Question

A 48-year-old Hispanic woman with a long history of obesity, dyslipidemia, and reactive airway disease presented to the hospital emergency department with a 5-day history of weakness, tactile fever, productive cough, nausea, and vomiting. She complained of increased urination and always being thirsty.  She drank 3-4 glasses of juice an hour.  Over the past week, she has gained 5 pounds.

On examination, her temperature was 99.1° F, blood pressure was 98/64 mmHg, pulse was 136, and respirations were 36. There was a strong odor from her breath. The patient was drowsy but cogent. Her head and neck exam revealed poor dentition and periodontal disease. Her lung sounds were clear without wheezes or rhonchi. Her heart sounds were normal. The abdominal exam revealed mild epigastric tenderness to deep palpation but no rebound tenderness or guarding. Extremities were well perfused with symmetric pulses.

Based on the above symptoms what other assessments, tests or procedures would the MD order or perform to help diagnosis the problem?

What results would you expect to find and why?

Based on your results what is the cause and pathology?

What are the patient’s risk factors?

Answer 1

Tests should include

• Serum glucose level
• Complete blood count
• Urinalysis to identify glucose and presence of ketones (since a strong odour from breath was noticed).
• Arterial blood gas analysis (to identify Pco₂, & pH).
• Serum Ketones
• Serum bicarbonates
• Beta hydroxybutyrate( to test the presence of ketones)
• Computed Tomograhy scan(CT Scan) as the patient has mild epigastric tenderness to deep palpation.

The results can be related to Diabetic Ketoacidosis. Even though it is not mentioned above that she is diabetic, symptoms of increased thirst and urination,weight gain,poor dentition and periodontal diseases reveals presence of diabetes and ketoacidosis. The expected result is

• increased serum glucose level above 250 mg /dL
• Serum bicarbonate 15-18 mEq/L
• High betahydroxybutyrate
• presence of serum and urine ketones
• Increased blood urea nitrogen

Cause and pathology

The presence of dyslipidemia and obesity points out to the fact that the patient might have diabetes which indeed developed insulin resistance.Insulin resistance happens when the body cells will be unable to take glucose from the blood,resulting in increased secretion of insulin by the pancreas to help glucose reach the cells.This can show a normal serum glucose level on blood test.So hyperinsulinemia might have lead this patient to Diabetic Ketoacidosis.

Risk factors

Long history of obesity and dyslipidemia