Can someone please help me answer questions 5-7. Please do not attempt to answer
ID: 3513209 • Letter: C
Question
Can someone please help me answer questions 5-7. Please do not attempt to answer the question unless you can answer all three questions. Thank you
CLINICAL CASE 9 Clinical Case 9/2 ENDOCRINE SYSTEM Diabetes mellitus A 14-year-old male is brought to the ER being found unresponsive. The patient's mother, who had not seen the child for over 24 hours, came home to find her son lying on the sofa unresponsive. Copious quantities of black colored vomit were evident. The child is a diabetic and gives himself his own medication. His mother was unsure when her son last took his medication. Blood pressure: 101/72; heart rate: 123; respirations: 32; oral temperature: 34.8°C,pulse oximetry: 100% on room air General: An approximately 65 Kg, thin male who is, in general, responsive only to very loud or painful stimuli. His oropharynx demonstrates very dry mucous membranes and a moderate amount of dried, black material which is strongly Gastrocult positive. His lungs are clear, but display Kussmaul respiratory pattern. Abdomen exam is negative. There are no other pathological findings. 1. How would you proceed from here? Does this patient need an IV? If so, what types of fluid do you want to initiate and at what rate? 2. What basic lab tests would you order? 3. In addition to saline the patient was given a bolus of 10 units of regular insulin IV while waiting for the lab results, do you find it necessary, too risky? A serum glucose determination (Accucheck) was too high to read. How does this affect your differential diagnosis? What additional care would you now render this patient? The results came back shortly thereafter, and showed an arterial blood gas pH of 6.92, CO2 of 9 and a bicarb of 2. The WBC count was 62.6 thousand (62,600), hemoglobin of 14.4 mg/dL, and hematocrit of 43.5%. His chemistry panel demonstrated a serum sodium of 127, potassium 5.2, chloride of 87, CO2 of less than 4. 5. 5, BUN of 32, creatinine 1.5, and a blood sugar of 1,582. The serum ketones were positive at a dilution of 1:32. What is your interpretation of these results? What additional treatment would you add? a. Blood sugar b. Serum ketones c. Dehydration d. Electrolyte changes; What type of acidosis is this? e. BUN and creatinine f. WBC 6. What might trigger a DKA? 7. Would you administer antibiotics?Explanation / Answer
Ans 5)
a. Blood sugar: Blood sugar of 1582 mg/ dL: Normal blood sugar is 120mg/dL, here it is 1582, so its hyperglycaemia. He is having diabetic ketoacidosis. This patient in question is type 1 diabetic [ As he is only 14 years of age, he has inborn error in his insulin( quantitative or qualitative abnormaility in insulin function). So, it is a TYPE 1 ( IDDM) diabetes mellitus, Type 2 diabetis happens in later life due to insulin receptors resistance.]. In type 1 diabetes diabetic ketoacidosis is very common. Body can not utilise the insulin to use circulating sugar, which causes liver to start glucoce production form protein and fats( gluconeogenesis), but as there is abnormality in insulin, created glucose remains in blood and can not be utilised by cells to get energy, as a result blood glucose increases sky high.
b. Serum ketones: Ketones( acetone, acetoacetate, beta-hydroxybuterate) are product of fat metabolism. Normal rnage of serum ketones is 3 mmol/Litre. Generally ketone test indicate <0.1 mmol/Litre is negative. Here it is positive at 1:32 dilution means that serum has been diluted 32 times till the serum ketone level is >0.1 mmol/ litre, So the patient's current serum ketone level is at least 0.1 x 32 =3.2mmol/litre . And it indicates that there is ketoacidosis.
c. Dehydration: Diabetic -----> High blood glucose level ------------> Osmotic diuresis -------------> Dehydration-------> concentration of ketones and other metbolites increased due to dehydration -----> menifestation diabetic ketoacidosis
d. Electrolyte changes:
Arterial blood pH = 6.92 [ normal is arround 7.4 ], so it is acidosis
Bicarbonate = 2 mEq/L [ Normal is 22 - 28 mEq/L or mMol/L], low serum bicarbonate
Sodium = 127 [ Normal value 135-145 mEq/L or mMol/L] , So hyponatremia is there.
Potassium = 5.2 mEq/ L or mMol/L [Normal 3.5 to 5.1 ], so mild hyperkalemia.
Chloride = 87 mEq/ L or mMol/L [Normal 95 - 105 ]
BUN = 32 [Normal 8 - 21 mg/L ]
From electrolyte changes we can see serum bicarbonate level (2 mMol/L)is severely reduced and pH bellow 7.4, so it is Metabolic Acidosis, because the acidosis is due to low bicarbonate level, which is a result from diabetic ketoacidosis.
e.
BUN = 32 [Normal 8 - 21 mg/L ], BUN is increased. This is due to break down of protein to produce more glucose in respose to diminishe energy utilization by body cells, which occurs in diabetes.
Creatinine: 1.5 [ normal value is 08 - 1.3 mg/dL] so creatinine is increased.
f) WBC:
Count is 62600/cc [ Normal is 4000 - 11000 /cc] , so there is leukocytosis.
Additional treatment:
Current treatment with saline with 10 unit bolus insulin will correct the dehyrdation and sodium and potassium imbalance. As insulin will start working extracellular potassium will go inside cell. Sodium from normal saline will correct the sodium deficit and aso the dehydration.
So we need to correct the metabolic acidosis additionally. So for this we need to add sodium bicarbonate IV slow infusion to correct the metabolic acidosis. Sodium bicarbonate will correct the bicarbonate deficit.
6. In this case this DKA probably was triggered by missed insulin dose. Missed insulin dose increased blood sugar level rapidly and caused DKA. The boy is only 14 years, and takes his own medicines, it is highly possible that he forgot to take his insulin in absense of his mother. His mothe does not knowthe last time when his son took medicine. Associated cause was dehydration( blood pressure was 101/72. pulse rate 123) [He is taking insulin because he is suffering from type 1 diabetes and insulin the main therapy in type 1 diabetes. Juvenile onset diabetes are usually type 1 diabetes.].
7. We must add antibiotic, as his blood test is showing that current leukocyte count is 62,600/cc which indicate that the boy have developed a infection. when he was first found there was no tmeperature, but susequently he was found to have leukocytosis, which means that he developed infection due to high blood sugar and DKA.