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Final clinical long case 55

Created: 27/3/2015
You are presented with a 20-year-old woman, 32 weeks pregnant, who is diabetic (insulin dependent).She has various social issues; for example, her father steals her insulin. She has had repeated presentations during this pregnancy with poorly controlled BMs. She is currently presenting with abdominal pain, nausea and vomiting and an infected hand.


Urea and electrolytes: raised urea
Full blood count: raised white cells and haemoglobin 10.0 g/dl.
Arterial blood gases: bicarbonate around 12 mEq/L
pH: 7.2
CO2: around 3.5 kPa
ECG: normal
Urine dipstick analysis: Ketones +++ and glucose ++


1. Summarise the case
2. What are the salient points?
3. What is your differential diagnosis?
4. Discuss the management of diabetic ketoacidosis.
5. How would you anaesthetise the patient for exploration of the hand?
6. You are asked to interpret an ultrasound image of the patient’s brachial plexus.
7. The patient begins to fit on injection of local anaesthetic; what is the differential diagnosis?

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