A 4-Year-Old Girl in Significant Distress

Alba Morales Pozzo, MD


March 05, 2019

Physical Examination and Workup

Upon physical examination, her vital signs are as follows:

  • Blood pressure: 80/40 mm Hg

  • Pulse: 165 beats/min

  • Temperature: 98.5°F (36.9°C)

  • Weight: 30 lb (13.6 kg; 10th percentile)

  • Height: 40 in (101.6 cm; 65th percentile)

The initial examination reveals an ill-appearing, severely dehydrated, and almost obtunded toddler. Her head and neck findings are normal except for dry lips, sunken eyes, and dry oral mucosae. Chest, abdominal, and extremity examinations reveal only a delayed capillary refill of 3-4 seconds. A neurologic examination is remarkable for somnolence. No skin lesions are noted.

Her initial laboratory findings are noted in the following table:

Table. Initial Laboratory Findings

Measurement Reference Range Patient's Results
Venous pH level 7.32-7.43 6.95
Glucose level 60-99 mg/dL 877 mg/dL
Hematocrit level 32%-40% 50%
Venous pCO2 level 40-55 mm Hg 5 mm Hg
Venous bicarbonate level 22-26 mEq/L <5 mEq/L
Anion gap 6-16 mmol/L 34 mmol/L
Serum osmolality 275-295 mosm/kg 312 mosm/kg

Management for severe diabetic ketoacidosis was rapidly implemented (intravenous rehydration and insulin therapy as per hospital protocol). A right femoral central venous catheter (CVC) was inserted for quick fluid resuscitation while in the ED. Twenty-eight hours after her admission to the intensive care unit, her parents note that she refuses to bear weight on her right leg, which now appears to be swollen.

The patient is awake, alert, and answers questions appropriately. She appears much improved compared with her physical examination upon admission, with moist, pink mucosae and brisk capillary refill. Her head and neck examination findings are normal. Her lung and heart sounds are normal. An abdominal examination is unremarkable.

Her right lower extremity is noted to be edematous from mid-foot to just above her knee. The pedal, posterior malleolar, and popliteal pulses on the right leg are palpable. The skin over the leg has mild erythema and is warm to the touch, with no visible lesions. She avoids putting weight on her right foot when she tries to stand and appears to be in moderate discomfort as she stands.


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