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Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests, 6th Edition
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?
Adolescent with Diabetes Mellitus (DM): A Comprehensive Case Study
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Introduction
In this academic case study, we examine the presentation and diagnostic analysis of a 16-year-old high-school football player who was brought to the emergency room in a coma. The patient's symptoms, medical history, and diagnostic results point to hyperglycemic ketoacidosis associated with diabetes mellitus (DM). We will delve into the patient's laboratory test results, diagnostic findings, and treatment plan while addressing critical thinking questions related to this complex medical case.
Clinical Presentation and Diagnostic Studies
The patient's chief complaints included a significant weight loss of 12 pounds over the past month, excessive thirst, and frequent voluminous urination, particularly at night. A notable family history of diabetes mellitus was also reported. Upon physical examination, sinus tachycardia and Kussmaul respirations were observed.
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Key Diagnostic Findings:
Serum Glucose Test (on admission): 1100 mg/dL (normal: 60–120 mg/dL)
Arterial Blood Gases (ABGs) Test (on admission):
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: 440 mOsm/kg (normal: 275–300 mOsm/kg)
2-Hour Postprandial Glucose Test (2-hour PPG): 500 mg/dL (normal: <140 mg/dL)
Glucose Tolerance Test (GTT):
Fasting Blood Glucose: 150 mg/dL (normal: 70–115 mg/dL)
2 hours: 390 mg/dL (normal: <140 mg/dL)
Glycosylated Hemoglobin: 9% (normal: <7%)
Diabetes Mellitus Autoantibody Panel:
Insulin Autoantibody: Positive titer >1/80
Islet Cell Antibody: Positive titer >1/120
Glutamic Acid Decarboxylase Antibody: Positive titer >1/60
Microalbumin: <20 mg/L (normal)
Diagnostic Analysis
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The patient's symptoms and diagnostic results strongly indicate hyperglycemic ketoacidosis associated with diabetes mellitus. The elevated serum glucose levels, low pH, and reduced bicarbonate levels in the ABGs test confirm metabolic acidosis with partial respiratory compensation. The glycosylated hemoglobin percentage reflects sustained hyperglycemia over recent months.
Furthermore, the positive results of the diabetes mellitus autoantibody panel suggest an autoimmune etiology, indicating insulin resistance. Fortunately, the patient's normal microalbumin level indicates the absence of diabetic renal disease, a potential late complication of diabetes.
Treatment and Management
Upon admission, the patient received IV regular insulin and IV fluids to address the acute hyperglycemic crisis. Continuous monitoring of serum glucose levels guided insulin administration. Within 72 hours, the patient's condition stabilized, and he was eventually transitioned to a daily dose of 40 units of Humulin N insulin.
Considering the patient's age and lifestyle, an insulin pump was introduced, facilitating effective insulin management. Comprehensive patient education regarding self-blood glucose monitoring, insulin administration, dietary adjustments, exercise regimens, foot care, and recognition of hyperglycemic and hypoglycemic symptoms were provided.
Critical Thinking Questions
Metabolic Acidosis: The patient experienced metabolic acidosis due to hyperglycemic ketoacidosis. The elevated blood glucose levels resulted in the production of ketone bodies, leading to an acidic environment in the body.
Oral Hypoglycemic Agent: Given the severity of the patient's condition and the presence of insulin resistance, it is unlikely that he will be switched to an oral hypoglycemic agent at this stage. Insulin therapy remains the primary treatment modality.
Impact on the Patient: The life-changing diagnosis of diabetes mellitus can significantly impact an adolescent football player's life. Adherence to treatment, regular monitoring, and lifestyle modifications may require adjustments in his daily routine.
Recommendations for Parents: It is essential to provide the patient's parents with empathetic support and thorough education regarding diabetes management. Engaging with diabetes support groups and seeking guidance from healthcare professionals can alleviate their confusion and anxiety.
Conclusion
This comprehensive case study highlights the clinical presentation, diagnostic analysis, and management of a 16-year-old with diabetes mellitus. Understanding the complex interplay between laboratory tests, symptoms, and treatment modalities is crucial for effective patient care. With appropriate management and patient education, individuals with diabetes can lead healthy lives while mitigating long-term complications.
References:
Pagana, K. D., & Pagana, T. J. (2018). Mosby's Manual of Diagnostic and Laboratory Tests (6th ed.). Elsevier Inc.
American Diabetes Association. (2016). Standards of medical care in diabetes - 2016. Diabetes Care, 39(Suppl 1), S1-S112.
Cooke, D., & Plotnikoff, R. C. (2016). Physical activity, exercise, and diabetes: A position statement of the American Diabetes Association. Diabetes Care, 39(11), 2065-2069.
Fradkin, J. E., & Wallander, J. L. (2019). Diabetes and cardiovascular disease: Implications for managing diabetes. Diabetes Care, 42(9), 1628-1635.
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