Make the diagnosis, Part II of III


You are all pretty much on track, but the final diagnosis still hasn’t been mentioned! I was thinking pretty much teh same as all you guys, that 1) I have to get him slowed down, 2) He’s gotta be in DKA and 3) why is he so calm and “with it” for someone in DKA????

A stat accucheck was around 300. High, but wouldn’t really explain DKA too well, besides, no history of diabetes, and he actually did see his doctor once in awhile. He kept complaining of being nasueated…I attributed that to his anginal equivalent and told him it would go away when we slowed his heart down.

First, we established 2 working IV lines, I had a tech pull the code cart up outside the room. The EKG machine ran a continuous 3 lead while my super nurse pushed first 6 mg of adenosine (rapid IV push followed by saline flush). Nothing. Not even a tiny bit of slowing. Then we pushed 12 mg followed by a huge 50ml saline rapid flush. Nothing.

OK, time for some “sleepy” medicine. After obtainign a quick verbal consent for conscious sedation and electric cardioversion, we gave 10mg of Etomidate, then 50J synchronized across his chest wall. One of the new nurses got to do it, she had never been in this type of code before. Our ER techs are also paramedics, so teh airway was well covered at the head of the bed, “just in case.” Of course, before I put anyone to sleep, airway adjuncts are ready, including suction & bag valve mask, dentures removed (learned that lesson already).

One shock (“THAT HURT,” he said, then went back to sleep) converted him to a sinus tachycardia at 140. I had to look at multiple monitors and strips to be convinced it was sinus, but 140 was a heck of a lot slower than 220.

First goal was accomplished, now I had to figure out what was really going on. DKA just didn’t quite fit, but the nurse insisted he smelled like ketones. Hyperosmolar Coma was out as well because, well, he wasn’t in a coma. In fact he was really pleasant. I ordered the following labs.

CBC, Lytes, BUN, Cr, Glucose, Ketones, ETOH, Urine drug screen, Serum Osmalarity.

Glucose 230
CBC hemocontrated (WBC 20, Hb 17, Plt 350)
Acetone 40
ETOH 21 mg/dl
Urine normal
Osmolar gap 40
Bun 18/Cr .9

When I got them back, I asked his mother to step out of the room so we could talk. “It’s OK,” he said with a smile,” I’m a momma’s boy.” With little prompting, he gave me a classic history for the final diagnosis.

What was the diagnosis, and what was the history?

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