Forty minutes later, the serum amylase comes back as normal. You can’t wait to tell the patient who was in hypovolemic shock with a blood pressure of 85/60 mmHg when you last saw him the good news.

However, ten minutes before the serum amylase came back, the patient had actually died from his untreated hypovolemic shock. The reason you didn’t find out was because the medical registrar asked switchboard to reroute your bleeps to the tea lady as she might provide safer care.

Score: 1/10 – Maybe a bit harsh, but the point is that the priority when a patient is in shock the priority is to treat the shock. Abdominal pain, vomiting and hyperglycemia can all be features of both pancreatitis and DKA, although the abdominal pain inDKA is generalised and that in pancreatitis tends to be epigastric with radiation to the back. Whether the underlying problem was pancreatitis or DKA, the shock should still have been managed first.

In a patient with glucose and ketones in the urine, you should confirm/rule out DKA with a venous blood gas.