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
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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.- Do you think the patient will eventually be switched to an oral hypoglycemic agent?
- How would you anticipate this life changing diagnosis is going to affect your patient according to his age and sex?
- The parents of your patient seem to be confused and not knowing what to do with this diagnoses. What would you recommend to them?
- 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.