Diabetic Ketoacidosis (Case Study Sample)

CASE-BASED LEARNING EXERCISE 2
A 26-year old man was brought to the ER due to severe epigastric pain and vomiting. Abdominal pain and vomiting started 2 days ago and the patient could not eat or drink water. He denies experiencing weight loss, cough, dysuria, or diarrhea. In the past month, he noticed that he would be unusually thirsty and would urinate more than his usual.
This is his first consultation. He denies being diagnosed with hypertension or diabetes. He did not undergo any laboratory or imaging procedures in the past. There were no previous admissions or surgeries.
His father is diabetic, currently on insulin regimen.
He smokes 1 pack of cigarettes per day for the past 6 years. He drinks alcoholic beverages occasionally, his last intake was on New Year’s eve. His diet is described as generally high in fat and carbohydrates.
On examination he was obese, slightly confused, tachypneic, his temperature was 39° C (102.2° F), pulse rate 104 beats per minute, respiratory rate 24 breaths per minute, supine blood pressure 100/70 mmHg; he also had dry mucous membranes, poor skin turgor, and epigastric tenderness. Lung sounds were vesicular, no crackles. Cardiac examination showed tachycardia, regular rhythm, normal S1 and S2, no S3, no murmurs. Abdomen was soft. CVA tenderness was positive on the right.
Initial tests at the ER showed hematocrit 48%, hemoglobin 14.3 g/dl (143 g/L), white blood cell count 18,000/ μ l, and glucose 450 mg/dl (25.0 mmol/L).
QUESTIONS:
1. What is your impression/diagnosis of the case? Give the complete diagnosis.
Hyperglycemic crisis, to consider diabetic ketoacidosis secondary to undiagnosed diabetes mellitus, with concurrent infection; to rule out acute abdomen; Dehydration, severe; Obesity
DKA Classic Manifestations

Patient Findings

Nausea/vomiting

(+)

Thirst/polyuria

With positive history of excessive thirst and urination

Abdominal pain/tenderness (may resemble acute pancreatitis or surgical abdomen)

Epigastric tenderness

Diabetes Mellitus

Glucose 450 mg/dL
Obese, no previous diagnosis of diabetes mellitus, with history of polyuria, polydipsia, and a family history of DM

Shortness of breath

Tachypnea

Tachycardia

(+) PR: 104 bpm

Dehydration/hypotension

Dry oral mucous membranes, poor skin turgor, supine blood pressure 100/70 mmHg, confused

Tachypnea/ Kussmaul respiration/respiratory distress

(+)

Lethargy/obtundation/cerebral edema/possibly coma

Confusion

Precipitating events: infection/trauma/UTI/Gastroenteritis/sepsis

Hyperthermia: 39C
Positive CVA, right.
Epigastric pain

Leukocytosis

WBC 18,000 /ul

The patient has an initial complaint of severe epigastric pain and vomiting, and these manifestations are nonspecific, suggesting a probable gastrointestinal pathology or a metabolic problem. The patient also mentioned manifestations referring to polydipsia and polyuria. These are classic manifestations of diabetes, and by associating these with the patient’s obesity and a positive family history for diabetes, the patient may have an undiagnosed or new-onset diabetes and this was further confirmed by the random blood glucose of 450 mg/uL (American Diabetes Association, 2021). Now that diabetes is confirmed, the patient’s manifestations of dehydration, tachypnea, altered level of consciousness, and hyperglycemia suggest a hyperglycemic crisis. This condition is categorized into diabetic ketoacidosis (DKA) and Hyperosmolar hyperglycemic nonketotic syndrome (HHNS) and the patient’s nausea, vomiting, and epigastric pain is highly associated with DKA because these are uncommon with HHNS (Kasper et al., 2015; Abbas et al., 2009). Abdominal pain, tachypnea, and altered level of consciousness are the manifestations that support acidosis and DKA. Abdominal pain is a frequent DKA manifestation, being more prevalent as arterial pH declines, and one study suggested that it may be related to acute hyperglycemia mediated impaired gastrointestinal motility and mesenteric ischemia precipitated by volume depletion. However, 35% of cases demonstrated that the precipitant of DKA is an underlying gastrointestinal process, and this may be considered when persistent abdominal pain occurs despite ketoacidosis resolution (Bello, 2018). Kussmaul breathing is another key feature of ketosis and is characterized by rapid and deep breathing, which may be associated with the patient's tachypnea. The altered level of consciousness may be associated with either volume depletion or acidemia related cerebral vasodilation (Stern, 2020; Kasper et al., 2015; American Diabetes Association, 2021; Hamdi, 2021).
A precipitating factor is needed to initiate a hyperglycemic crisis, and the most common are infection, stressful events (i.e., illness, trauma, surgery), or a newly diagnosed diabetes mellitus. As previously mentioned, the patient is hyperthermic, and patients experiencing hyperglycemic crises and hyperthermia are suspected with infection. Thus, an infectious process is considered due to the patient’s concurrent hyperthermia and CVA tenderness because pyelonephritis presents clinically with flank or back pain, fever, chills, malaise, nausea and vomiting (Pincavage, 2020). The leukocytosis of 18,000 u/L may be associated with the patient’s stress response, and this is usually seen more in patients with DKA, or with ongoing infectious processes. (Kasper et al., 2015; American Diabetes Association, 2021). Further, the patient’s epigastric pain and vomiting may be associated with an underlying gastrointestinal problem. He is a cigarette smoker with 6 pack-years and a moderate alcoholic drinker, but the last intake being on New Year’s Eve, and combining these risk factors with obesity and a high fat and carbohydrate diet (hypertriglyceridemia), the patient’s epigastric pain may be associated with an acute pancreatitis as these are known risk factors for these conditions. Due to these uncertainties, further diagnostic studies will help rule out possible sources of the patient’s abdominal pain and the source of the patient’s hyperthermia.
DDX: Hyperosmolar hyperglycemic nonketotic syndrome;acute pancreatitis
2. Explain the bases for each of your differentials.
Hyperosmolar Hyperglycemic State
Subjective bases:
Hyperosmolar Hyperglycemic State previously known as Hyperosmolar hyperglycemic Nonketotic Syndrome is a complication of diabetes mellitus characterized by hyperglycemia, dehydration, hyperosmolar plasma, and altered consciousness. It can be precipitated by infections, medications, non-adherence to therapy, undiagnosed diabetes, substance abuse, and coexisting diseases (Stoner, 2017). It often occurs in patients with type 2 diabetes, often in the setting of physiologic stress (Brutsaert, 2020). The stress response to any acute illness such as infection or Acute Pancreatitis tends to increase counterregulatory hormones that favor elevated glucose levels (Avichal, 2021). The patient may have an acute condition causing epigastric pain and vomiting wherein the etiology must be determined. Patient’s increased thirst and urge to urinate more often would be classic symptoms of diabetes. Although he denies diagnosis of hypertension and hyperglycemia in the past, clinical symptoms and family history of diabetes suggests the presence of diabetes. His high fat and high carbohydrate diet predisposes him to diabetes. Undiagnosed diabetes can further lead to HSS due to the absence of hyperglycemic control. Loss of circulating water volume due to hyperosmolarity and diuresis may result in patients with HHS having up to 9L of water deficit. Hyperosmolarity can also trigger thirst mechanisms. In the presence of HHS, if the renal water loss is not compensated for by oral water intake, dehydration may lead to hypovolemia.
Objective bases:
HSS is characterized by hyperglycemia, hyperosmolar plasma, dehydration and altered consciousness. The patient was described to be slightly confused and had signs of extreme dehydration such as dry mucous membranes and poor skin turgor. High levels of counterregulatory hormones combined with low levels of insulin reduce peripheral glucose uptake. Glycosuria causes greater loss of water resulting in hyperosmolarity and dehydration, which can then lead to altered consciousness. If an infectious disease precedes HSS common signs would include fever, tachypnea and tachycardia (Adeyinka, 2021) and leukocytosis. Tachycardia and tachypnea can also be a compensatory mechanism from decreased intravascular volume, which can also lead to hypotension due to decreased cardiac output.
Acute Pancreatitis
Subjective Bases
Acute pancreatitis usually presents abruptly within days, and manifests with severe epigastric pain associated with nausea and vomiting. The patient presented with an unusual thirst and would urinate more than usual (polydipsia and polyuria) which symptoms of diabetes 1 month PTC. Several researches have proven the association of the inflammation of the pancreas leading to the damage of the pancreatic cells therefore altering the production of insulin and glucagon, resulting in...