Vomiting and abdominal pain

A 24-year-old Ghanaian female known type 1 diabetic presented with a 3-day history of vomiting, abdominal pain, polyuria, and polydipsia. She had stopped taking her insulin 5 days ago due to inability to afford medication. She appeared drowsy and dehydrated on arrival. No fever.

GCS: 12/15. BP: 90/60 mmHg, HR: 124 bpm (weak and thready), RR: 26/min (Kussmaul breathing), Temp: 37.0°C. Fruity breath odour noted. Skin: dry with poor turgor. Abdomen: generalized tenderness. Eyes: sunken.

Blood glucose: 28mmol/L. ABG: pH 7.12, HCO3 8mmol/L, PaCO2 20mmHg. Serum ketones: strongly positive. Urine ketones: 4+. Na 132, K 3.1 (total body deficit), Cl 98, HCO3 8. Urine: glucose 4+, ketones 4+. FBC: WBC 18×10⁹/L. CXR: clear.

Diabetic Ketoacidosis (DKA) secondary to insulin non-compliance

IV fluid resuscitation: 1L 0.9% saline over 1 hour, then guided by clinical response. Fixed-rate insulin infusion 0.1 units/kg/hr. Potassium replacement (3.1→3.5 before insulin). Hourly monitoring: glucose, ketones, electrolytes. Resolved precipitating cause (non-compliance). Patient education on insulin importance. Linked to subsidized insulin program.

• 1. DKA is defined by the triad: hyperglycaemia, ketonaemia, and metabolic acidosis.
• 2. ALWAYS check potassium before starting insulin - hypokalaemia can be fatal.
• 3. Do NOT start insulin if K+ <3.5mmol/L.
• 4. Kussmaul breathing is a compensatory respiratory alkalosis.
• 5. Non-compliance and infection are the most common precipitants in Africa.