Question

An 18-year-old female was taken to the emergency room in coma. Her parents noticed that she had polydipsia, polyuria, and rapid weight loss which started approximately 1 month ago and had worsened in the last week. She had not been taking any medications and the clinical history was otherwise unremarkable. On examination, breathing was deep and rapid (Kussmaul respiration), pulse rate was 100 beats per minute, and blood pressure 110/70 mmHg; she also had signs of dehydration. She was drowsy and confused. Rapid hematology and biochemical tests showed hematocrit 44%, hemoglobin 13 g/dl (140 g/L), white blood cell count 12,000/ μl, glucose 520 mg/dl (28.9 mmol/L), urea 50 mg/dl (8.5 mmol/L), creatinine 0.8 mg/dl (70.7 μmol/L), Na+ 148 mEq/L, K+ 4.6 mEq/L, PO4 3-2.0 mEq/L (0.64 mmol/L), and Cl− 112 mmol/L. Arterial pH was 7.0, PO 2 98 mmHg, PCO 2 25 mmHg, HCO 3−12 mEq/L, and O 2 sat 98%.

1. What is your diagnosis? Which additional biochemical tests are required to confirm the diagnosis?
2. How will you manage this patient?

Answer 1

A. The glucose and urea levels are very high (520 mg/dL). Normal level is 125 mg/dL. Normal level of urea is 7-20 mg/dL.

Creatinine and potassium levels are normal. Sodium level is elevated (normal 135-145 Eq/L. Phosphate level is low (normal 0.97-1.45 mmol/L). Chloride level is elevated (normal 98-106 mmol/L).

The arterial pH is low (normal range- 7.35-7.45). Bicarbonate levels are low (normal range-23-30 mEq/L). Oxygen saturation is in normal range.

Anion gap (AG) = [Na] –([Cl] + [HCO3]) = (148-112) + 12= 48

This value is higher than the normal range of 8-16 mEq/L

Metabolic acidosis is seen as bicarbonate is low, and anion gap values are high. Further there is hyperglycemia.

The Diagnosis: Type 1 Diabetic ketoacidosis

Additional diagnostic test: Presence of increased ketone bodies in urine to confirm ketosis is required. Levels of beta hydroxybutyrate in serum. This is because ketone bodies formation is stimulated by dehydration.

B. The patient is dehydrated. Hence, intravenous fluid needs to be administered. To reduce glucose levels, the patient should be given insulin intravenously. The dosage is 0.5-0.8 IU/kg per day. Periodic glucose testing is done to monitor decline in serum glucose. If the patient is conscious, feeding can be initiated.