Teachable Moments Teaching Demonstrations Script
Case presentation, PART 1:
Learner: I’ve just seen a 23 year-old female who has fever, lightheadedness, dysuria, and back
pain. She has had type 1 diabetes for about 3 years and, she says, really has been in pretty good
control. Vital signs include a temperature of 39.7 degrees C, pulse 110, and BP 90/56 with a
little drop when she sits up. On exam, her lungs were clear, the heart was fast but I didn’t hear
any murmurs, she had a kind of quiet abdomen but not really painful, and there was tenderness
when pounding her back--you know, CVA tenderness. All we have lab-wise is a urinalysis with
4+ glucose, “large” ketones, and a positive nitrite test. Her fingerstick blood sugar was >600.
Preceptor: Well, it’s obvious she has pyelo triggering DKA. She needs to be admitted for IV
fluids and antibiotics and insulin. You need to call the triage officer.
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PART 2:
Learner: …blood sugar was >600.
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Preceptor: Why do you think she has a fever?
Learner: Well, she has pyelonephritis.
Preceptor: Why do you say that?
Learner: She has fever, dysuria, back pain, and an abnormal urine.
Preceptor: Why do you get fever with a UTI or pyelo?
Learner: Inflammation releases endogenous pyrogens and…
Preceptor (cutting learner off): What else could cause these findings? How come you haven’t
mentioned anything about her diabetes? If she has DKA, which you haven’t even mentioned
yet, she should be dehydrated. Is she? Does she look sick?
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PART 3:
Learner: …blood sugar was >600.
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Preceptor: You know, the management of diabetic ketoacidosis can be quite challenging--you
do think she has DKA, don’t you? There are several things you need to think about, especially in
regards to insulin…
5 MINUTES LATER (with learner looking restless and bored)
…adherence to this type of regimen is particularly difficult for someone of this age who hasn’t
had previous problems with her diabetes…
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PART 4:
Learner: …blood sugar was >600.
Preceptor: Let’s see if we can figure out what’s going on. What features of her current illness
are most concerning?
Learner: Her fever, rapid pulse, orthostatic hypotension, elevated glucose…
Preceptor: Why do these concern you?
Learner: It could mean she has diabetic ketoacidosis.
Preceptor: Is DKA the only illness that presents like this your woman?
Learner: I guess pyelo could do it as well, except for the glucose.
Preceptor: What findings suggest pyelo?
Learner: The fever, dysuria, back pain--you know, costovertebral pain--and, of course, the
abnormal urine.
Preceptor: So, if these go together, how do you suppose the pyelo triggered DKA?
Learner: Infection causes an increase in metabolic rate, with increase in insulin requirement
and maybe some kind of insulin block, I guess…
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PART 5:
Learner: …blood sugar was >600.
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Preceptor: What do you think is going on with this young woman?
Learner: I think she might have DKA.
Preceptor: Can you explain your reasoning?
Learner: She has fever, dysuria, CVA tenderness, orthostatic blood pressure, and um, elevated
glucose, ketones, and nitrite positive dipstick urine. She probably has DKA started by the pyelo.
Oh gosh, I forgot to ask when she last took her insulin.
Preceptor: Your reasoning makes sense. You identified many of the key features of the Hx and
PE and you pointed out important lab test abnormalities. But we need to know about her
adherence to the insulin regimen, especially if she tried increasing her dose, or even when the
last does was. We must figure out her fluid status, something you didn’t mention much in the
presentation. When I see someone with diabetes who is this sick, and no doubt she does have
DKA, I try to think about my first intervention and that always includes hydration. You can
correct many of her problems with IV fluids, assuming she’s as dry as I suspect. Let’s go take a
look. You can tell me your other plans after we see her.