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Clinicopathologic Conference

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by

Ana Rita Hermosisima

on 27 October 2014

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Transcript of Clinicopathologic Conference

Differential Diagnosis
History of Present Illness
Physical Examination
Laboratory Test Results
Type 1 DM
& DKA
Differential
Diagnosis
Diabetic Ketoacidosis in DM
Manifestations & Precipitating Factors
Symptoms and physical signs of DK and usually develop over 24 hr.
DKA may be the initial symptom complex that leads to a diagnosis of type 1 DM, BUT it more frequently occurs in individuals with established DM.
Type 1 Diabetes
an Introduction
Clinicopathologic Conference
Level III - Group 7

A 21 year-old female is brought by her friend to the ER with nausea, vomiting, lethargy and dehydration.

Her history is not known since no immediate relative was there.

She was coughing for several days
and was febrile.

An empty insulin bottle,
syringes and a glucose meter
were found in her handbag.
Physical Examination
Patient is lethargic.

BP: 80/50mmHg HR: 130bpm RR: 33cpm

Skin: cool clammy, poor skin turgor

HEENT: dry mucous membrane,
pink palpebral conjunctiva

C/L: no lesions noted, equal chest rise,
tachypnea, clear breath sounds

CVS: heart sounds normal, tachycardic
Abdomen: flat, normal bowel sounds, soft,
no tenderness, no organomegaly

Extremities: no gross deformities

Neurologic Exam: oriented
& responsive, generally weak
Other Tests:
CXR : Mild inflammatory process in the left basal
ECG: Sinus tachycardia
Pathogenesis
of DKA
Laboratory Results
of DKA
Management
of DKA
Management
of Pneumonia
Management
of Type 1 Diabetes
Complications and
Prognosis
Differential Diagnosis
Differential Diagnosis
Clinical Impression:
Nausea &
Vomiting
Thirst
Polyuria
Abdominal Pain
Tachycardia
Shortness of Breath
Dehydration
Hypotension
Respiratory
Distress
Lethargy
Abdominal Tenderness
Hyperglycemia
Ketosis
Metabolic acidosis (increased anion gap)
Serum bicarbonate <10 mmol/L
Arterial pH 6.8-7.3
Osmolality (300-320 mOsml/mL)

Reduced sodium, chloride, phosphorus, magnesium
Elevated BUN and serum creatinine
Serum potassium mildly elevated
Leukocytosis
Hypertrigyceridemia
Hyperlipoproteinemia
Hyperamylasemia
ketonemia
Diabetic Ketoacidosis
Secondary to Pneumonia
- Young adult, 21 y.o
- Vomiting
- Lethargic
- Signs of volume depletion: dehydrated,
cold clammy skin
- Metabolic acidosis
- Arterial PH 7.2
- Arterial PCO2 23 mmHg
- Serum Bicarbonate decreased (10 mEq/L)
- Decreased PCO2 and PO2 with respiratory compensation
- Increased Anion Gap (16) normal: 10-14
- Leukocytosis (17,300 mg/ul)
- Creatinine only slightly increased (2 mg/dL)

Prevention
Moderate Risk CAP (In-patient)
i. Cefuroxime (Zegen, Zinacef) 750mg – 1.5gm q 8 hr IV
ii. Ampicillin-Sulbactam (Unasyn) 750 mg – 1.5gm q 8 hr IV
iii. Co-Amoxiclav (Amoclav) 600mg – 1.2gm q 8 hr IV

+

Azithromycin 5oomg IV q 24 hr
or
Fluoroquinolone PO:
Ex. Levofloxacin (Levox) 750mg tab OD PO x 5-7 days
Moxifloxacin 400mg OD PO 5-7 days


Check your ketone level.
Be prepared to act quickly.
Yearly pneumocccal and influenza vaccines

Cerebral edema
Severe or fatal brain damage
ARDS
Mucous plugging
Arterial and venous thromboembolism
Make a commitment to managing your diabetes.
Monitor your blood sugar level.
Adjust your insulin dosage as needed.
Type 1 Diabetes
Basis:
Age (21 years old)
Glucosuria (Glucose ++++)
Increased Capillary Blood Sugar (700 mg/dL)
Empty Insulin bottle & glucometer found
Full transcript