A patient on insulin therapy develops capillary glucose 15 mmol/L and ketones 4.5 mmol/L. What is the most appropriate immediate course of action?

• A. Optimize insulin dosing and monitor
• B. Increase fluids and recheck in 1 hour
• C. The patient shows signs of diabetic ketoacidosis and requires an urgent medical review
• D. Start oral rehydration therapy only

Answer: (C)

Ketones found with elevated blood glucose in a patient on insulin strongly points to diabetic ketoacidosis or at least impending DKA, which needs urgent medical evaluation. The presence of significant ketonemia indicates that the body is in a state of insulin deficiency relative to needs, leading to acidosis and dehydration if not treated promptly. In suspected DKA, the immediate plan is hospital-based management with fluid resuscitation, electrolyte correction (especially potassium), and insulin therapy as indicated, all under close monitoring. Outpatient tweaks like pushing more fluids and rechecking later or simply optimizing insulin dosing do not address the underlying acute metabolic derangements and can allow progression to dehydration, electrolyte disturbances, and worsening acidosis. Starting oral rehydration only also falls short because it won’t correct the acid-base imbalance or the insulin deficiency driving the ketosis. Therefore urgent medical review is the appropriate course of action.