Question

Case#9 Diane could not remember whether she had taken her 6 PM insulin dose when, in fact, she had done so. Unfortunately, she decided to give herself the evening dose (for the second time). When she did not respond to her alarm clock at 6 AM the following morning, her roommate tried unsuccessfully to awaken her. The roommate called 911 and Diane was rushed to the ER in a coma. Her skin was flushed and slightly moist. Her respirations were slightly slow. Her vitals were: heart rate 75 bpm, blood pressure- 112/87, respiratory rate: 10 rpm, oxygen saturation, 100% at room air. 1. What is Diane's diagnosis? What is the mechanism involved? 2. What clinical signs and symptoms help to distinguish a coma caused by an excess of blood glucose and ketone bodies due to a deficiency of insulin (DKA) from a coma caused by a sudden lowering of blood glucose (hyperglycemic coma) induced by the inadvertent injection of excessive insulin? 3. What is the pathophysiology leading to the elevation of blood glucose after a meal differs between patient with insulin-dependent diabetes mellitus(IDDM) and those with non-insulin-dependent diabetes mellitus (NIDDM)? Explain both. 4. What are the types of treatment available to help Diane in the future? 471

Answer 1

DIABETES MELLITUS is a metabolic disorder characterized by the presence of chronic hyperglycemia accompanied by greater or lesser impairment in the metabolism of carbohydrates, lipids and proteins.

1. DIABETIC SHOCK/COMA: From the signs and symptoms mentioned above, she can be diagnosed as in the state of diabetic coma or shock. It is a serious life threatening condition, which affects a person with diabetes when they have a low levels of blood sugar in the body. MECHANISM: The job of insulin is to help the cells of the body to pick up sugar and uses it as energy. When there is too much of insulin in the blood( due to overdose or other reasons), the cells absorb much more sugar than they need to. The excess of insulin also causes the liver itself to release less sugar fom the food that is eaten which results in a condition called hypoglycemia. This further allow the body to not function properly.

2. SIGNS AND SYMPTOMS OF AN INSULIN OVERDOSE: Mild symptoms of hypoglycemia includes a) confusion b) irritability c) anxiety d) depression e) shakiness e) dizziness f) rapid heartbeats g) sweating, chills and h) blurred vision. Severe symptoms of hypoglycemia includes a) difficulty in thinking b) seizures c) loss of consciousness, d) coma or e) even death.

DIABETIC KETOACIDOSIS: is a serious condition that can lead to diabetic coma or even death due to high or low level of blood sugar in the body of patient with diabetes. The signs and symptoms includes a) dehydration b) loss of unconsciusness and c) air hunger.

3. Pathophysiology of Type 1 diabetes mellitus or IDDM (insulin-dependent diabetes mellitus): is a combination of lymphocytic infiltration and destruction of insulin-secreting beta cells of the Islets of Langerhans in the pancreas. As beta-cells declines, the production of insulin secretion also decreases to maintain adequate blood glucose level. After a norma meal, the persons glucose level increases by the production of beta-cells in the body. Normally in Type 1 DM, glucagons secretion is not suppressed by hyperglycemia which leads to elevated glucagons level due to insulin deficiency.

Endogenous production is excess in patient with type 2 diabetes before a meal and fails to suppress it after eating due to impaired insulin-induced suppression of endogenous glucose production. It is characterized by a combination of peripheral insulin resistance and inadequate insulin secretion by pancreatic beta-cells. Insulin resistance leads to excess production of free fatty acids. Further, genetic variants released from endocrine cells stimulate insulin secretion in response to digestion of food.

4. TREATMENT PLAN: a) Administer glucagon injection to treat unconsciousness and to reduce the attack of hypoglycemia by increasing the blood glucose level b) continuous monitoring of blood glucose levels and vital signs. c) intravenous dextrose to raise blood glucose levels.