Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests

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?    

Sample Solution

 

The patient was in metabolic acidosis due to the development of diabetic ketoacidosis (DKA). DKA is a serious complication of diabetes that occurs when the body produces high levels of ketones. Ketones are produced when the body does not have enough insulin to use glucose for energy. When ketone levels become too high, they can build up in the blood and cause the blood to become acidic.

In this patient's case, his insulin resistance was preventing his body from using glucose for energy. As a result, his body began to break down fat for energy, which produced ketones. The high levels of ketones in his blood caused his blood to become acidic.

Full Answer Section

      In this patient's case, his insulin resistance was preventing his body from using glucose for energy. As a result, his body began to break down fat for energy, which produced ketones. The high levels of ketones in his blood caused his blood to become acidic.
  1. Do you think the patient will eventually be switched to an oral hypoglycemic agent?
It is possible that the patient may eventually be switched to an oral hypoglycemic agent. However, this will depend on a number of factors, such as his ability to manage his blood sugar levels with insulin, his lifestyle, and his preferences. Oral hypoglycemic agents are medications that can help to lower blood sugar levels. They work in a variety of ways, but they all ultimately help the body to use insulin more effectively. If the patient is able to manage his blood sugar levels well with insulin, he may eventually be able to switch to an oral hypoglycemic agent. However, if he is not able to manage his blood sugar levels well with insulin, he may need to continue taking insulin injections.
  1. How would you anticipate this life changing diagnosis is going to affect your patient according to his age and sex?
A diagnosis of diabetes can have a significant impact on a person's life, especially a teenager. At this age, teenagers are going through a number of changes, both physically and emotionally. They are also trying to establish their independence. A diagnosis of diabetes can add an additional layer of stress and complexity to their lives. For this patient, being a male athlete may also present some challenges. Athletes often have demanding schedules and may find it difficult to manage their diabetes around their training and competition. They may also be concerned about the impact of diabetes on their athletic performance. It is important for the patient to receive support from his family, friends, and healthcare team. He will need to learn how to manage his diabetes on a daily basis, which will include monitoring his blood sugar levels, taking insulin, and eating a healthy diet. He will also need to learn how to prevent complications of diabetes.
  1. The parents of your patient seem to be confused and not knowing what to do with this diagnoses. What would you recommend to them?
It is common for parents to feel confused and overwhelmed when their child is diagnosed with diabetes. The following are some recommendations for parents:
  • Educate yourselves about diabetes. The more you know about diabetes, the better equipped you will be to help your child manage their condition. There are many resources available to help you learn about diabetes, such as books, websites, and support groups.
  • Talk to your child's healthcare team. They can provide you with specific information about your child's diabetes and how to manage it. They can also answer any questions you have.
  • Be supportive. Let your child know that you are there for them and that you will help them manage their diabetes.
  • Help your child develop a diabetes management plan. This plan will include information about how to monitor blood sugar levels, take insulin, eat a healthy diet, and exercise.
  • Be patient. It takes time for people with diabetes to learn how to manage their condition. Be patient with your child as they are learning.
It is also important for parents to remember that they are not alone. There are many other parents who have children with diabetes. There are also many support groups available for parents of children with diabetes. These groups can provide you with support and advice from other parents who are going through the same thing.  

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