Question

Using the case study below, prepare a 3-5 page paper.

A 21-year old female (A.M) presents to the urgent care clinic with symptoms of nausea, vomiting, diarrhea, and a fever for 3 days. She states that she has Type I diabetes and has not been managing her blood sugars since she’s been ill and unable to keep any food down. She’s only tolerated sips of water and juices. Since she’s also been unable to eat, she hasn’t taken any insulin as directed. While helping A.M. from the lobby to the examining room you note that she’s unsteady, note that her skin in warm and flushed and that she’s drowsy. You also note that she’s breathing rapidly and smell a slight sweet/fruity odor. A.M. has a challenge answering questions but keeps asking for water to drink.

You get more information from A.M. and learn

• She had some readings on her glucometer which were reading ‘high’
• She vomits almost every time she takes in fluid
• She hasn’t voided for a day but voided a great deal the day before
• She’s been sleeping long hours and finally woke up this morning and decided to seek care

Current labs and vital signs:

1. What is the pathophysiology for the condition you believe A.M. has?
2. Relate the etiology and clinical manifestations for the condition you identified for A.M.

The practitioner at the urgent care facility makes the decision that A.M. needs to go to the hospital by ambulance. Once at the Emergency Department (ED), the ED physician orders these items:

1. 1000 ml Lactated Ringer’s (LR) IV stat
2. 36 units NPH (Humulin N) and 20 units regular (Humulin R) insulin SQ now
3. CBC with differential; CMP: blood cultures X2 sites; clean-catch urine for UA and C&S; stool for ova and parasites; Clostridium difficile toxin, and C&S; serum lactate; ketone; osmolality; ABGs on room air
4. 1800 calorie, carbohydrate controlled diet
5. Bed rest
6. Acetaminophen (Tylenol) 650 mg orally Q4 hrs PRN
7. Furosemide (Lasix) 60 mg IV push now
8. Urinary output every hour
9. VS every shift

The orders above -- which are questionable related to her condition and which are appropriate?

3. What are the expected treatments for this condition?

Answer 1

The pathophysiology of the condition which the patient experience it s termed to be Diabetic ketoacidosis. In this condition the blood sugar levels are very high due to imbalance in its absorption and usage by the cells due to lack of insulin function. This simultaneously increases the content of potassium in the blood leading to hyperkalemia both leads to symptoms nausea ,vomiting,diarrhea, .This results in loss of electrolytes from the body altering the acid base balance,hypotension. To manage this the heart rate increase.In order to combat this the skin becomes warm to prefer fluid.The increase in ketone leads to increase in breathing pattern and a fruity odor smell.The renal system is impaired leading to decreased urine output and prone for infection resulting g in elevation of body temperature

2.The etiology are

• Uncontrolled blood glucose levels
• Medication non compliance
• Lack of adequate and appropriate diet

The clinical manifestation are

• Nausea
• Vomiting
• Diarrhea
• Fruity odour smell
• Decreased urine output
• Tachycardia
• Tachypnea
• Hypotension
• Fever

The appropriate tests are CBC,blood culture, urine tests to rule out infect

Ketones to find out ketoacidosis

ABG to rule out oxygen and acid base balance

Serum lactate to assess for shock

The investigation which are questionable are

Stool test and C difficile can be done in case of suspicion direct gastrointestinal infection

The expected treatment are

• Insulin therapy to reduce blood glucose levels
• Insulin calcium bicarbonate infusion to decrease the elevated potassium level
• Intravenous fluid to improve blood volume and urine output
• Antibiotics to treat infection
• Antipyretics to reduce fever
• Antiemetics to reduce nausea and vomiting
• Antidiarrhoeal to prevent loose stools