Patient: [Patient Name]
Date: [Date of Encounter]
I. Reason for Visit:
Altered mental status, lethargy, vomiting, abdominal pain (suggestive of DKA)
Blood test results concerning for DKA
II. History of Present Illness:
Known diabetes mellitus (type 1, type 2, or gestational)
Duration of symptoms (nausea, vomiting, abdominal pain, polyuria, polydipsia)
Recent illness, infection, or stress (potential triggers)
Medication adherence (insulin)
Use of any illicit substances (contributing factors)
III. Past Medical History:
Previous episodes of DKA
Other diabetes complications (retinopathy, neuropathy, nephropathy)
IV. Family History:
Diabetes in first-degree relatives
V. Social History:
Smoking, alcohol, or illicit drug use
VI. Physical Exam:
Vital signs (BP, HR, RR, Temp) – assess for dehydration, Kussmaul respirations (rapid, deep breathing)
Mental status – lethargy, confusion, coma (in severe cases)
Dehydration signs (dry mucous membranes, poor skin turgor)
Abdominal exam (assess for tenderness)
VII. Laboratory Studies:
Blood glucose: Elevated (typically >250 mg/dL)
Serum ketones: Elevated (positive urine ketones may also be checked)
Arterial blood gas (ABG): Metabolic acidosis (respiratory compensation may be present initially)
Electrolytes: Potassium (may be initially high, then become depleted), sodium (often elevated), phosphorus (may be low)
Serum osmolality: Elevated
VIII. Assessment:
Diabetic ketoacidosis based on clinical presentation (altered mental status, Kussmaul respirations, dehydration) and laboratory findings (hyperglycemia, ketonemia, metabolic acidosis).
Severity of DKA (mild, moderate, severe) – based on blood pH, bicarbonate level, and mental status.
Identify potential precipitating factors (illness, medication non-adherence).
IX. Plan:
Fluid resuscitation: Intravenous fluids (isotonic crystalloids) to correct dehydration and electrolyte imbalances.
Insulin therapy: Intravenous insulin administration to correct hyperglycemia and promote ketone clearance.
Electrolyte replacement: Potassium, sodium, and phosphorus replacement as needed based on lab results.
Continuous glucose monitoring (CGM) or frequent blood sugar checks: Close monitoring of blood glucose levels to guide insulin therapy.
Underlying cause management: Address any identified precipitating factors (e.g., antibiotics for infection).
Nutritional support: Once hemodynamically stable and ketonemia resolves, provide appropriate nutrition to prevent further complications.
X. Prognosis:
Discuss the prognosis based on the severity of DKA and prompt initiation of treatment.
Early diagnosis and treatment can lead to successful reversal of DKA and prevent complications.
XI. Notes:
Address the patient’s concerns and those of family members.
Provide education on DKA risk factors, signs and symptoms, and importance of medication adherence.
Document education provided and patient understanding.
XII. Resources:
Consider providing patient education materials on diabetic ketoacidosis from reputable sources (e.g., American Diabetes Association (ADA), American Association of Clinical Endocrinologists (AACE)).