagnosis: DKA<br />
Examination: Dry mucous membranes, decreased skin turgor, dry tongue - appears dehydrated.<br />
Investigations: Blood glucose > 250mg/dL, Ketones > 3mmol/L, pH 7.27.</p>
</Section>
<Section>Plan of care
<p>Immediate fluid replacement as per standard DKA pathway - start 0.9% Sodium Chloride<br />
Fixed rate Actrapid insulin infusion at 5 units/hour initially<br />
Hourly venous blood gas<br />
Review clinical condition every 1 hour at a minimum<br />
Consider stepping down treatment once ketosis has resolved<br />
Will need re-assessment upon discharge for long term insulin plan.</p>
</Section>
</Note>