Chapter 11: Hyperglycemic Crisis: Diabetic Ketoacidosis in Type 1 Diabetes

PATIENT PRESENTATION

Chief Complaint

“I feel weak and am short of breath.”

History of Present Illness

PJ is a 23-year-old Caucasian female who is brought to the emergency department (ED) by her mother for generalized weakness and deep, labored breathing. She complains of having polyuria, polydipsia, diminished appetite, nausea and vomiting, and abdominal pain for the past 2 to 3 days. Patient denies fever, chills, heartburn, melena, hematemesis, diarrhea, or constipation.

Patient states that she was diagnosed with diabetes mellitus type 1 about 3 months ago, at which time she received prescriptions for insulin degludec, insulin lispro, and lisinopril. She admits to not picking up the insulin degludec due to cost. However, she does have insulin lispro and lisinopril at home. She states that she has been taking her lisinopril, but not her insulin lispro. At this previous visit, she was also instructed to schedule an appointment with an endocrinologist and a registered dietitian; however, she has not done either.

Past Medical History

Type 1 diabetes mellitus, microalbuminuria

Surgical History

None

Family History

Father with type 1 diabetes

Social History

Lives with her parents

Occasional EtOH use (drinks socially on the weekends).

Denies tobacco use.

Immunization

Up-to-date with childhood vaccinations, including hepatitis B vaccination series

Insurance

Aetna HMO

Allergies

No known drug allergies

Home Medications

• Insulin degludec 15 units subcutaneous every day at bedtime

• Insulin lispro 5 units subcutaneous every day prior to each meal

• Lisinopril 10 mg PO daily

• Nexplanon® 65 mg subdermal (inserted 6 months ago)

Physical Examination

Vital Signs

Temp 98.1°F, HR 118 bpm, RR 28 breaths per min, BP 88/64 mmHg, O₂ sat 92%, Ht: 5′5″, Wt: 54.5 kg

General

Altered, lethargic female

HEENT

Normocephalic, PERRLA, EOMI

Pulmonary

SOB, (+) Kussmaul respirations, fruity breath

Cardiovascular

Tachycardic, hypotensive, weak pulse, NSR, no m/r/g

Abdomen

Mild abdominal tenderness, (+) bowel sounds

Neurologic

Drowsy and altered, A&O × 2 (person and place)

Extremities

Dry mucous membranes, poor skin turgor, increased capillary refill time

Laboratory Findings