DKA Practice Questions

Question 1

A 27-year-old man with a past medical history of type I diabetes mellitus presents to the emergency department with altered mental status. The patient was noted as becoming more lethargic and confused over the past day, prompting his roommates to bring him in. His temperature is 99.0°F (37.2°C), blood pressure is 107/68 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air. Laboratory values are ordered as seen below.

Serum:
Na+: 144 mEq/L
Cl-: 100 mEq/L
K+: 6.3 mEq/L
HCO3-: 16 mEq/L
BUN: 20 mg/dL
Glucose: 599 mg/dL
Creatinine: 1.4 mg/dL
Ca2+: 10.2 mg/dL

Which of the following is the appropriate endpoint of treatment for this patient?

Accepted Answer

Normal anion gap

Answer

Clinically asymptomatic

Answer

Normal glucose

Answer

Vitals stable

Answer

Normal potassium

Question 2

A 17-year-old male presents to your office complaining of polyuria, polydipsia, and unintentional weight loss of 12 pounds over the past 3 months. On physical examination, the patient is tachypneic with labored breathing. Which of the following electrolyte abnormalities would you most likely observe in this patient?

Accepted Answer

Hyponatremia

Answer

Hypophosphatemia

Answer

Hypermagnesemia

Answer

Hyperkalemia

Answer

Hyperphosphatemia

Question 3

A 22-year-old woman with a history of type I diabetes mellitus presents to the emergency department with nausea, vomiting, and drowsiness for the past day. Her temperature is 98.3°F (36.8°C), blood pressure is 114/74 mmHg, pulse is 120/min, respirations are 27/min, and oxygen saturation is 100% on room air. Physical exam is notable for a confused and lethargic young woman. Initial laboratory values are notable for the findings below.

Serum:
Na+: 139 mEq/L
Cl-: 100 mEq/L
K+: 2.9 mEq/L
HCO3-: 9 mEq/L
BUN: 20 mg/dL
Glucose: 599 mg/dL
Creatinine: 1.1 mg/dL
Ca2+: 10.2 mg/dL
AST: 12 U/L
ALT: 10 U/L

An initial ECG is notable for sinus tachycardia. Which of the following is the best initial step in management for this patient?

Accepted Answer

Normal saline, insulin, and potassium

Answer

Normal saline and insulin

Answer

Insulin and potassium

Answer

Normal saline and potassium

Answer

Normal saline, insulin, potassium, and sodium bicarbonate

Question 4

A 27-year-old man presents to the emergency department with his family because of abdominal pain, excessive urination, and drowsiness since the day before. He has had type 1 diabetes mellitus for 2 years. He ran out of insulin 2 days ago. The vital signs at admission include: temperature 36.8°C (98.2°F), blood pressure 102/69 mm Hg, and pulse 121/min. On physical examination, he is lethargic and his breathing is rapid and deep. There is a mild generalized abdominal tenderness without rebound tenderness or guarding. His serum glucose is 480 mg/dL. Arterial blood gas of this patient will most likely show which of the following?

Accepted Answer

↓ pH, ↓ bicarbonate and ↑ anion gap

Answer

↑ pH, ↑ bicarbonate, and normal pCO2

Answer

↑ pH, normal bicarbonate and ↓ pCO2

Answer

↓ pH, ↓ bicarbonate and normal anion gap

Answer

↓ pH, normal bicarbonate and ↑ pCO2

Question 5

A previously healthy 14-year-old girl is brought to the emergency department by her mother because of abdominal pain, nausea, and vomiting for 6 hours. Over the past 6 weeks, she has also had increased frequency of urination, and she has been drinking more water than usual. She has lost 6 kg (13 lb) over the same time period despite having a good appetite. Her temperature is 37.1°C (98.8°F), pulse is 125/min, respirations are 32/min, and blood pressure is 94/58 mm Hg. She appears lethargic. Physical examination shows deep and labored breathing and dry mucous membranes. The abdomen is soft, and there is diffuse tenderness to palpation with no guarding or rebound. Urine dipstick is positive for ketones and glucose. Further evaluation is most likely to show which of the following findings?

Accepted Answer

Decreased total body potassium

Answer

Excess water retention

Answer

Serum glucose concentration > 800 mg/dL

Answer

Increased arterial pCO2

Answer

Increased arterial blood pH

Question 6

A 48-year-old man presents with DKA. Initial treatment is initiated with fluids and insulin infusion. Labs show glucose 460 mg/dL, pH 7.18, bicarbonate 10 mEq/L, potassium 4.5 mEq/L, and creatinine 2.8 mg/dL (baseline 1.0). After 4 hours, glucose decreases to 380 mg/dL but pH worsens to 7.12, bicarbonate drops to 8 mEq/L, and lactate is 5.2 mmol/L (initially 1.8). Blood pressure is 85/50 mmHg. Evaluate the clinical situation and necessary intervention.

Accepted Answer

Evaluate for sepsis or other concurrent illness causing lactic acidosis

Answer

Administer additional fluid bolus for persistent hypotension

Answer

Increase insulin infusion rate to accelerate ketone clearance

Answer

Add bicarbonate therapy for worsening acidosis

Answer

Continue current management as DKA takes time to resolve

Question 7

A 25-year-old woman with type 1 diabetes presents with DKA. She admits to intentionally withholding insulin to lose weight. This is her fifth DKA admission in 8 months. Current pH is 7.14, glucose 520 mg/dL, bicarbonate 11 mEq/L. Medical costs exceed $150,000 for recurrent admissions. The team is frustrated. Evaluate the comprehensive management approach beyond acute DKA treatment.

Accepted Answer

Multidisciplinary approach including psychiatry, eating disorder specialist, diabetes educator, and close outpatient follow-up

Answer

Referral to ethics committee for discussion of resource allocation

Answer

Involuntary psychiatric commitment for non-compliance

Answer

Insulin pump placement to prevent future manipulation

Answer

Standard DKA treatment with discharge to outpatient endocrinology

Question 8

A 55-year-old man with type 2 diabetes and end-stage renal disease on hemodialysis presents with DKA. Initial glucose is 580 mg/dL, pH 7.12, bicarbonate 10 mEq/L, and potassium 6.2 mEq/L. He is fluid overloaded with bilateral crackles and peripheral edema. His last dialysis was 3 days ago. Evaluate the optimal management strategy addressing both DKA and renal failure.

Accepted Answer

Insulin infusion with limited fluids and urgent hemodialysis

Answer

Standard DKA protocol with furosemide for fluid management

Answer

Bicarbonate therapy to correct acidosis without fluids

Answer

Subcutaneous insulin with no IV fluids due to volume overload

Answer

Standard DKA protocol with aggressive fluid resuscitation

Question 9

A 38-year-old pregnant woman at 28 weeks gestation with type 1 diabetes presents with nausea and vomiting. Labs show glucose 310 mg/dL, pH 7.27, bicarbonate 15 mEq/L, and positive urine ketones. Fetal monitoring shows reactive non-stress test. She has been taking her insulin but unable to eat for 24 hours due to hyperemesis. Analyze the optimal management approach considering maternal and fetal risks.

Accepted Answer

Aggressive DKA treatment with lower glucose targets (100-150 mg/dL) and close fetal monitoring

Answer

Standard DKA protocol with standard glucose targets (200-250 mg/dL)

Answer

Immediate cesarean delivery followed by DKA treatment

Answer

Conservative management with oral intake and subcutaneous insulin

Answer

Standard DKA protocol with delivery planning after stabilization

Question 10

A 42-year-old man with type 1 diabetes on insulin pump presents with DKA after pump malfunction. He is admitted and started on IV insulin infusion. After 14 hours of treatment, his glucose is 210 mg/dL on D5-0.45% saline, pH 7.36, bicarbonate 19 mEq/L, and anion gap 12. He is alert, eating, and requesting to go home. Evaluate the appropriate transition strategy.

Accepted Answer

Give subcutaneous insulin, overlap for 1-2 hours, then stop IV insulin and observe

Answer

Switch to subcutaneous insulin and discharge immediately

Answer

Stop IV insulin immediately and restart insulin pump at home

Answer

Continue IV insulin for another 6 hours to ensure stability

Answer

Discontinue IV insulin, discharge with oral medications

DKA

Study Resources

Lessons

Questions

Flashcards

Lessons

DKA diagnostic criteria

Precipitating factors identification

Initial assessment and risk stratification

Fluid resuscitation principles

Insulin therapy protocols

Electrolyte management (particularly potassium)

Acid-base monitoring and management

Transition from IV to subcutaneous insulin

Cerebral edema prevention and management

Mixed DKA/HHS management

Special populations (pregnancy, elderly)

Patient education for prevention

Disposition decision making

Practice Questions

Flashcards

About DKA for USMLE

Lessons in DKA

Master DKA