Case Study Diabetic Ketoacidosis

A 25 year old young woman came to the hospital with fever and mild confusion. During the previous few weeks she had experienced polydipsia, polyphagia and polyuria, with significant weight loss (12 kg). She reported pain in her left flank area, with dysuria, for the previous 48 hours. Her mother reported that her daughter's breath had a peculiar, uncommon smell, and that her breaths were more frequent.

A physical exam was remarkable for evidence of dehydration. She had a low supine blood pressure (85/60 mmHg), with increased pulse rate (120 per min) and respiratory rate (32 breaths per min). Her breath had an acetone smell. There was mild clouding of sensorium, but without focal neurological signs. She had fever (37.9 °C [100.2 °F]) and tenderness on percussion of the left flank area (positive Giordano sign). A capillary blood glucose measurement showed a very high level: 484 mg/dl (26.9 mmol/L). At the same time, ketone bodies measured in the capillary blood with a portable meter (Medisense Xtra) were also very high: 4.5 mmol/L (note: these strips measure only ß-hydroxybutyrate [b-HB] and not acetoacetate in the blood; levels > 3mmol/L are considered a sign of ketosis). Arterial blood gas analysis showed the following: pH 7.08 (7.35-7.42); pCO2 8 mmHg (35-45); pO2 120 mmHg (80-100); and HCO3 6 mmol/L (24-32).

The diagnosis of diabetic ketoacidosis (DKA) was made. An ECG, a chest X-ray and further laboratory tests were done. The results were:

Blood glucose: 525 mg/dl (29.1 mmol/L) (75-110 mg/dl [4.2-6.1 mmol/L])

Sodium: 124 mmol/L (132-144)

Chloride: 88 mmol/L (93-108)

Urea: 92 mg/dl (15.3 mmol/L) (18-36 mg/dl [3.0-6.0 mmol/L])

Creatinine: 3.2 mg/dl (282.9 mmol/L) (o.7-1.2 mg/dl [61.9-106.1 mmol/L]) Urinalysis: Urine cloudy and foul smelling, glucose: ++++, ketone: +++, many WBCs, abundant microorganisms, many RBCs. CBC: Haematocrit: 44%, WBC: 22,000/ml (polymorphonuclear 88%).

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