HISTORY:
for
Blood glucose level:
Recent HbA1c level: %
, episodes , ,
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Skin:
Extremities: , , cap refill , pulses ,
Neurologic: cranial nerves , strength , sensation , reflexes , cerebellar function , gait
Mental status: , , speech , mood , thought process , , judgment
ASSESSMENT:
,
DDx:
PLAN:
- Blood work: , , , , ,
- Urinalysis
- ECG
- Chest X-ray
- Follow protocol
- Normal saline 1L bolus, then 500cc/h x2h, then 250cc/h x4h
- KC 20 meq/L at 150cc/h if K less than 5.5 (must have urine output)
- 0.1 units/kg/h (stop when pH normalized)
- Bicarbonate infusion if pH < 7.0-7.1
- Urine output monitoring
- Referral to ER
- Monitor glucose level every 1 hour
- Monitor electrolytes and blood gas every 2 hours
- Monitor vital signs every 15 minutes
- Admission to intensive care unit
- Referral to endocrinologist
- Follow-up in