The remainder of the physical examination is unremarkable.

Deep tendon reflexes are 4+ with bilateral clonus at the ankles. Neurologic/psychiatric examination shows that the patient is conscious but oriented to person and place only. Extremities/spine examination shows 4+ pitting edema in both lower extremities to the midthigh region. The cervix is dilated to 1 cm and 50% effaced. Genital examination reveals an edematous vulva. The fetus is cephalic by palpation with a fetal heart rate of 144 beats/min. Abdominal examination shows a gravid uterus with a fundal height of 37 cm. There is marked vasospasm on funduscopic examination with normal disc margins and a minor tongue laceration. There is a grade 2/6 systolic ejection murmur at the left sternal border without radiation.

Cardiovascular examination shows a loud S4 and bounding central and peripheral pulses. Physical examination shows tachycardia, a low-grade fever, and elevated blood pressure. In this particular patient, the history of type 1 diabetes mellitus presenting with prolonged nausea and vomiting and lethargy and drowsiness, combined with the physical examination findings of fever, thready pulses, tachycardia, signs of dehydration, and diffuse abdominal tenderness are highly suggestive of the diagnosis of diabetic ketoacidosis due to infection and inadequate insulin. Taken together, the history and physical examination findings support the initial impression of complications of type 1 diabetes mellitus. Neurologic/psychiatric examination shows that the patient is lethargic but oriented. Abdominal examination reveals diffuse mild tenderness without guarding, rebound, or masses. HEENT/neck examination shows dry mucous membranes. Cardiovascular examination shows thready central and peripheral pulses. Physical examination reveals elevated temperature, tachypnea, tachycardia, and hypotension. The patient appears drowsy, lethargic, and acutely ill.

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