Chapter 83: Type 1 Diabetes Mellitus And Ketoacidosis: Disconnected Level II

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LEARNING OBJECTIVES

After completing this case study, the reader should be able to:

• Recognize signs and symptoms of diabetic ketoacidosis (DKA).

• Determine laboratory parameters for the diagnosis and monitoring of DKA.

• Identify anticipated fluid and electrolyte abnormalities associated with DKA and their treatment.

• Recommend appropriate insulin therapy for treating DKA.

• Identify therapeutic decision points in DKA treatment and provide parameters for altering therapy at those points.

PATIENT PRESENTATION

Chief Complaint

“I felt weak and nauseated during softball practice. I checked my blood glucose and it read HI” (blood glucose >600 mg/dL).

HPI

Mary McGee is a 21-year-old woman with a history of type 1 diabetes, diagnosed 3 years ago. She is a college senior at the local university where she also plays softball. She started using an insulin pump approximately 6 months ago.

She noticed she was unusually tired and short of breath at the beginning of her practice and then began feeling weak and nauseated. She was also very thirsty during practice. Her softball coach said she seemed “a little confused.” He advised her to check her blood glucose and it read “HI”. She checked her insulin pump and noticed the pump had become disconnected. She is unsure how long she has been without insulin. She vomited two times since shortly thereafter and was transported via EMS to the ED.

PMH

Type 1 DM diagnosed 3 years ago. No prior hospitalizations for DKA or prior surgeries.

FH

Parents are alive and healthy. One twin sister who also has type 1 DM.

SH

College student; no tobacco, alcohol, or illicit drug use. Sexually active; in a monogamous relationship.

Meds

NovoLog 100 U/mL, per insulin pump

Basal rates:

• 0.6 U/hr 0000–0300

• 0.9 U/hr 0300–0700

• 0.8 U/hr 0700–1100

• 0.7 U/hr 1100–1730

• 0.8 U/hr 1730–0000

Correction factor: 1 U:40 mg/dL >120 mg/dL

Insulin:carbohydrate ratios:

• 1:10 insulin:carbohydrate before breakfast

• 1:15 insulin:carbohydrate before lunch and dinner

Glucagon injection kit, as needed

Ortho-Cyclen (35 mcg ethinyl estradiol/0.25 mg norgestimate) one tablet PO once daily × 3 years

Allergies

NKDA

ROS

Complains of blurry vision, lethargy, shortness of breath, nausea, polyuria, and polydipsia. Denies constipation, diarrhea, and headache.

Physical Examination

Gen

WDWN Caucasian woman appearing her stated age, with deep respirations, ketones on her breath, and slurred ...