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Clinical Case Presentation February 2024

Prepared by Dr Lee AV

Supervised by Dr Terence Ong (Universiti Malaya Medical Centre)


  • Mrs FA, a 65-year-old woman, lost her balance and fell on her right hip. She presented to the emergency department 3 hours later, complaining of severe pain over her right hip and unable to ambulate.

  • There was no history of fever, nausea, vomiting, diarrhoea, or other symptoms indicating an infectious disease. She has no recent weight loss.

  • She has multiple comorbidities, which included Type 2 Diabetes Mellitus, diagnosed 8 years ago, dyslipidemia and bilateral knee osteoarthritis.

Social History

  • Married with 5 children

  • Lives with husband and eldest son

  • Ex-smoker

  • Worked as an executive at a business corporation

  • Education level: Degree


  • Medications included gliclazide modified release(MR), dapagliflozin and metformin combination, with ezetimibe and atorvastatin combination. There was no history of steroids, traditional supplements or alcohol consumption.

  • Prior to the fall, she was living with mild frailty (clinical frailty scale 5) and was able to ambulate with a walking stick.

Clinical examination

  • On examination, her temperature was 36.4°C, blood pressure 173/88 mmHg, pulse 108 beats per minute, oxygen saturation 100% on room air and respiratory rate 20 breaths per minute. Clinically dry. Her DXT was 5.4 mmol/L.

  • She has a BMI of 23.37 kg/m2. Her Glasgow Coma Scale was 15/15. AMTS 9/10.

  • The right lower limb was shortened and externally rotated, with tenderness over the right hip. She was able to move her ankle dorsiflexors, plantar flexors, and extensor hallucis longus.

  • The sensation was intact to light touch over the medial, lateral, dorsal, plantar, and first dorsal web space. Dorsal is pedis pulse was palpable 2+.


  • Her pelvic X-ray revealed a right pertrochanteric femur fracture.

  • Regular analgesic syrup morphine and tablet paracetamol were served.

  • She was planned for Right Trochanteric femoral nail.


  • The patient was fasting for 8 hours for the operation. However, it was noted she had sinus tachycardia (pulse 111 beats per minute), was clinically dry, BP 131/73mmHg, temperature was 36.6°C, oxygen saturation 100% on room air and respiratory rate 20 breaths per minute. Repeated DXT was 5.4 mm ol/L.

  • Her chest was clear to auscultation bilaterally. Heart sounds were at a regular rate and rhythm. The abdomen was benign.

  • ECG showed sinus tachycardia with no acute ischemic changes.

  • The chest radiograph was normal.

Blood investigations

  • FBC: WCC 10, Hb 14, Plt 178

  • Renal profile: Na 135, K 3.2, Ur 2.5, Cr 37, chloride 105

  • Electrolytes: Ca 2.25 (corrected), Phos 0.85, Mg 0.7

  • Liver function: Bil 16, ALP 84, ALT 17, Albumin 32

  • HbA1c 8.2%

  • VBG : pH 7.32, HCO3 15.7, BE -13.4, lactate 0.7

  • UFEME Glucose 3+, ketone 2+

  • serum ketone 5.6


  1. What would be the provisional diagnosis?

  2. What would be the provisional diagnosis?

  3. How will you manage this patient?

  4. What are the challenges in managing diabetic emergencies in older adults?

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  1. What would be the provisional diagnosis? 

  • euglycemia ketoacidosis ( triad comprising high anion gap metabolic acidosis with positive serum and urine ketones when serum glycemic levels are <250 mg/dL)

2. what is the precipitating factor in this case?

  • recent use of SGLT2 inhibitor

  • prolonged fasting

  • dehydration

  • hip fracture (trauma)

3. how will you manage this patient? 

  • withhold SGLT2 inhibitor 

  • Start Fluid Replacement With Monitoring of Electrolytes and Ketones

  • Continuous insulin infusion, starting at a rate of 0.05 U/kg/hour to 0.1 U/kg/hour , with IVD Dextrose Administration

  • Prophylactic LWMH (withhold 12hours prior to operation)

  • Expedite surgery : minimize the duration of perioperative fasting (liaise with aneast to schedule OT list as afternoon case, allowed a light meal for breakfast, carbohydrate-rich drink up to…

Replying to

Good reminder to all of us esp sglt2i has been so promising in the realm of DM and HF mx


So cryptic! I am sure you meant to say Euglycaemic Diabetic Ketoacidosis.


Reminder (to me as well ..)to tell patient about sick day rules when putted on SGLT inhibitor.

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