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A 9-month-old patient presented to the pediatric emergency department with difficulty breathing after being seen briefly in clinic. His mother first noticed his symptoms of excessive drowsiness and lack of appetite 2 days prior. These symptoms would later progress to vomiting and difficulty breathing. The mother denied a fever and diarrhea in the last week, but did state the child had simultaneous ear infections treated with a 10-day course of amoxicillin 3 weeks ago. The mother did recount recent introduction of solid food and a father-in-law with type 1 diabetes mellitus. Initial evaluation in the emergency department revealed tachypnea, tachycardia, intercostal retractions, decreased capillary refill and peripheral pulses. Given the patient's severe dehydration, respiratory distress, and the fact that he met SIRS (systemic inflammatory response syndrome) criteria, intravenous access was obtained and the patient was given a bolus of normal saline and intubated. Initial laboratory tests revealed bicarbonate of 8 mmol/L, glucose of 431 mg/dL, and an ammonium level of 109 mcg/dL. A venous blood gas (VBG) was obtained that showed an appreciable anion gap and a pH of 6.9. At this point the patient was determined to most likely be in DKA and insulin was given. Urinalysis would later confirm the diagnosis of diabetic ketoacidosis (DKA) by meeting criteria of a pH less than 7.3 or bicarbonate less than 15 mmol/L, glucose greater than 200 mg/dL, and presence of urine ketones. Subsequent VBG would reveal improvement in the patient's blood pH. The patient continued to improve clinically, was extubated the following day, and released from the hospital 4 days later. Final DiagnosisDiabetic ketoacidosis secondary to type 1 diabetes mellitus.