What is the approach to taking a history for a patient with diabetic ketoacidosis (DKA)?

Approach to Taking a History for a Patient with Diabetic Ketoacidosis (DKA)

When taking a history from a patient with suspected DKA, focus on identifying precipitating factors, particularly infection (occurring in 30-50% of cases), medication non-compliance, and new-onset diabetes, as these are critical for proper management and prevention of recurrence. 1, 2

Key Components of DKA History

Cardinal Symptoms

• Polyuria, polydipsia, polyphagia (classic diabetes symptoms)
• Weight loss
• Nausea, vomiting, abdominal pain (present in up to 25% of DKA cases)
• Weakness and fatigue
• Altered mental status (ranging from alertness to drowsiness or coma)
• Dyspnea or Kussmaul respirations (deep, rapid breathing)
• Duration of symptoms (DKA typically evolves over 24 hours, while HHS develops more gradually)

Precipitating Factors

1. Infection (most common trigger - 30-50% of cases) 2

   • Urinary tract infection
   • Pneumonia
   • Other infections (skin, dental, etc.)

2. Insulin-related issues

   • Missed insulin doses or inadequate insulin administration
   • Insulin pump failure
   • Recent changes in insulin regimen

3. New-onset diabetes (especially in children)

4. Medication-related

   • Recent use of SGLT2 inhibitors (can cause euglycemic DKA) 3
   • Use of medications that affect carbohydrate metabolism:
     • Corticosteroids
     • Thiazide diuretics
     • Sympathomimetic agents (dobutamine, terbutaline)

5. Other medical conditions

   • Recent surgery or trauma
   • Myocardial infarction
   • Cerebrovascular accident
   • Pancreatitis
   • Alcohol consumption
   • Psychological stress

Diabetes History

• Type of diabetes (type 1 or type 2)
• Duration of diabetes
• Previous episodes of DKA and precipitating factors
• Current diabetes management:
  • Insulin regimen (type, dose, timing)
  • Oral medications
  • Blood glucose monitoring practices
  • Recent HbA1c results (typically elevated >10%) 4

Recent Medical History

• Recent illnesses or stressors
• Changes in appetite or fluid intake
• Sick day management practices
• Recent medication changes
• Access to medical care and medications

Special Considerations

Euglycemic DKA

• Ask about SGLT2 inhibitor use, as these medications can cause DKA with normal or only slightly elevated blood glucose levels (<250 mg/dL) 3
• Recent insulin use, decreased caloric intake, alcohol consumption, pregnancy, liver disease

Pediatric Patients

• New-onset diabetes is a common cause of DKA in children
• Focus on duration of symptoms, recent illnesses, and weight loss

Elderly Patients

• Higher mortality risk in this population 2
• Assess for comorbidities that may complicate management

Pitfalls to Avoid

1. Overlooking euglycemic DKA: Don't rule out DKA based on normal blood glucose levels alone, especially in patients taking SGLT2 inhibitors 3

2. Missing subtle presentations: Elderly patients or those with chronic diabetes may present with atypical symptoms

3. Incomplete medication review: Always ask specifically about insulin adherence, recent medication changes, and SGLT2 inhibitor use

4. Failure to identify infection: Patients with DKA may be normothermic or hypothermic despite infection; hypothermia is a poor prognostic sign 5

5. Neglecting psychosocial factors: Issues like financial constraints, health literacy, and access to care can contribute to DKA episodes

By systematically addressing these key components in your history-taking, you can identify the underlying cause of DKA, guide appropriate treatment, and develop strategies to prevent recurrence. Remember that patient education about diabetes self-management and sick day protocols is essential for preventing future episodes of DKA 1.