Posted: June 28th, 2022

A 19-year-old Marine was brought to the infirmary

“A 19-year old marine was brought to the infirmary after passing…
“A 19-year old marine was brought to the infirmary after passing out during basic training. He had repeatedly complained of severe weakness, dizziness, and sleepiness during the preceding 4 weeks of boot camp. In a previous episode 3 weeks earlier, he had drowsiness and generalized tiredness, and was brought to the infirmary, where after IV administration of saline, he was returned to duty with the diagnosis of dehydration. Upon questioning, he reported unquenchable thirst, and the repeated need to urinate. On the last day, he complained of vague abdominal pain, which was worse on the morning of admission. He had vomited once. During examination, he was oriented but tachypneic. He appeared pale, dehydrated with dry mucous membranes, and poor skin turgor.

His respiratory rate was 36/minute with deep, laborious breathing; his heart rate was 138/minute regular, and his blood pressure was 90/60. His chest was clear, heart tones were normal. There was an ill-defined generalized abdominal tenderness, which was otherwise soft to palpation and showed no rebound. There was a generalized muscular hypotonia; his deep tendon reflexes were present but very weak.

Laboratory, on admission, showed glucose of 560 mg/dl, sodium 154, potassium 6.5, pH 7.25, bicarbonate 10 mM/liter, chloride 90, BUN 38 mg/dl, creatinine 2.5 mg/dl. (Normal values: glucose, 70-114 mg/dl; Na = 136-146; K, 3.5-5.3; Cl, 98-108; bicarbonate, 20-32 [all in mM/l]; BUN, 7-22mg/dl; creatinine, 0.7-1.5 mg/dl). A urine sample was 4+ for glucose and had “large” acetone. HbA1c was 14% (n=4-6.2%). Serum acetone was 4+ undiluted, and still positive at the 4th dilution. Beta-Hydroxybutyrate level was 20 millimols/liter (normal=0.0-0.3 mM/l).

He was treated with insulin and saline I.V. By the 4th hour of treatment, potassium chloride was added to the IV at a rate of 15 mEq/hour. Sixteen hours later, he was active, alert, well hydrated and cheerful, indicating he felt extremely well. He requested that his IV be discontinued. His physician decided to switch his insulin to subcutaneous injections and to start a liquid diet. He was later put on a diabetes maintenance diet and treated with one injection of Human Lente insulin in the morning. Although his blood sugars the next morning were 100-140 mg/dl, he had frequent episodes of hypoglycemia during the day, and his HbA1c was 9%. Eventually, he was put on 3 injections of regular insulin/day, and a bedtime intermediate duration (Lente) insulin.”

—-revised from https://lcu.edu/

Questions:

Interprete patient’s lab results:
His respiratory rate was 36/minute with deep–name this condition______
his heart rate was 138/minute regular–name this condition___
his blood pressure was 90/60–name this condition___
Glucose of 560 mg/dl ___–name this condition___
sodium 154–name this condition___
potassium 6.5–name this condition___
pH 7.25, bicarbonate 10 mM/liter, CO2 normal–Name this acid/base imbalance___
chloride 90_______
BUN 38 mg/dl, creatinine 2.5 mg/dl –What condition is indicated by these two? ____

(Normal values: glucose, 70-114 mg/dl; Na = 136-146; K, 3.5-5.3; Cl, 98-108; bicarbonate, 20-32 [all in mM/l]; BUN, 7-22mg/dl; creatinine, 0.7-1.5 mg/dl).

A urine sample was 4+ for glucose and had “large” acetone. Serum acetone was 4+ undiluted, and still positive at the 4th dilution. Beta-Hydroxybutyrate level was 20 millimols/liter (normal=0.0-0.3 mM/l). —What condition is indicated by this?

HbA1c was 14% (n=4-6.2%) —What condition is indicated by this?

Which evidence in the case supports the diagnosis of Diabetes? Which type of diabetes do you suspect the patient has? How would you confirm this type of DM?
What is the diagnosis of the marine when he was brought to the infirmary? All evidence
Why did the patient improve after being given Insulin and IV saline?
He was hyperkalemic on admission, and yet, why was potassium later added to the IV infusion? (hint: acidosis and alkalosis)

_____________________

Interpret patient’s lab results:

Respiratory rate of 36/minute with deep: Kussmaul respirations
Heart rate of 138/minute regular: Tachycardia
Blood pressure of 90/60: Hypotension
Glucose of 560 mg/dl: Hyperglycemia
Sodium of 154: Hypernatremia
Potassium of 6.5: Hyperkalemia
pH of 7.25, bicarbonate 10 mM/liter, CO2 normal: Metabolic acidosis
Chloride of 90: Normal
BUN of 38 mg/dl, creatinine of 2.5 mg/dl: Kidney damage
A urine sample was 4+ for glucose and had “large” acetone. Serum acetone was 4+ undiluted, and still positive at the 4th dilution. Beta-Hydroxybutyrate level was 20 millimols/liter (normal=0.0-0.3 mM/l): This indicates diabetic ketoacidosis (DKA).

HbA1c was 14% (n=4-6.2%): This indicates long-term hyperglycemia, consistent with diabetes.

Which evidence in the case supports the diagnosis of Diabetes? Which type of diabetes do you suspect the patient has? How would you confirm this type of DM?

The following evidence in the case supports the diagnosis of diabetes:

* Hyperglycemia
* Kussmaul respirations
* Ketonuria
* Hyperkalemia
* DKA

The patient’s age and presentation are consistent with type 1 diabetes. Type 1 diabetes is an autoimmune disease that destroys the cells in the pancreas that produce insulin. Insulin is a hormone that helps the body use glucose for energy. Without insulin, glucose builds up in the blood, leading to hyperglycemia.

To confirm the diagnosis of type 1 diabetes, the patient would need to have a fasting blood sugar level of 126 mg/dl or higher, or a random blood sugar level of 200 mg/dl or higher. The patient would also need to have antibodies to insulin in their blood.

What is the diagnosis of the marine when he was brought to the infirmary? All evidence
The patient’s diagnosis when he was brought to the infirmary is diabetic ketoacidosis (DKA). DKA is a serious complication of diabetes that occurs when the body does not have enough insulin. Insulin is a hormone that helps the body use glucose for energy. Without insulin, glucose builds up in the blood, leading to hyperglycemia. When the blood sugar level gets too high, the body starts to break down fat for energy. This process produces ketones, which are acidic substances. Ketones can build up in the blood and cause DKA.

The patient’s symptoms of DKA include:

Code snippet
* Hyperglycemia
* Kussmaul respirations
* Ketonuria
* Hyperkalemia
* Dehydration
* Confusion
* Coma
Use code with caution. Learn more
Why did the patient improve after being given Insulin and IV saline?
The patient improved after being given insulin and IV saline because insulin helped the body use glucose for energy and saline helped to rehydrate the patient. Insulin also helped to remove the ketones from the blood.

He was hyperkalemic on admission, and yet, why was potassium later added to the IV infusion? (hint: acidosis and alkalosis)
The patient was hyperkalemic on admission because he was in DKA. DKA is a metabolic acidosis, which means that the body has too much acid in the blood. This acidosis can cause the potassium level in the blood to rise. Adding potassium to the IV infusion helped to correct the acidosis and lower the potassium level in the blood.

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