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Diabetes Mellitus Type 1 (DM1)
11
Diabetes Mellitus Type 1 (DM1)
By: Trevor Moore, Mikayla Mellon, Ndidi Nwanaforo, Kelli Steele
Date 1
Background:
Background
S.C. is a 13-year-old female who was in relatively good health who had occasional colds or influenza episodes. She has never had to go to the hospital before. A few months ago she was diagnosed with type one diabetes mellitus.
Last night before dinner, the patient took her usual dose of insulin, lispro, for blood sugar of 193 mg/dL. She began feeling nauseated before going to bed and then woke up with a stomachache around midnight and began vomiting. Her blood glucose at the time was 397 mg/dL. Her mother tried to get her to drink some diet ginger ale and eat a few crackers, but she could not keep anything down. She vomited several more times and started breathing very heavily.
S.C.’s mother suspected ketoacidosis and took her daughter to the ER. S.C. denis fever, chills, cough, sore throat and painful urination. S.C. states she had mild diarrhea for the past 36 hours. S.C. also states that a few of her classmates had been sick, having flu-like symptoms.
(Bruyere, 2009)
Chief Complaints
- "I have been throwing up since yesterday"
- "I have had a stomach ache"
- "I feel very weak."
(Bruyere,2009)
History of Present Illness
HPI
S.C.’s mother noticed that S.C. seemed less active than normal and pale over the past few months. S.C. stated she had been feeling tired and was seriously thinking about quitting the volleyball team.
Seemingly, S.C. was contantly hungry and thirsty so she had been frequently eating snacks. Even with the increased fluid and coloric intake she says that she has lost weight. Her clothes were starting to feel “too big” for her. She had noticed that she was going to the bathroom much more than before. S.C. states that she has become more irritable and has difficulty concentrating on her homework.
S.C.’s mother was alarmed by these changes and took her to the family physician, where she was diagnosed with type one diabetes mellitus. S.C. and her parents were taught proper insulin administration, blood glucose testing, urine testing, foot care, and menu planning. S.C. was started on a daily schedule of insulin.
(Bruyere, 2009)
Family History
- Both mother and father live in the household and are well
- One older brother, age 17, with type 1 DM (Diagnosed at age 10)
- Two younger sisters, ages 9 and 11, without health problems.
- Maternal grandmother died at age 50 from renal complications of type I DM
Family and Social History
Social History
• "B" student in school
• Member of volleyball team and school band
(Bruyere, 2009)
Medications
• Insulin lispro according to a sliding scale
• NPH insulin at breakfast and bedtime
• Additional insulin lispro if urinary ketones are elevated
Medications and Allergies
No Known Allergies
(Bruyere, 2009)
Patient Information
Review of Systems
Patient Informtion
- HEENT: Denies blurry vision, dizziness, head trauma, ear pain, tinnitus, dysphasia and odynophagia
- CV: No complaints of chest pain, orthopnea, or peripheral edema
- RESP: Denies coughing, wheezing, or dyspnea
- GI. Vomiting with nausea, abdominal pain, mild diarrhea, and food-fluid intolerance as noted above
- GU: Had polyuria (large volumes every 2 hours) last evening but has not urinated since waking up. No complaints of dysuria or hematuria.
- OB-GYN: Started menstruating 13 months ago. Menses flows for 5 days and is regular every 28 days. Not sexually active and denies any vaginal discharge, pain, or pruritus.
- NEURO: Denies weakness in the arms and legs. No complaints of headache, paresthesias, dysesthesias, or anesthesias.
- DERM: No history of rash or other skin lesions and no diaphoresis
- ENDO: Denies heat or cold intolerance
(Bruyere, 2009)
Vital Signs
BP: 90/65 (Supine)
RR: 28
Pulse: 126
Temp.: 99.5F
Height: 5 ft
Weight: 87 lbs.
(Bruyere, 2009)
Physical Exam
General
- A&O, thin white girl who looks ill
- Deep respirations
- Smell of acetone on her breath
Skin
- Pale and dry, no lesions
- Moderately decreased turgor
Neck and LN, Chest, Rect, Ext, Neuro
- WNL
HEENT
- MM dry and phrynx erythematous without tonsillar exudates
- PERRLA,NC/AT, EOM intact, fundi normal, ears normal
CV
- PMI normal and non-displaced
- S1 and S2 normal, without S3 or S4 murmurs or rubs
- RRR
- Carotid, femoral, and dorsalis pedis pulses are weak bilaterally
- No carotid, abd, or femoral bruits heard
ABD
- Soft and NT without organomegaly or masses
- BS are subnormal
(Bruyere, 2009)
Lab Results
U/A:
SG 1.018
pH 5.5
Glu 3+
Protein (-)
Ketones 3+
Chest Xray:
Normal
EKG:
ST
Lab Results
Na: 127 mEq/L
K: 6.1 mEq/L
Cl: 98 mEq/L
HCO3: 15 mEq/L
Anion Gap: 20.1 mEq/L
BUN: 23 mg/dL
Cr: 1.5 mg/dL
Glucose (Fasting): 554 mg/dL
Acetone: 3+
Hemoglobin: 13.1 g/dL
Hematocrit: 48%
RBC: 5.3 million/mm3
Plt: 358,000 /mm3
MVC: 90 fL
MCHC: 33 g/dL
WBC: 11,500 /mm3
Neutrophils: 40%
Bands: 11%
Lymphs: 45%
Monos: 4%
ESR: 18 mm/hr
ABG (on Room Air):
pH 7.23, PaO2, 107 mm Hg, PaCO2, 20 mm Hg, O2, saturation 97%
(Bruyere, 2009)
Question 1
Questions
Question: "Some people I know with diabetes can take pills," says S.C.
"Why can't I take pills instead of having to take insulin?" she asks. What is an appropriate response to her question?
Answer: There are two types of diabetes mellitus. Type 1 which is an autoimmune condition that is chronic that is caused by an insulin deficiency that occurs due to the destruction of beta-cells in the pancreas that produce insulin. These people do not produce any insulin. A different type of the disease is type 2 (non-insulin-dependent diabetes mellitus) which is resistance to insulin, dysfunction of the beta cells, and inflammation that lasts several months or years which all cause blood glucose dysregulation and vascular issues.
Since the people with DM1, like you, don't produce insulin you must take insulin to lower your blood sugar. The pills will not be effective because your beta-cells do not produce any insulin production. People with type 2 produce insulin. They are resistant to the insulin but the pills help them by making them more sensitive to the insulin, by decreasing glucagon secretion, and/or by suppressing the glucose produced in the liver.
(Bruyere,2009)(DeFonzoet al., 2015)
(Katsarou et al., 2017)
Question 2
Question: "What is the single greatest risk factor for type 1 diabetes mellitus that this patient has?"
Answer: The single greatest risk factor for this patient is a family history of diabetes type 1. Her brother, a first degree relative (sibling), has type 1 diabetes that was diagnosed at 10 years-of age. Her grandmother also died at age 50, due to renal complications of diabetes mellitus type 1. Type 1 diabetes is a disease that has multiple factors that must include certain genes that are exacerbated by environmental factors such as viruses, foods, and drugs.
(Bruyere, 2009)
(Rewers & Ludvigsson, 2016)
(Rogers, 2023)
Question 3
Question: "What causes heavy breathing in a patient with type 1 diabetes mellitus?"
Answer: In a patient with Type 1 diabetes mellitus, diabetic ketoacidosis must be considered as a serious complication. Diabetic Ketoacidosis (DKA), involves the buildup of ketones, resulting in a significant decrease in pH, thus causing metabolic acidosis. Heavy breathing in a patient with type 1 diabetes mellitus is the body compensating during DKA. More specifically, hyperventilation is caused by a decrease in serum bicarbonate and pH level, forcing the body to expel more CO2 in an attempt to prevent pH and bicarbonate from decreasing more and furthering the acidotic state. Patients will first experience tachypnea, while progressing to a deeper, hyperpneic state of breathing as acidosis progresses.
(Gallo de Moraes & Surani, 2019)
(Rogers, 2009)
Question 4
Question: "What is this heavy breathing called?"
Answer: As described in the previous question, during DKA, a patient may present with tachypnea that progresses to hyperpnea. This type of breathing associated with this complication is known as Kussmaul respirations (Rogers, 2023, p. 710-711).
Question 4
(Rogers, 2023)
Question 5
Question: "Why is it appropriate for the physician to inquire about fever, chills, diarrhea, cough, sore throat, and painful urination?"
Answer: The physician should inquire about these symptoms for two reasons. First, patients with diabetes are increasingly more likely to develop infections for several reasons. One of these reasons being that certain pathogens flourish in sites that have high glucose content. Second, if the patient is experiencing hyperglycemia and complications associated with it, it could be a result of an underlying infection or illness that could be revealed by looking closer at symptoms such as those stated above (Rogers, 2023, p. 711-714).
(Rogers, 2023)
Question 12
Question: "Identify four laboratory test results that are consistent with a diagnosis of diabetic ketoacidosis."
Answer: Four laboratory test results that are consistent with a diagnosis of diabetic ketoacidosis (DKA) are the reduced amount of bicarbonate (HCO3) which in S.C. is 15 mEq/L while the normal range is 22-28mEq/L. S.C. 's anion gap is increased at 20.1 mEq/L while the normal range is 10-12 mEq/L. S.C.’s fasting glucose is 554mg/dL and a glucose level of greater than 250 mg/dL qualifies the patient as having diabetic ketoacidosis. S.C.’s acetone/ketone level is 3+ while normal is under 0.6 mmol/ L.
Question 12
(Rogers, 2022)
(Bruyere, 2009)
Question 13
Question: "How was anion gap determined in this patient?"
Answer: Anion gap =[Na+ (127) + K+ (6.1)] - [HCO3- (15) + Cl- (98)] = 133.1 - 113 = 20.1
The anion gap is calculated by subtracting the values of the bicarbonate and chloride from the sodium and potassium.
(Rogers, 2022)
Question 13
(Bruyere, 2009)