Question

Case #3

An unconscious young man in taken to the hospital emergency room. His temperature is elevated; pulse rate increased; respiration rate increased; skin warm and dry, with poor turgor. His breath is noted to have an aromatic odor, and alcohol ingestion is suspected.

Venous blood is drawn for stat chemistry tests and hematology. A catheterized specimen of urine is tested with multiple reagent strips and refractometer in the emergency room. A drop of finger puncture blood is used to screen for glucose with a reflectance meter.

Urinalysis Results:

Physical Appearance:
color:	pale
transparency: Chemical Screening:	clear
pH:	5
specific gravity:	1.010	(reagent strip)
	1.031	(refractometer)
protein	negative
blood	negative
nitrite	negative
leukocyte esterase	negative
glucose	>2000 mg/dL
ketones	moderate
bilirubin	negative
urobilinogen	normal

Emergency room blood glucose: >500 mg/dL

1. What is the most likely cause of unconsciousness in this patient?
2. What is the cause of the aromatic odor noticed on the breath of this patient?
3. Explain the difference in the specific gravity values.
4. Why is it important to determine the cause of unconsciousness in this patient?

Answer 1

1. The most likely cause of unconsciousness in this patient is Diabetic ketoacidosis. Diabetic ketoacidocis occurs when body produces high level of blood acids (ketones) due to lack of insulin. Insulin is required for entering the glucose molecules into the muscle cells or other tissues. In case of insufficient insulin, body start tos break down fat as energy source. This process produces a large amount of acids in the bloodstream known as ketones, which may lead to diabetic ketoacidosis if untreated. The symptoms of diabetic ketoacidosis includes excessive thirst, frequent urination, dehydration, shortness of breath, confusion etc and if untreated it may lead to unconsciousness, coma and even death.

2. The cause of the aromatic odor noticed on the breath of this patient is high levels of blood acids called ketones. This high levele of blood acids results into the exhalation of acetone during expiration.

3. The specific gravity of urine is increased in case of diabetic kketoacidosis due to high level of sugar (glucose) in the urine.

4. It is important to determine the cause of unconsciousness in this patient because the reason behind the uncosciousness may be either increased blood sugar level or dehydration or shock, and exhaustion or may be combination of these and different therapy startegies are applied for different reasons.