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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

Why was this patient in metabolic acidosis?
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?

Full Answer Section

The patient's symptoms of excessive thirst, frequent urination, and weight loss are all classic signs of high blood sugar. His high blood sugar and positive insulin autoantibodies indicate that he has type 1 diabetes. Type 1 diabetes is an autoimmune disease that causes the body to attack and destroy its own insulin-producing cells.

It is unlikely that the patient will eventually be switched to an oral hypoglycemic agent. Oral hypoglycemic agents are only effective for people with type 2 diabetes. Type 2 diabetes is a condition in which the body becomes resistant to insulin or does not produce enough insulin. Since the patient has type 1 diabetes and his body does not produce insulin, he will need to take insulin injections for the rest of his life.

This life-changing diagnosis is likely to have a significant impact on the patient, especially given his age and sex. As a 16-year-old high school football player, he is likely to be very active and social. He will need to learn how to manage his diabetes on a daily basis, which may include monitoring his blood sugar, taking insulin injections, and following a strict diet and exercise plan. He may also need to avoid certain activities, such as playing sports, if his blood sugar is too high or too low.

It is important for the patient to have a strong support system in place to help him cope with his diagnosis and learn to manage his diabetes. This support system may include his family, friends, healthcare team, and other people with diabetes.

Here are some specific ways to help the patient cope with his diagnosis and manage his diabetes:

Provide education and support: The patient and his family should be educated about diabetes and how to manage it. This education should cover topics such as blood glucose monitoring, insulin administration, diet, exercise, and foot care. The patient should also have access to support groups and other resources for people with diabetes.
Develop a treatment plan: The patient's healthcare team should develop a treatment plan that is tailored to his individual needs. This treatment plan should include specific targets for blood sugar levels, as well as instructions for monitoring blood sugar and taking insulin.
Make lifestyle changes: The patient may need to make some lifestyle changes to manage his diabetes. This may include following a healthy diet, exercising regularly, and avoiding smoking and excessive alcohol consumption.
Monitor blood sugar levels regularly: The patient should monitor his blood sugar levels regularly to ensure that they are within the target range. This monitoring can be done using a blood glucose meter.
Take insulin injections as prescribed: The patient should take insulin injections as prescribed by his healthcare team. Insulin injections help to lower blood sugar levels.
Seek medical help if needed: The patient should seek medical help if he experiences any problems with his diabetes, such as high blood sugar, low blood sugar, or other symptoms.

Sample Answer

The patient was in metabolic acidosis due to 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 enough insulin, the body breaks down fat for energy, which produces ketones. Ketones are acidic substances that build up in the blood and cause acidosis.