The nurse raises an eyebrow and does a capillary ketone. It takes a while as she has to find the strips, which are kept in a cupboard that no one knows the combination code for as everyone is a locum. Eventually the result comes back as 4.5 mmol/L.

“I hope that was helpful, doctor.”

“I can’t describe how helpful it was,” you say, as you check your indemnity certificate.

The patient’s observations are now: Pulse 146, BP 73/51 mmHg, Temp 37.4, RR 28, Sats 100% oa

The nurse had already bleeped your registrar before you ask. The Med SpR looks at the patient, starts some fluids and asks you what the diagnosis is. You suggest hyperglycemia and possible DKA. The medical registrar asks for the latest pH, bicarbonate and potassium. You instead provide him with a very up to date capillary ketone of 4.5 mmol/L and an awkward smile.

The registrar asks you to go to the doctors office and prepare the post take ward round list for 9am for the rest of this shift. It’s currently 10:30pm.

Score: 1/10 – It’s best to refresh the diagnostic criteria for DKA. Also remember to give fluids in any patient who may be hypovolemic and in shock, provided there are no features of fluid overload.