Diabetes Flashcards
A 19-year-old man presents to the emergency department with abdominal pain and fatigue for the past 24 hours. For the past two days, the patient has had poor appetite, increased thirst, and frequent urination. On further questioning, the patient mentions that he has no dysuria but has been having difficulty breathing for the past several hours. Past medical history is unremarkable. Temperature is 37.0 °C (98.6 °F), pulse is 108/min, blood pressure is 100/65, respiratory rate is 22/min, and oxygen saturation (SpOz) is 99% on room air. On physical examination, the patient is fatigued. Mucous membranes appear dry. The lungs are clear to auscultation. The abdomen is soft and nontender to palpation. The patient’s posterior calves are tender to palpation bilaterally. Serum bicarbonate is 12 mEq/L and creatinine is 1.7 mg/dL. Urinalysis shows 3-5 WBC/hpf and no bacteria. Chest x-ray is unremarkable. What should be ordered next?
This young patient with fatigue, nonspecific abdominal pain, increased thirst, and frequent urination has symptoms suggestive of undiagnosed diabetes mellitus and severe hyperglycemia. Physical examination finding of dry mucous membranes and hypotension suggests severe dehydration. Low serum bicarbonate indicates metabolic acidosis that could be secondary to diabetic ketoacidosis in this setting. This patient should be aggressively resuscitated with intravenous 0.9% saline. The diagnostic approach in patients with acute dyspnea should be systematic. In hemodynamically stable patients, focused history and physical examination should be performed. Pulmonary causes of dyspnea generally present with abnormal lung sounds and often hypoxemia. Diffusely decreased or abnormal breath sounds with wheezing can be seen in asthma and COPD exacerbations. Patients with COPD may have hyperinflated lungs on chest imaging and chronic metabolic alkalosis on laboratory testing. Localized decreased or abnormal breath sounds may indicate pneumothorax or pneumonia, and chest imaging can differentiate between the two. Pneumonia will generally have associated fever and leukocytosis, with focal consolidations or diffuse infiltrates on imaging. Cardiovascular causes (e.g. heart failure) will usually present with signs of volume overload such as jugular venous distention, pulmonary crackles and peripheral edema. Electrocardiogram may show arrhythmia, ischemic changes (e.g. ST segment elevation) or specific findings such as electrical alternans (in cardiac tamponade) or S1Q3T3 (in pulmonary embolism). While pulmonary embolism often presents with dyspnea and chest pain, lungs will be clear to auscultation. Metabolic/Toxic causes should be suspected when cardiopulmonary exam and chest imaging are unremarkable. Oftentimes there is no associated hypoxemia in these cases. This patient likely has diabetic ketoacidosis. Severe metabolic acidosis has led to compensatory hyperventilation and dyspnea. Anxiety and panic disorder can also cause dyspnea and the rest of the workup will be negative. Neuromuscular causes, such as amyotrophic lateral sclerosis or Guillain-Barré syndrome, should also be ruled out in the appropriate clinical setting.
A 20-year-old man presents to the emergency department to be evaluated for abdominal pain, vomiting, and frequent urination over the last 24 hours. Over the past several days, he has been much more thirsty than usual and has experienced severe fatigue. He has no burning with urination. He does not use tobacco, alcohol, or other recreational drugs and has not recently taken any supplements. He has no significant past medical history.
Temperature is 37.3 °C (99.1 °F), pulse is 114/min, respiratory rate is 20/min, and blood pressure is 99/62 mm Hg. Cardiopulmonary exam is within normal limits. Abdominal exam reveals mild diffuse abdominal tenderness without rebound or guarding. Neurological exam is nonfocal. Basic metabolic panel is obtained and shows sodium 128 mEq/L, chloride 91 mEq/L, and bicarbonate 14 mEq/L. Which of the following additional historical or physical examination findings is likely to be present given the most likely underlying condition?
A) Family history of type 1 diabetes
B) History of kidney stones
C) Recent weight gain
D) Acetazolamide use
E) Decreased visual acuity
Diabetic ketoacidosis is a common cause of an elevated anion gap metabolic acidosis, and patients typically present with polyuria, polydipsia, nausea, vomiting, abdominal pain, and tachypnea. Patients may have a personal or family history of type 1 diabetes mellitus or other autoimmune disorders. This patient presents with abdominal pain, vomiting, polyuria, and polydipsia and is found to have an elevated anion gap metabolic acidosis. Together, this patient’s symptoms and elevated anion gap are highly suggestive of diabetic ketoacidosis. This typically occurs in patients with type 1 diabetes mellitus (DM), who often have a family history of type 1 DM or other autoimmune diseases. Patients with diabetic ketoacidosis (DKA) usually present with signs of hyperglycemia (polyuria, polydipsia), fatigue, and Gl symptoms (nausea, vomiting, abdominal pain). Altered mental status can occur but is more common in a hyperosmolar hyperglycemic state.
Since DKA is more common in type 1 diabetes mellitus, patients may have a family history of type 1 diabetes mellitus or a personal or family history of other autoimmune diseases. On physical examination, patients will be uncomfortable-appearing and may have altered mentation. They are usually tachypneic as the body tries to compensate for metabolic acidosis by inducing a relative respiratory alkalosis. The mucous membranes are typically very dry as patients can be extremely volume-depleted. Generalized abdominal tenderness is common. Tachycardia and hypotension are also common due to the severe volume depletion which is often seen.
