22 year old male with altered mental status

The following scenario is from the application Resuscitation:

You arrive on scene to a 22 year old male with altered mental status.

His girlfriend provides the history, and reports that the patient has been in bed for the last two days complaining of a complete lack of energy. His symptoms are associated with extreme weight loss of approximately 4.5kg. He was urinating more than normal but has since improved.
She denies any previous known episodes.
He denies fever, chest pain, dyspnoea, or back pain.
He does have some nausea and vomited a couple of times the other day. The vomiting was non bloody.

Next steps?

Humm...

Check all basic obs.

Has the Pt been eating/drinking? Check BM reading? Skin turgor. How rapid has the weight loss occurred? Access GCS, fast test. PEARLA. Ask if any headache occured, if so what was it like (thunder clap, tension, any visual disturbances). Any recent travel (infection risk areas)?

Any burning/funny smells when urinating? Any signs of odema in the legs?
PMH??

Ok:

Scene safe
Response:Alert, but speaking in one/two word responses A: Patent B: Deep Respirations, tachypnoeic C: Thready pulses.

Obs:
Hr 108
RR 40
Sats 88
BP 96/60
Temp 37
BM 54.7

Weight loss has been 10lb over the last few days. FASTneg GCS 14/15 - E4V4M6 PEARLA normal, no headache. Urine glucose +++ no oedema in legs.

PMH patient denies history.

What next?

Oh wow! Interesting obs...

Administer 15Lts high flow O2. Confirm if any respiratory disease and titrate as necessary. Elevate legs. Coach breathing aiming for 12-20.

IDDM? Taken Insulin today? If new onset may present as Diabetic ketoacidosis.

Check for signs of dehydration and administer fluids if necessary. ECG.

Pre alert PD09 and scoot on out of there!

The high flow oxygen reduces the RR to 27 and sats increase to 94%. Patient struggles to coach respirations and still maintains deep breathing. Bp improves.

Not known diabetic. However patient is presenting with possible Diabetic Ketoacidosis.

ECG: https://upload.wikimedia.org/wikipedia/commons/d/d7/12_lead_sinus_tachycardia_young.JPG

?fluid therapy - discuss.

Any differentials?

Not a clue about fluids... I guess if pt is dehydrated then start a 0.9% sodium chloride fluid infusion??

Any breath sounds indicated for the use of SAL? Might help to bring RR down.

Diagnosis at this stage:

Hyperglycaemic episode.

Poss pt is unaware they have IDDM.

? PE. Any cough? recent travel? Distended neck veins?

Ok so as per ambulance guidelines only fluids given if the patient is dehydrated.

The diagnosis is Diabetic Ketoacidosis. The increased, deep respirations (Kussmaul's breathing) is associated with metabolic acidosis.

Potential differentials:

Alcoholic ketoacidosis
Acute pancreatitis
Salicylate (Aspirin) toxicity
Septic shock and Pulmonary Embolism to consider.