Clinical Case 1

This is a case study I am doing for my anatomy and physiology class.  Some of the terminology will be above the heads of average readers.

The Case:  A 28- year-old African-American man (of normal height & weight), was found unconscious in front of his door way. Upon arrival to hospital his wife was interviewed and stated that for two days he was frequently urinating in the middle of the night, vomiting, scratching his feet and started drinking grape juice 5-6 glasses a day. He also started running into walls and was constantly dropping his briefcase. When he entered the emergency department he appeared to be in a drunken stupor and emitted a sweat-fruity aroma from his breath, and he also experienced Kussmaul breather (a rapid, deep respiratory pattern).


Other clinical findings:

Blood glucose = 375 mg/dL (normal= 70 -
110mg/dL)
Positive urine glucose
Positive urine ketones
Blood pH = 6.95 (normal= 7.2 - 7.4)

He also has findings consistent with a deep ulceration to the plantar aspect of one of his great toes and retinal damage.


Analyzation and Plan: History of present illness, current symptoms, and diagnostic tests indicate that this 28 year-old African American male is suffering from newly onset or uncontrolled Type II diabetes.  It is possible he could be manifesting Type I but it would be really rare for new onset type I at his age.  His race and sex also put him at a higher risk for diabetes.

The frequent urination is common in uncontrolled diabetes as you are trying to dump excess glucose via diureses.  The influx of glucose in the blood also causes osmotic dehydration as water is pulled from cells and tissues to dilute glucose in the blood.  With type II diabetes the beta cells in his pancreas are producing deficient or ineffective insulin and he has become unable to maintain normal blood glucose levels.  All the fructose in the grape juice the patient is drinking to slate his extreme thirst is probably making things worse, continually elevating his blood glucose and worsening his dehydration.

Your cells need insulin to use glucose and essentially begin to starve without it.  Consequently your body begins breaking down large amounts of stored fatty acids in an attempt to utilize the energy to maintain ATP production.  This ineffcient process dumps large amounts of these fatty acids into general circulation.  His weak acid-base system is unable to manage the influx of fatty acids (ketones) in his blood and his blood is becomming acidic.  The fruity scent of his breath and his hyperventilation is typical in diabetics trying to blow off CO2 to lower blood pH.  He is also trying to dump ketones into his urine.  Between the ketones in his urine and the dehydration his kidneys are taking a real beating.

It is also possible he is in renal failure due to prolonged hyperglycemia.  The glucose can sort of clump up in the renal tubules and also cause diffuse microvascular damage causing nerve dysfunction and/or death.  In the patient's extremities this microvascular damage combined with atherosclerotic peripheral artery disease which diabetics are also prone to is causing peripheral neuropathy and the horrible foot ulcer.  He probably can’t feel that part of his foot.

The diabetic foot ulcer is a Wagner grade III since it is to the bone.  It looks like the ulcer is down to the joint between the distal and proximal phalanx of the hallux.  He’ll need broad spectrum IV antibiotic coverage especially something that covers Staph until a wound culture comes back.  If the lesion is down to the bone he will need a biopsy and a culture of the bone to rule out osteomyelitis and set up long-term management.

His confusion, weakness and discoordination is most likely the result of dehydration and diabetic ketoacidosis (DKA) and it could be causing a little cerebral edema.  Considering the blood chemistry his pH is becoming dangerously low.  Humans must maintain a very tight pH range to maintain homeostasis.  Almost every cellular interaction depends on stable pH.

A blood glucose of 375 isn’t super mega ultra high but some diabetics are extremely sensitive and this patient has probably had uncontrolled blood glucose levels for some time considering the foot ulcer and retinal damage.  He has most likely been floating a blood glucose above 180 for several months with some general malaise but no major ill effect until the scale tipped and the dehydration pushed him into DKA.  Meanwhile the disease was doing it's work.  Since he couldn't feel the ulcer he probably let it slide, same with the declining vision.  Most people don't want to believe they are sick and denial is a powerful and terrible master.

First and foremost this patient will need rehydration and an insulin regimen.  This patient requires admission to the hospital critical care unit where he can be closely monitored.  Provided he did not have any major brain swelling his mental faculties should return but he unfortunately probably lost a few IQ points.  He has a relatively high probability of surviving this incident but his long term outlook is poor.  The dialysis will take some of the load off of his kidneys but the damage is done.

Everyone’s physiology is a little different.  I’ve noticed that diabetics are either genetically inclined to tolerate or not tolerate the disease.  For some people diabetes hits them like a cement truck.  This patient is one of those people.  Renal failure, diabetic ulcers, and retinitis at age 28 is not good.  Even if he survives this he is not going to live very long.  He will need weekly dialysis, proper wound care with possible amputations, and frequent eye exams to see if he needs laser surgery to tack down his retina to avoid detachment.  

This sucks.  Especially when patients are this young.  I've seen this before working in the ER and knowing that a patient will probably never go back to a normal life despite your best efforts is depressing to say the least.  There is almost always a heavy price to pay when we cheat death.