Diabetes Inpatient Resident Expectations

A structured guide for residents presenting inpatient diabetes cases at CHLA Pediatric Endocrinology — covering the admission HPI framework and the daily SOAP note format including insulin management, electrolyte surveillance, cerebral edema risk, and discharge readiness.

HPI

Symptoms

• Polyuria, polydipsia, polyphagia
• Nausea, vomiting, abdominal pain
• Fatigue, weight loss (new onset)
• Altered mentation or decreased consciousness (severe)

ED Course

• Presenting vitals and triage acuity
• Initial fluid bolus — volume and rate
• Insulin initiation — time and rate
• Key labs resulted in the ED
• Disposition decision (floor vs. PICU)

Physical

• General appearance and level of distress
• Tachycardia, Kussmaul breathing, hypotension
• Hydration: mucous membranes, skin turgor, cap refill
• Neuro: alertness, orientation, oculomotor exam
• Abdomen: tenderness (common in DKA)

Labs

Diagnostics

• pH — venous or arterial blood gas
• Bicarbonate — from BMP or blood gas
• Glucose — serum or POC
• Ketones — BHB preferred; or urine ketones

Additional values

• Neuro exam — baseline mental status at presentation
• Corrected sodium — Na + 2.4 × [(glucose − 100) ÷ 100]
• Potassium — must be repleted before or concurrent with insulin

SOAP

Subjective

Management — last we spoke

• Insulin drip status — current rate, or if weaned/discontinued
• MDI regimen (if transitioned or pre-existing)
  • Basal — units and time
  • ICR (Insulin-to-Carbohydrate Ratio)
  • ISF (Insulin Sensitivity Factor) and threshold ("target")
• Electrolytes supplementation — active orders (K, Mg, Phos); concentrations in IVF or oral

Overnight events

• Basal insulin — exact time and units given overnight
• Hyperglycemia corrections — units of rapid-acting insulin administered and triggering BG values
• RN concerns
• Family-elicited concerns

Objective

Vitals

• HR, RR, BP

Physical exam

• Neuro — awake (or arousable), alert, oriented ×3; oculomotor exam (CN III, IV, VI)
• Hydration — mucous membranes, cap refill; reconcile with HR/BP
• Injection sites
• Cardiac — sinus rhythm

Labs

• DKA status — pH, HCO₃ (goal ≥ 18 mEq/L for resolution)
• Electrolytes surveillance — corrected sodium, potassium, magnesium, phosphorus
• Glucose range — goal 70–180 mg/dL; hypoglycemic events (< 70): treatment (juice, D10 bolus)
• Any other concerning labs

Assessment

One-liner

• DKA initial status — severity at presentation (mild / moderate / severe)
• DKA status — resolved or unresolved

Problem-based plans

Hyperglycemia

• Basal — dose, timing, adequacy of overnight coverage
• ICR — current ratio; assessment of post-prandial control
• ISF & threshold — sensitivity factor and correction target
• Assessment of glycemic control and recommendations

Electrolyte derangement

• Current supplementation — oral vs. IV; which electrolytes
• Frequency of lab checks

Risk of cerebral edema

• Document risk explicitly at every encounter
• Flag: headache, irritability, altered mental status, bradycardia, focal neuro changes
• Oculomotor exam findings if abnormal

Discharge readiness

• Family cleared by Diabetes RN, RD, SW Education complete; social work assessment done
• Prescriptions sent and secured Insulin, supplies, CGM — confirmed with specialty pharmacy
• Follow-up scheduled
• Anticipatory guidance provided
• Diabetes Hotline confirmed — 323-361-2311

Anticipatory guidance

• DKA — nausea/vomiting/headache; glucose > 250 mg/dL for 3 or more hours despite correction with rapid-acting insulin (Humalog/Lispro)
• Hypoglycemia — 2 or more episodes < 70 mg/dL on fingerstick