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?

Instructions:

formulate what may be happening with A.M. and how you would improve her condition. I need 3 pages please don't just answer the questions it's a paper . 3 pages no less please , if you can't do it please don't do it . like I said don't just answer the questions one by one but just add them all together it is a research paper . NOTHING IS MISSING. i need a full 3 pages please. also i need new answers

Answer 1

The patient is a young female with Type 1 diabetes mellitus on insulin. Here the patient is having vomiting ,altered sensorium, not able to drink, fruity odour in the breath all are suggestive of diabetic ketoacidosis.

Diabetic ketoacidosis mainly occurs due to insulin deficiency, peripheral insulin resistance, counter regulatory hormonal actions (like cortisone, growth hormone, catecholamine) leads to hyperglycemia, ketoacidosis, electrolyte imbalance. The patient will be having a blood sugar level more than 600mg/dL .Urinary ketone will be present. Electrolyte imbalance mainly seen is hypokalemia .

Here symptoms and signs of the condition includes altered consciousness, acidotic breathing, fruity odour in the breath, hypotension, decreased frequency of passing urine,vomiting.

Laboratory tests should include blood glucose, renal function test, serum electrolyte,liver function test, urine analysis for ketone bodies as well as presence of any infection.

The intervention should include fluid replacement with half normal saline or normal saline. About 4 litters of fluid is replaced intravenously over 5-6 hours. Insulin is given as infusion with close monitoring of blood sugar. If the blood comes below 250mg/dL, then insulin infusion is given along with dextrose normal saline to prevent hypoglycemia. Potassium chloride infusion is also given as insulin infusion can also cause hypokalemia.

Monitoring of blood pressure, pulse rate, respiratory rate should be done periodically. Blood sugar monitoring should be done on an hourly basis till the patient become stable.

The first and most important step in the treatment of diabetic ketoacidosis is correction of dehydration. Then only comes the correction of blood sugar and electrolyte imbalance.

Once the patient become normal, assess all the laboratory parameters once again. Titrate the usual dose of insulin according to random blood sugar. Discharge the patient with advice regarding diabetic diet,predispising factors for diabetic keoacidosis etc.