Review of Symptoms and Lab Results
The reported nausea, vomiting, and abdominal pain may indicate a GI disorder, but combined with the patient’s diabetes, unusual thirst, constant urination, and fatigue, the symptoms are more indicative of an endocrine disorder (Lippincott Williams & Wilkins, 2006).
Some of the patient’s lab results fall into the normal range: BUN of 16 mg/dl (normal is 8 — 25 mg/dl); creatinine of 1.3 (normal is 0.5 — 1.7 mg/dl); sodium of 139 mEq/L (normal is 135 — 145 mEq/L); blood pressure of 90/60 (normal is less than 120/80); and temperature of 99 .1Â°F (Chernecky & Berger, 2001; Pagana & Pagana, 2003).
Other lab results fall outside of the normal range: glucose of 420 mg/dl is very high (normal is 60 to 110 mg/dl); 4+ glucose and 3+ ketones are very high (normal is no glucose or ketones present in the urine); pH of 7.12 is low (normal is 7.35 — 7.45); PCO2 of 17 mmHg is low (normal is 35 — 45 mmHg); chloride of 112 mEq/L is high (normal is 98 — 106 mEq/L); bicarbonate of 5.6 mEq/L is low (normal is over 18); pulse of 136 is high (normal ranges from 60 and 100); and respiratory rate of 36 is high (normal ranges from 12 to 20) (Chernecky & Berger, 2001; Kitabchi, Umpierrez, Miles, & Fisher, 2009; Pagana & Pagana, 2003).
A possible diagnosis for this patient is diabetic ketacidosis, which is one of the most serious complications of diabetes and is often seen in emergency departments (Wolfson, et al., 2009). Previously, diabetic ketacidosis (DKA) was considered primarily a complication of type 1 diabetes, but since the late 1990s, DKA has increasingly been found to be a complication of type 2 diabetes, particularly among obese African-Americans (Kitabchi, et al., 2009; Wolfson, et al., 2009).
Typical symptoms of DKA include polyuria (excessive urination), polydipsia (excessive thirst), vomiting, nausea, abdominal pain, weight loss, weakness, and blurred vision (Wolfson, et al., 2009). The patient reports six of these eight symptoms.
Justification of Diagnosis
The diagnostic criteria for DKA are arterial pH less than 7.30, serum bicarbonate less than 18 mEq/l, plasma glucose greater than 250 mg/dL, positive urine ketone, positive serum ketone, and anion gap greater than 12 (Kitabchi, et al., 2009). For the variables that were tested, the patient meets all of these thresholds for DKA. Further, Wolfson, et al. (2009) write that “In the case of a patient known to have diabetes who presents with the typical signs and symptoms of & #8230;DKA, it is enough to establish the presence of hyperglycemia, ketosis, and acidosis to be confident of the diagnosis.”
Hyperglycemia: The patient’s blood glucose level of 420 mg/gl is very high and far exceeds the threshold of 250 mg/gl. This patient is hyperglycemic.
Acidosis: The arterial blood gas reading of pH [HIDDEN] is less than 7.3, which establishes acidosis (Lee-Lewandrowski, Burnett, & Lewandrowski, 2002; Wolfson, et al., 2009), and the high anion gap (AG) also supports metabolic acidosis. The AG is calculated by subtracting the sum of the bicarbonate and chloride levels from the serum sodium level; for this patient, 139 – (5.6 + 112). The AG for this patient is 21.4 mEq/L, which exceeds the diagnostic threshold of 12 mEq/L (Wolfson, et al., 2009).
Ketosis: Ketosis is determined by the presence of ketones in the blood, while the presence of ketones in the urine is ketonuria (Haber & Ward, 2002). The patient’s urinalysis result of 3+ ketones indicate ketonuria (Haber & Ward, 2002); a serum ketone test could be conducted to confirm the diagnosis of DKA.
Chernecky, C.C., & Berger, B.J. (Eds.). (2001). Laboratory tests and diagnostic procedures. Philadelphia: Saunders.
Haber, M.H., & Ward, P.C.J. (2002). Urine. In K. McClatchey (Ed.), Clinical laboratory medicine. Philadelphia: Lippincott Williams & Wilkins.
Kitabchi, A.E., Umpierrez, G.E., Miles, J.M., & Fisher, J.N. (2009). Hyperglycemic crises in adult patients with diabetes. Diabetes Care, 32(7): 1335 — 1343. doi: 10.2337/dc09-9032.
Lee-Lewandrowski, E., Burnett, R.W., & Lewandrowski, K. (2002). Electrolytes and acid-base balance. In K. McClatchey (Ed.), Clinical laboratory medicine. Philadelphia: Lippincott Williams & Wilkins.
Lippincott Williams & Wilkins. (2006). Endocrine disorders. In The Lippincott manual of nursing practice. Philadelphia: Lippincott Williams & Wilkins.
Pagana, K.D., & Pagana, T.J. (2003). Mosby’s diagnostic and laboratory test reference. St. Louis: Mosby.
Wolfson, A.B., Hendey, G.W., Ling, L.J., Rosen, C.L., Schaider, J.J., & Sharieff, G.Q. (Eds.). (2009). Harwood-Nuss’ clinical practice of emergency medicine. Philadelphia: Lippincott Williams & Wilkins.
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