ETD: DKA with electrolyte imbalance secondary to infective AGE

I am kinda guilty for missing the DKA initially in this case. Luckily my boss found my mistake and rectified it.

75 years old lady, underlying hypertension, DM, dyslipidaemia, AF on warfarin, brought in by son, claimed to have 2 episodes of fall, presented with less responsiveness and body weakness. Our initial walking diagnosis is TRO intracranial bleed because of history of fall and history of taking anticoagulant.

Further history noted patient had been having poor oral intake for 1 month with abdominal discomfort and loose stool for past few days, however we were too focused on the history of fall, as patient looked drowsy and weak, so we decided to hydrate the patient and send patient for CT brain first. 

CT brain was normal. We were thinking it could be some kind of electrolyte imbalance, given the history of poor oral intake and some ongoing loose stool episodes, which makes patient weak and fell down at home. 

My EP came for round after lunch, she immediately found something unusual from the patient, which was the capillary glucose level, it was 19. We didn't realise the glucose level was high until it was reminded by our EP. She then requested for an urgent VBG and serum ketone. It turned out that the serum ketone was 5, and blood gas showed bicarb level of 12. And at the same time we traced the lab results, the Na was only 112, K was 3.2. 

Therefore, this was not just a simple fall case, it was a DKA case, which could be exacerbated by AGE, given the history of DM, with loose stool for past few days prior to presentation, along with electrolyte imbalance, again, caused by the AGE, that ultimately led to the body weakness and fall episodes.

Patient was then immediately upgraded to red zone and started with fluid resuscitation and DKA regime for hydration. Bedside scan noted her IVC was actually kissing. We pumped her up with several pints of normal saline, together with fixed scale insulin, her hydration status got better after few hours, blood sugar level also reduced, but she was still in metabolic acidosis state. We then referred this case to medical for further management.