Description

Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests, 6th Edition

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 physical examination results were essentially negative except for sinus tachycardia and Kussmaul respirations.

Diagnostic Analysis

The patient’s symptoms and diagnostic studies were classic for hyperglycemic ketoacidosis associated with DM. The glycosylated hemoglobin showed 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                                                                                                                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, showing 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 self-blood glucose monitoring, insulin administration, diet, exercise, foot care, and recognition of the signs and symptoms of hyperglycemia and hypoglycemia was given.

Critical Thinking Questions and Answers

1. Why was this patient in metabolic acidosis?

The patient was in metabolic acidosis due to diabetic ketoacidosis (DKA). DKA is a severe complication of diabetes mellitus, typically type 1 diabetes, where the body lacks sufficient insulin to utilize glucose for energy. Consequently, the body starts breaking down fat for fuel, producing ketones as a byproduct. These ketones accumulate in the bloodstream, leading to metabolic acidosis. The key indicators of metabolic acidosis in this patient include:

• High serum glucose level (1100 mg/dL): Indicates severe hyperglycemia, a hallmark of DKA.
• Arterial blood gases (ABGs): The pH of 7.23 (acidotic), low Pco2 (30 mm Hg), and low HCO3 (12 mEq/L) are consistent with metabolic acidosis.
• Kussmaul respirations: A compensatory mechanism to reduce acidosis by exhaling more CO2.

2. Do you think the patient will be switched eventually to an oral hypoglycemic agent?

It is unlikely that the patient will be switched to an oral hypoglycemic agent. The patient’s positive diabetes mellitus autoantibody panel (insulin autoantibody, islet cell antibody, and glutamic acid decarboxylase antibody) strongly suggests type 1 diabetes mellitus. Type 1 diabetes is characterized by autoimmune destruction of pancreatic beta cells, resulting in an absolute deficiency of insulin. Unlike type 2 diabetes, which can often be managed with oral hypoglycemic agents that enhance insulin sensitivity or secretion, type 1 diabetes requires exogenous insulin for glucose regulation. Therefore, the patient will likely need to continue insulin therapy, possibly with adjustments in the form of an insulin pump or multiple daily injections.

3. How do you anticipate this adolescent's social life is going to be affected?

The adolescent’s social life is likely to be affected in several ways:

• Diet and Eating Habits: He will need to be mindful of his carbohydrate intake and follow a specific diet, which may restrict him from participating in spontaneous eating events common among teenagers.
• Regular Monitoring and Insulin Administration: Frequent blood glucose monitoring and insulin injections or pump adjustments can be disruptive and may make him feel different from his peers.
• Physical Activity: While he can still participate in sports, he will need to carefully manage his blood glucose levels before, during, and after physical activity to prevent hypoglycemia or hyperglycemia.
• Emotional and Psychological Impact: Dealing with a chronic condition like diabetes can be stressful and may lead to feelings of isolation or anxiety. Peer support and understanding are crucial.

4. How could you help this patient to be compliant with his treatment?

To help this patient be compliant with his treatment, several strategies can be employed:

• Education: Provide comprehensive education on diabetes management, including blood glucose monitoring, insulin administration, diet, and the importance of adherence to the treatment plan.
• Support Systems: Encourage participation in diabetes support groups for adolescents where he can share experiences and tips with peers facing similar challenges.
• Technology: Use technology like insulin pumps, continuous glucose monitors (CGMs), and smartphone apps to help manage diabetes more efficiently and with less disruption to daily life.
• Involvement in Care: Involve the patient in his own care planning to increase his sense of control and responsibility. This can include setting achievable goals and creating a schedule that fits his lifestyle.
• Regular Follow-ups: Schedule regular follow-up appointments with a healthcare team to monitor his progress, address any issues, and adjust his treatment plan as necessary.
• Psychological Support: Provide access to counseling or mental health services to help him cope with the emotional aspects of living with diabetes.

These strategies can help the patient integrate diabetes management into his daily routine more seamlessly and improve his overall adherence to the treatment plan.