The case study revolves around a 56-year-old Caucasian male who presents to the primary care clinic with complaints of dizziness and nausea for the past four days. The patient states that he has been unable to get out of bed since the onset of symptoms, and they worsen when he attempts to stand. He denies experiencing headaches or blurry vision. Additionally, he reports increased urination and thirst over the past few days and mentions that he consumed a large sweet tea prior to seeking medical attention. It is important to note that the patient is currently out of his prescribed medications, Lantus and metformin, due to financial constraints until he receives his disability check. He is disabled as a result of his second cerebrovascular accident (CVA), which has left him with generalized weakness. The patient’s medical history includes diabetes mellitus (DM), hypertension (HTN), and coronary artery disease (CAD). On arrival at the clinic, the vital signs are recorded as blood sugar 405 mg/dL, blood pressure 190/101 mmHg, heart rate 102 beats per minute, respiratory rate 20 breaths per minute, and temperature 98.5°F.
In order to analyze this case study using evidence-based practice, several questions need to be addressed:
1. What is the most likely diagnosis for this patient’s current symptoms, based on his presentation and medical history?
Based on the patient’s symptoms and medical history, the most likely diagnosis for his current presentation is diabetic ketoacidosis (DKA). Dizziness, nausea, and an inability to stand are indicative of metabolic derangement commonly associated with DKA. Moreover, the patient’s history of diabetes mellitus and his elevated blood sugar level of 405 mg/dL further support this diagnosis. Additionally, the patient’s lack of access to his prescribed antidiabetic medications, Lantus and metformin, due to financial constraints may have led to the development of DKA.
2. What are the pathophysiological mechanisms underlying the development of diabetic ketoacidosis?
Diabetic ketoacidosis occurs due to an absolute or relative insulin deficiency. In the absence of sufficient insulin, the body is unable to utilize glucose as a source of energy. Consequently, the body starts breaking down fatty acids as an alternative source of energy, leading to the production of ketones. The accumulation of ketones in the bloodstream leads to an increase in blood acidity, resulting in the characteristic metabolic acidosis observed in DKA. Additionally, the liver’s increased gluconeogenesis and glycogenolysis further contribute to the elevated blood glucose levels seen in DKA.
3. How does diabetic ketoacidosis typically present clinically?
Clinically, diabetic ketoacidosis is characterized by the triad of hyperglycemia, ketosis, and metabolic acidosis. Patients often present with symptoms such as nausea, vomiting, polyuria, and polydipsia. Dehydration and electrolyte imbalances are common due to the osmotic diuresis resulting from hyperglycemia. Additionally, patients may exhibit signs of deep and rapid breathing known as Kussmaul respirations, indicative of compensatory respiratory alkalosis in response to metabolic acidosis.
4. What are the immediate priorities in managing this patient?
The immediate priorities in managing this patient include rehydration, insulin administration, correction of electrolyte imbalances, and monitoring of vital signs. Given the patient’s elevated blood sugar level and signs of dehydration, intravenous fluids containing isotonic saline should be administered to restore fluid volume and correct electrolyte imbalances. Regular insulin should also be administered to promote glucose uptake and inhibit ketone production. Frequent monitoring of the patient’s vital signs, blood glucose levels, and electrolyte levels is crucial to ensure appropriate management and prevent potential complications. Additionally, addressing the patient’s financial constraints and ensuring access to prescribed medications for diabetes management should be considered long-term priorities.