Name: Alicia Henning
Case Study 4: Diabetic Ketoacidosis in Type 1 Diabetes Mellitus:
graded case study is required for your student portfolio, so please type your answers. Due 11/26. Point
value: 25.
MN, a 33-year-old Hispanic woman with type 1 diabetes, is brought to the clinic by her mother in a
semicomatose state. MN is 5’4” (163 cm) and currently weighs 112 lb (51 kg). Her mother reports that
she was unable to wake MN after Thanksgiving dinner and was concerned that she might not be
receiving enough insulin. She reports that MN has lost 9 lb (4.1 kg) in the last 2 days after coming down
with a cold. According to her mother, she complained of dizziness, fatigue, frequent urination, and being
excessively thirsty and hungry. She often fell asleep after meals.
Past Medical History
MN has been a type 1 diabetic for the past 3 years. Except for the current illness, she has been well but
has been more sedentary and recently reported a decreased exercise capacity. Recent assessment of
her kidney function and an eye examination were normal.
MN’s usual schedule and food intake consist of the following:
1. She takes 2 insulin injections a day. One shot of regular plus intermediate insulin before
breakfast and one shot of regular plus intermediate insulin before dinner.
2. A 2000-calorie food plan distributed among three meals and two snacks that she received from
the dietitian at the hospital when she was first diagnosed 3 years ago. It consists of 50%
carbohydrate, 20% protein, and 30% fat. MN has noted that “sticking to her diet” is one of the
most difficult aspects of her diabetes self-care.
3. Monitoring and recording blood glucose is done by means of a home glucose monitor before
breakfast and dinner. Her goal is to maintain her fasting capillary glucose levels between 70 and
120 mg/dL, but they are above 150 mg/dL approximately 50% of the time. Her morning readings
are usually elevated. Her glucose self-monitoring results are rarely below 60 mg/dL.
Family History
MN’s mother developed type 1 diabetes in her late 30s and is currently treated with daily insulin
injections. Her paternal grandfather developed diabetes in his sixties and was treated initially with oral
medication.
Social History
MN has a hectic schedule during the week. She works long hours at a law firm and attends classes two
nights a week. MN tries to go to the gym before work but is often too tired. She does not smoke and
drinks alcohol only socially on weekends when she occasionally goes dancing with friends. On these
nights, she may have two or three glasses of wine but feels weak shortly after drinking and reports that
she “is just too tired to dance the way she used to.”
MN’s Usual Intake
Breakfast (office, 7:30 a.m.)
Instant oatmeal
(flavored, apple-cinnamon)
1 package
Coffee
Whole milk
Sugar
Orange Juice
12 oz (360 mL)
2 Tbsp.
2 packets
12 oz (360 mL)
Lunch (fast-food restaurant, 1:00 p.m.)
Hamburger
Roll
Lettuce
Tomato
Apple Juice
4 oz (113 g)
1
1 leaf
2 slices
12 oz (360 mL)
Snack (vending machine, 5:00 p.m.)
Pretzels
Cola
1 oz (28 g)
20 oz (600 mL)
Dinner (home, 8:00 p.m.)
Chicken breast (baked
Rice
Black beans
Olive Oil
Mixed salad
French dressing
Iced tea (sweetened)
6 oz (170 g)
1 cup
1 cup
1 Tbsp.
1 cup
2 Tbsp.
16 oz (480 mL)
Snack (home, 11:00 p.m.)
Chocolate chip cookies
Whole milk
3 small
8 oz (240 mL)
Total calories: 2863 kcal
Protein: 124 g (17% of total calories)
Carbohydrate: 403 g (56% of total calories)
Total fat: 87 g (27% of total calories)
Saturated fat: 27 g (8% of total calories)
Monounsaturated fat: 35 g (11% of total calories)
Cholesterol: 287 mg
Dietary fiber: 25 g
Sodium: 2386 mg
Physical Examination
Vital Signs
Temperature: 101.3°F (38.5°C) (note: fever often accompanies dehydration)
Heart rate: 120 beats per minute (BPM) (60-100 is normal)
Respiratory rate: 28 BPM (15-20 is normal)
Blood pressure: 120/60 mm Hg
Height: 5’4” (163 cm)
Weight: 112 lb (51 kg)
Body mass index (BMI): 19.2 kg/m²
General appearance: Sick-looking woman with deep and rapid respirations. Acetone was noted
on her breath. By examination she was assessed to have lost at least 10% of her body weight
as fluids.
Eyes: Dry conjunctivae.
Throat: Her buccal mucous membranes were dry.
Neck: No thyromegaly
Heart and lung examination: Normal.
Abdomen: Soft but generally mildly tender. No hepatosplenomegaly.
Extremities: Cool and mottled in the periphery, with weak but equal pulses.
Neurologic: Lethargic but easily aroused. Once aroused, she was able to provide a coherent
history. She responded to verbal orders and was oriented to time, place, and person.
The rest of her examination was normal.
Laboratory Tests
Patient’s Laboratory Values
White blood cell: 20,800/mm³
Hematocrit: 47%
Glucose: 620 mg/dL
Sodium (Na): 123 mEq/L
Potassium (K): 4.5 mEq/L
Chloride (Cl): 95 mEq/L
Blood urea nitrogen (BUN): 35 mg/dL
Creatinine: 2.0 mg/dL
Calcium (Ca): 9.2 mg/dL
Phosphate (PO4): 2.5 mg/dL
Acetone: 4+
Venous pH: 7.10
Triglyceride: 300 mg/dL
Cholesterol: 220 mg/dL
A1C: 8.5%
Normal Values
4500-11,000/mm³
36%-46%
70-110 mg/dL
133-143 mEq/L
3.5-5.3 mEq/L
98-108 mEq/L
7-18 mg/dL
0.6-1.2 mg/dL
9.0-11.0 mg/dL
2.5-4.6 mg/dL
Negative
7.35-7.45
<150 mg/dL
<200 mg/dL
4%-6%
Patient’s Urinary Laboratory Values
Specific gravity: 1.031
pH: 4.5
Glucose (Chem strip): 4+
Ketone bodies (Chem strip): 4+
Protein (Chem strip): negative
1.002-1.030
5-6
Negative
Negative
Negative
Treatment and Course
MN was diagnosed with diabetic ketoacidosis (DKA) and transported to the hospital for treatment.
Immediate management for DKA was aimed at replacing her past and ongoing fluid and electrolyte
losses and decreasing her plasma glucose level at a rate of 50 to 100 mg/dL per hour. Sodium chloridecontaining intravenous fluids and a continuous infusion of insulin were started. Potassium chloride and
potassium phosphorus were added to intravenous fluids as MN’s serum potassium decreased further.
Glucose was also added to intravenous fluids when plasma glucose decreased to below 250 mg/dL.
Clinically, she improved gradually: She became more alert, polyuria and polydipsia decreased, appetite
improved, and her fever abated. Twenty-four hours after admission her laboratory tests were as follows:
plasma glucose: 160 mg/dL, Na: 138 mEq/L, K: 4.2 mEq/L, Cl: 108 mEq/L, 18 mg/dL ,creatinine: 1.0
mg/dL, PO4: 3.2 mg/dL, venous pH: 7.35, and triglycerides: 200 mg/dL. Her urine had only 1+ glucose
and trace ketones.
New Insulin Regimen
Subsequently, MN’s usual subcutaneous insulin dose and diabetic diet were restarted. Because of the
high A1C, her total daily insulin dose was increased and she instructed on an intensive insulin injection
regimen. Her insulin regimen was changed to of long-acting glargine at bedtime for background and,
depending on her carbohydrate intake, 5 to 10 units of rapid-acting insulin before meals to give her
more flexibility in her lifestyle. Glargine provides basal insulin without peaks and is proven to decrease
the incidence of both hypoglycemia and prebreakfast hyperglygemia caused by the Somogyi effect.
CASE QUESTIONS (This will take you through the ADMIE process)
Assessment
Diet
1. Evaluate MN’s usual diet in terms of protein, carbohydrate (quality and quantity), and
fat intake.
17% of MN’s total calories come from protein. She is close to her goal of 20% of total calories
from protein. She’s eating mostly lean protein (baked chicken and beans)which is good. She
also had a hamburger. I would let her know it is okay every once and a while to have a
hamburger but it is important to stick with lean protein because it has less saturated fat which
will help her decrease her risk for cardiovascular disease.
56% of MN’s total calories are from carbohydrates. Her goal is to have 50% of her total calories
come from carbohydrates. I would talk to her about consuming less CHO. She spreads the CHO
out through out the day fairly well however her snack after lunch was too high in carbs. The
quality of CHO needs to be improved. She is consuming a lot of simple carbohydrates. She is
drinking a lot of sugary drinks. I would recommend eating fruit instead of drinking juice. Also
instead of drinking cola or sweetened ice tea, I would recommend lowfat milk or water. She is
drinking whole milk. I would recommend switching to low fat milk to reduce the amount of
saturated fat she is consuming.
27% of MN’s total calories are from Fat and 8% are from saturated fat. Here I would
recommend that she switch from whole milk to low fat milk. I would also talk to her about
including more monounsaturated fatty acids like avocados, nuts, etc.
2. Using carbohydrate exchanges, estimate the carbohydrate intake at each meal and
snack.
Breakfast
1 package Instant oatmeal (apple-cinnamon)
2 carb
2 packets sugar
1 carb
12 oz orange juice
3 carb
Lunch
1 Roll
12 oz apple juice
2 carb
3 carb
Snack
28g Pretzels
20 oz Cola
2 carb
4.5 carb
Dinner
1 cup Rice
1 cup Black Beans
16oz sweetened ice tea
3 carb
2 carb
1 carb
Snack
3 small Chocolate chip cookies
Whole Milk
Total:
1 carb
1 carb
25.5 carb choices for one day
3. What substitutions, if any, would you recommend for items that she is currently
consuming?
I would tell MN would be ideal for her to have about 13 carb choices throughout the day. I
would look with her at her usual food intake and decide together where she would feel
comfortable cutting out some carbs. Starting with breakfast, oatmeal is great but would she be
willing to switch to plain oatmeal? Another recommendation would be to replace sweetened
drinks (cola, juice, ice tea) with water or low fat milk. (Also switch from whole milk to low-fat
milk). I would see if she would want to replace juice with a piece of fruit. For snacks, she could
think about adding MUFAs such as nuts and avocado.
4. What concerns would you have regarding the 2-3 glasses of wine she consumes
periodically?
I would be concerned she is becoming hypoglycemic because she says she feels weak and tired
after drinking. Alcohol blocks gluconeogensis and counter regulatory mechanisms. I would talk
to her about getting her blood glucose levels under control before she drinks alcohol.
5. Estimate MN’s kcalorie and protein needs. Use Mifflin-St.Jeor and activity level for
normal daily activities from your assessment handout. Show your work.
Protein needs: 51kg * 1.0 g = 51 g of protein a day
Kcalorie needs:
Mifflin-St.Jeor for BMR
10 * 51 + 6.25 * 163 - 5 * 33 – 161 = 1203 kcals *1.3 (lightly active) = 1564 kcals
Anthropometrics
6. Calculate MN’s IBW, %IBW and %UBW.
IBW= 100 + (5*4) = 120
%IBW= 112/120= 93%
%UBW= 112/121 = 92.5%
7. What is your assessment of her weight? Any concerns?
Yes, she has lost 9 lbs in 2 days. The concern would be catabolism related to lack of insulin and
loss of glucose in the urine. She lost 10% of body as fluids. Dehydration from polyuria is a
concern. Also osmotic diuresis causing increased loss of water and increased loss of
electrolytes.
8. What is the most likely reason MN has lost weight given that she has been consuming
more than adequate kcals?
It is likely MN is in a catabolic state. Glucose release by the liver is increased due to lack of
insulin to inhibit glycogenolysis. High glucose causes polydypsia and polyuria. Fat catabolism
has also increased because of lack of insulin. Fat oxidation without adequate glucose in cell
results in ketone production. MN’s dehydration has contributed to her weight loss.
Biochemical
9. Which of her lab values indicate:
Acidosis
Blood pH fell below 7.35. It was 7.10
Decreased sodium and Chloride levels: Sodium was 123 mEq/L (normal 133-143 mEq/L)
Chloride was 95 mEq/L (normal 98-108 mEq/L)
Acetone was 4+ and it should be negative
Dehydration
Elevated blood urea nitrogen (BUN) 35 mg/dl (normal 7-18mg/dl)
Elevated glucose 620 mg/dl (normal 70-110 mg/dl)
Increased Creatinine 2.0 mg/dL (normal 0.6-1.2 mg/dL)
Elevated Hematocrit 47% (normal 36-46%)
Possible kidney dysfunction
Increased Creatinine 2.0 mg/dL (normal 0.6-1.2 mg/dL)
Elevated blood urea nitrogen (BUN) 35 mg/dl (normal 7-18mg/dl)
Protein in urine came out negative but there is a possibility for microalbuminuria
Cardiovascular risk
Elevated Triglycerides and Cholesterol. Triglyceride 300 mg/dL (normal <150 mg/dL) Cholesterol
220 mg/dL (normal <200mg/dL)
Elevated A1c
10. What does her A1c value tell you?
Her elevated A1c at 8.5% (for diabetes >7%) tells me that she is not controlling her blood
glucose very well. Hemoglobin A1c provides an average of her blood sugar control over 3
months. It tells us her blood glucose has been high for the past 3 months. This increases her risk
for cardiovascular disease, nephropathy and retinopathy.
11. Why are ketones and glucose present in her urine? Ketones are present because her
body cannot use glucose as a fuel source because there is no insulin or not enough
insulin. Fat is used for fuel instead. Without glucose in the cell, the byproducts of fat
catabolism are ketones which build up in the body and some are excreted in the urine.
Blood glucose levels rise because the liver makes more glucose to try to combat the fat
breakdown.
Physical signs/symptoms
12. What physical signs/symptoms indicated uncontrolled diabetes and DKA?
Deep and rapid respirations, acetone noted on her breath, lost 10% of her body weight as
fluids, dizziness, fatigue, frequent urination, being excessively thirsty and hungry, dry skin, and
high temperature.
Diagnosis
13. Write one PES statement appropriate for MN at the time of admission.
Involuntary weight loss related to polyuria and dyhydration as evidenced by weight loss of 9 lbs
in two days.
Intervention
14. MN states that she has trouble sticking to her diet. What strategy other than a set
insulin regimen could be used to make her diet more flexible yet maintain glycemic
control?
I would talk to her about an Insulin pump. I’d explain that it gives her a constant small
dose of Regular insulin. The pump also releases extra insulin when you need it, such as
before a meal.
Another option would be multiple daily injections to allow for a more flexible diet.
I would also talk about the importance of not skipping meals and eating at the same
time each day. Adding more MUFAs can help control blood glucose as well as exercise. I
would talk to her about healthy convenient foods such as baby carrots, tangerines, nuts,
etc.
15. Do you have any recommendations to change her glucose monitoring regimen she was
doing before admission?
It is important to have a regular blood glucose monitoring regimen. She should check
before and after meals, at bedtime, in the middle of night, and before/after exercise.
When she goes dancing with her friends or drinks alcohol, she should check it.
Monitoring and Evaluation
16. Assume MN leaves the hospital with good glycemic control. What lab values would you
want to follow to ensure good glycemic control, adequate kidney function, and reduced
cardiovascular risk?
I would want to see near normal blood glucose levels and an optimal lipid profile.
Glucose levels:
A1c < 7.0%
Preprandial plasma glucose: between 70-120 mg/dl
Postprandial plasma glucose: < 160 mg/dl
Lipid goals:
LDL < 100
HDL > 50
TGY < 150
BP < 130/80
Kidney function
Creatinine: 0.6-1.2 mg/dl
blood urea nitrogen (BUN): 7-18mg/dl
Urine should be negative for protein