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 because of hyperglycemic ketoacidosis associated with diabetes mellitus (DM). The high glucose levels in the blood led to the production of ketones as an alternative energy source. Ketones are acidic byproducts of fat metabolism, and their accumulation in the blood resulted in an imbalance in the acid-base status, leading to metabolic acidosis.
- It is unlikely that this patient will be switched to an oral hypoglycemic agent. The presence of positive insulin antibodies indicates a degree of insulin resistance, which suggests that the patient’s body may not respond effectively to oral hypoglycemic agents. Insulin injections or an insulin pump are typically required to manage insulin resistance and regulate blood glucose levels in patients with type 1 diabetes or severe type 2 diabetes.
- This life-changing diagnosis of diabetes mellitus is likely to have a significant impact on the patient, considering his age and sex. As a 16-year-old high-school football player, he may face several challenges in managing his diabetes while maintaining an active lifestyle. He will need to learn how to monitor his blood glucose levels regularly, administer insulin, adjust his diet, and incorporate exercise safely. The diagnosis may require lifestyle modifications, including meal planning, timing of insulin administration, and careful management of physical activities. Emotionally, he may also need support to cope with the demands and potential limitations imposed by the condition.
- In light of the parents’ confusion and uncertainty, the following recommendations can be made:
- Education: It is important to provide the parents with comprehensive education about diabetes mellitus, its management, and potential complications. They should understand the importance of blood glucose monitoring, insulin administration, proper diet, exercise, and foot care. They should also be familiar with the signs and symptoms of hyperglycemia and hypoglycemia.
- Diabetes management team: Encourage the parents to seek the assistance of a multidisciplinary diabetes management team, which may include endocrinologists, certified diabetes educators, dietitians, and psychologists. This team can provide ongoing support, guidance, and education to the patient and his family.
- Support groups: Suggest joining local or online support groups for parents and families of children with diabetes. These support groups can provide emotional support, share experiences, and offer practical tips for managing diabetes effectively.
- Regular follow-up: Emphasize the importance of regular follow-up visits with healthcare providers to monitor the patient’s progress, adjust insulin doses if needed, and address any concerns or difficulties the family may have.
- Encourage open communication: Encourage the parents to communicate openly with the healthcare team, asking questions and seeking clarification whenever necessary. It is essential for them to feel comfortable discussing concerns, challenges, and any changes in the patient’s condition.
Overall, providing the parents with knowledge, resources, and ongoing support will help them navigate the challenges associated with their child’s diabetes diagnosis and ensure the best possible care for their son.