A diabetic 15yr. old gir in a coma was brought to the emergency department by he

Question

A diabetic 15yr. old gir in a coma was brought to the emergency department by her parents. She has been on insulin for the past 8 years but, according to her parents, had not been very diligent lately about taking her insulin injections. The following laboratory results were obtained on this patient:

LAB TEST RESULTS REFERENCE RANGE

Venous Blood

Glucose 1050 mg/dl Reference: 70-110 mg/dl

Albumin 3.0 g/dl Reference: 3.5-5.0 g/dl Total

Calcium 8.2 g/dl Reference: 8.6-10.0 g/dl

BUN 35 mg/dl Reference: 7-18 mg/dl

Creatinine 1.3 mg/dl Reference: 0.5-1.3 mg/dl

Lactate 5.0 mmol/L Reference : 0.5-2.2 mmol/dl

Na+ 145 mmol/L Reference: 136-145 mmol/L

K+ 5.8 mmol/L Reference: 3.4-5.0 mmol/L

Cl- 87 mmol/L Reference: 98-107 mmol/L

HCO3- 8 mmol/L Reference: 22-26 mmol/L

Osmolality 385 mOsm/kg Reference: 275-295 mOsm/kg

Arterial Blood

pH 7.11 Reference: 7.35-7.45

pO2 98 mmHg Reference: 83-100 mmHg

pCO2 20 mmHg. Reference: 35-45 mmHg

Urine Glucose 4+ Reference: Negative

Ketones 4+ Reference: Negative

a. What is the most likely diagnosis in this patient? Explain which result(s) support your answer.

b. Calculate the anion gap using the patient’s results. Explain the most probable cause of the anion gap result. SHOW ALL WORK!

d. Explain why the chloride, bicarbonate and pCO2 levels are decreased.

e. What is the significance of the plasma osmolality?

f. Explain the etiology behind the patient’s urine results.

Explanation / Answer

a) The patient has excessive amounts of glucose accumulated in her blood as she has not been regularly taking her insulin injections. The venous blood shows Glucose levels of 1050 mg/dl ( as compared to the normal range of 70-110 mg/dl). These are dangerously high levels of sugar accumulated in the blood.

d) Chloride, bicarbonate and CO2 levels decreased due to the development of Diabetic ketoacidosis. (Accumulated glucose and ketone bodies which aere eventually thrown out through the urine).

e) Plasma osmolality refers to the body's electrolyte-water balance. In this case, since her blood glucose are dangerously high, the body tries to excrete the excess sugar through the urine. Thus the plasma osmolality decreases. This inturn supresses the Anti-duretic hormone. Inturn, dilute urine is released to get rid of large amounts of sugar and water from the body. Thus, as large amounts of sugar and water is released through the urine, the plama osmolality comes back to normal levels.

F) The urine levels show dangerous amounts of ketone bodies and glucose levels. This is one way in which the body tries to get rid of the excess sugars accumulated due to the inactivity of natural insulin and also irregular intake of injected insulin. Thus, the urine output increases and is also dilute as large amounts of water is lost.

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