Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests, 6th Edition
Adolescent With Diabetes Mellitus (DM)
Case Studies
The patient, a 16-year-old high-school football player, was brought to the emergency room in a coma. His mother said that during the past month he had lost 12 pounds and experienced excessive thirst associated with voluminous urination that often required voiding several times during the night. There was a strong family history of diabetes mellitus (DM). The results of physical examination were essentially negative except for sinus tachycardia and Kussmaul respirations. Studies Results Serum glucose test (on admission), p. 227 1100 mg/dL (normal: 60–120 mg/dL) Arterial blood gases (ABGs) test (on admission), p. 98 pH 7.23 (normal: 7.35–7.45) PCO2 30 mm Hg (normal: 35–45 mm Hg) HCO2 12 mEq/L (normal: 22–26 mEq/L) Serum osmolality test, p. 339 440 mOsm/kg (normal: 275–300 mOsm/kg) Serum glucose test, p. 227 250 mg/dL (normal: 70–115 mg/dL) 2-hour postprandial glucose test (2-hour PPG), p. 230 500 mg/dL (normal: <140 mg/dL) Glucose tolerance test (GTT), p. 234 Fasting blood glucose 150 mg/dL (normal: 70–115 mg/dL) 30 minutes 300 mg/dL (normal: <200 mg/dL) 1 hour 325 mg/dL (normal: <200 mg/dL) 2 hours 390 mg/dL (normal: <140 mg/dL) 3 hours 300 mg/dL (normal: 70–115 mg/dL) 4 hours 260 mg/dL (normal: 70–115 mg/dL) Glycosylated hemoglobin, p. 238 9% (normal: <7%) Diabetes mellitus autoantibody panel, p. 186 insulin autoantibody Positive titer >1/80 islet cell antibody Positive titer >1/120 glutamic acid decarboxylase antibody Positive titer >1/60 Microalbumin, p. 872 <20 mg/L Diagnostic Analysis The patient’s symptoms and diagnostic studies were classic for hyperglycemic ketoacidosis associated with DM. The glycosylated hemoglobin showed that he had been hyperglycemic over the last several months. The results of his arterial blood gases (ABGs) test on admission indicated metabolic acidosis with some respiratory compensation. He was treated in the Case Studies Copyright © 2018 by Elsevier Inc. All rights reserved. 2 emergency room with IV regular insulin and IV fluids; however, before he received any insulin levels, insulin antibodies were obtained and were positive, indicating a degree of insulin resistance. His microalbumin was normal, indicating no evidence of diabetic renal disease, often a late complication of diabetes. During the first 72 hours of hospitalization, the patient was monitored with frequent serum glucose determinations. Insulin was administered according to the results of these studies. His condition was eventually stabilized on 40 units of Humulin N insulin daily. He was converted to an insulin pump and did very well with that. Comprehensive patient instruction regarding selfblood glucose monitoring, insulin administration, diet, exercise, foot care, and recognition of the signs and symptoms of hyperglycemia and hypoglycemia was given.
Critical Thinking Questions
1. Why was this patient in metabolic acidosis?
2. Do you think the patient will eventually be switched to an oral hypoglycemic agent?
3. How would you anticipate this life changing diagnosis is going to affect your patient according to his age and sex?
4. The parents of your patient seem to be confused and not knowing what to do with this diagnoses. What would you recommend to them?
- This patient was in metabolic acidosis due to a condition known as diabetic ketoacidosis (DKA). DKA is a serious complication of diabetes mellitus, typically seen in cases of uncontrolled or undiagnosed diabetes. It occurs when there is a severe lack of insulin in the body, which leads to the breakdown of fats for energy. This breakdown produces ketones, which are acidic substances. The accumulation of ketones in the bloodstream lowers the blood pH, resulting in metabolic acidosis. In this case, the patient’s high serum glucose levels, Kussmaul respirations (deep, rapid breathing), and the abnormal arterial blood gases (low pH and low bicarbonate) all indicate the presence of metabolic acidosis.
- It’s unlikely that this patient will eventually be switched to an oral hypoglycemic agent. In cases of type 1 diabetes, like the one presented in the case study, the pancreas does not produce insulin. Therefore, these patients require insulin therapy for the rest of their lives. Oral hypoglycemic agents are generally used to manage type 2 diabetes, where the body still produces some insulin but may not use it effectively. This patient was stabilized on insulin therapy, and given that he was diagnosed with positive insulin autoantibodies, it’s likely he has type 1 diabetes, which requires insulin replacement therapy.
- This life-changing diagnosis of type 1 diabetes is likely to have a significant impact on the patient, given his age and involvement in high school sports. Adolescents often find it challenging to cope with the demands of diabetes management, which include regular blood glucose monitoring, insulin administration, dietary restrictions, and lifestyle adjustments. The patient may need to modify his diet and manage his insulin levels, which can affect his ability to participate in sports and other activities. Additionally, he may experience emotional and psychological stress related to managing a chronic condition. Proper support from healthcare professionals, family, and friends is crucial to help him adapt to this new reality.
- To support the parents of the patient in understanding and managing this diagnosis, it’s essential to provide education and resources. Recommendations for the parents include:
a. Education: Provide them with comprehensive education on diabetes, its management, and potential complications. They need to understand the importance of blood glucose monitoring, insulin administration, and dietary modifications.
b. Nutrition guidance: Collaborate with a registered dietitian to develop a customized meal plan that suits the patient’s needs. This will help the parents prepare meals that are consistent with his treatment plan.
c. Emotional support: Offer information on support groups and counseling services for both the patient and the parents to help them cope with the emotional aspects of this diagnosis.
d. Practical guidance: Teach the parents how to recognize the signs and symptoms of hypo- and hyperglycemia and how to respond to them. Discuss the importance of regular follow-up with healthcare providers and maintaining a healthy lifestyle.
e. Encourage open communication: Emphasize the importance of communication between the parents and their child. Encourage the patient to express his concerns, ask questions, and actively participate in his own care.
f. Provide written materials: Offer pamphlets or brochures on diabetes management, as well as reliable online resources for ongoing support and education.
g. Involve a diabetes care team: Ensure that the family has access to a healthcare team that includes endocrinologists, nurses, dietitians, and diabetes educators who can provide ongoing guidance and support.
h. Address concerns and questions: Be available to answer any questions and address concerns the parents may have, and offer reassurance that with proper management, their child can lead a healthy life with diabetes