Vet AI Scribe for Emergency Critical Care

Ziggy

Saturday, September 13, 2025 at 2:07 AM

ICU admission — hour 0

Subjective

Chief Complaint

Referred overnight for collapse, vomiting and profound lethargy in a 9-year-old neutered male miniature schnauzer with newly diagnosed diabetes mellitus.

History

• Diagnosed diabetic 11 days ago; started on 4 units NPH insulin q12h.
• Owner reports the last two doses were skipped because he would not eat.
• Vomiting four times in 24 hours; polyuria and polydipsia marked for the past week.
• Previous history of pancreatitis 14 months ago.
• No toxin exposure. No other medications.

Objective

Vitals on Presentation

• Weight: 9.1 kg
• Temperature: 99.2°F
• Heart rate: 168 bpm
• Respiratory rate: 48 breaths/min, deep and regular
• Blood pressure: 82 mmHg mean (oscillometric)
• Mucous membranes: Tacky, brick red; capillary refill 3 seconds
• Mentation: Obtunded, responsive to touch
• Estimated dehydration: 10%

Point-of-Care Diagnostics

• Blood glucose: 512 mg/dL
• Blood ketones (beta-hydroxybutyrate): 5.8 mmol/L
• Venous blood gas: pH 7.11, pCO2 22 mmHg, HCO3 8 mmol/L, anion gap 29
• Sodium: 138 mmol/L Potassium: 3.1 mmol/L Chloride: 104 mmol/L
• Phosphorus: 2.4 mg/dL
• Lactate: 4.1 mmol/L
• PCV/TS: 58% / 8.4 g/dL
• Urinalysis: Glucosuria 4+, ketonuria 3+, specific gravity 1.028

Physical Exam

• Abdomen: Tense on cranial palpation; pain response localised
• Cardiac: Sinus tachycardia; no murmur; femoral pulses weak but synchronous
• Respiratory: Kussmaul pattern; lungs clear on auscultation
• Skin: Reduced turgor over the dorsum

Assessment

Primary Problem List

1. Diabetic ketoacidosis — pH 7.11, beta-hydroxybutyrate 5.8 mmol/L, high anion gap
2. Hypovolaemic shock — mean arterial pressure 82 mmHg, lactate 4.1 mmol/L
3. Hypokalaemia (3.1 mmol/L) — will fall further once insulin and fluids begin
4. Hypophosphataemia — at risk of haemolysis
5. Suspected pancreatitis as the precipitating illness

Differentials for the Precipitating Cause

• Acute pancreatitis (most consistent with history and abdominal pain)
• Urinary tract infection
• Hyperadrenocorticism
• Insulin under-dosing from the two skipped doses alone

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Plan

Stabilisation — first 6 hours

• Fluids: Balanced isotonic crystalloid, 20 mL/kg bolus over 20 minutes, reassess; then rehydrate the remaining deficit over 12-24 hours
• Potassium: Supplement to 40 mmol/L in the fluid bag at current serum potassium; recheck at 4 hours before any insulin is started
• Insulin: Withhold until potassium is above 3.5 mmol/L and volume is restored. Then regular insulin CRI at 0.05-0.1 U/kg/hr, titrated to a glucose fall of no more than 50-75 mg/dL per hour
• Dextrose: Add to fluids once glucose falls below 250 mg/dL, to allow the insulin CRI to continue clearing ketones
• Analgesia: Methadone 0.2 mg/kg IV q4h
• Antiemetic: Maropitant 1 mg/kg IV q24h

Monitoring

• Blood glucose hourly during the insulin CRI
• Electrolytes and venous blood gas q4h for the first 24 hours
• Phosphorus q12h; supplement if below 1.5 mg/dL
• Blood pressure, mentation and urine output q2h
• Body weight q12h as a fluid balance check

Further Diagnostics

• Canine specific lipase
• Abdominal ultrasound once haemodynamically stable
• Urine culture
• Full biochemistry and CBC

Transition Criteria

• Move to intermittent subcutaneous insulin once eating voluntarily, ketones resolving, and acid-base normalised

Client Communication:
Owner updated at admission and at the four-hour recheck. Explained that the two skipped insulin doses did not cause this on their own — that an underlying illness, most likely pancreatitis, is driving both the vomiting and the ketosis, and that treating the diabetes alone will not be enough. Set the expectation of two to four days in hospital with hourly monitoring, and reviewed the specific risk that correcting the sugar too quickly is more dangerous than correcting it slowly. Estimate provided and approved.

— Dr. Samuel Achebe, DVM, DACVECC