A 16 year old woman is brought to the ER by a friend because she has become dizz

Question

A 16 year old woman is brought to the ER by a friend because she has become dizzy and abnormally fatigued. Her BP 95/60, Temp is 99.6 F, pulse is 110 and she is breathing at a

rate of 25 breaths per minute. She is generally thin at 103 lbs, 5’4”. She complains that she is very thirsty and has been urinating frequently the last week, PU/PD. She has a

history of 3 UTI in the past year and thinks this problem has re- occurred. The U/A : Sp Grav 1.004, cloudy, pale yellow, protein 3+, glucose 4+, ketones 2+, WBC 2+, RBC 1+, pH 7, Sediment : High numbers of WBCs, bacteria, few RBCs, several Renal epithelial casts and misc. debris noted.

1. Does she have anotherurinary tract infection, UTI? ___________________________

a. What else does she have? ____________________________Type ? _______________

A CNA asks you if you think she will need insulin or oral meds, what do you say?_________

b. How or why does her endocrine problem increase the likelihood that she will have a UTI?

c. The doctor says she has “ polyuria ” due to an osmotic diuresis what do those terms mean?How do these definitions relate to your answer in 1a.?

2. The doctor orders a blood chemistry as well saying that the protein in the urine could be due to high WBCs and RBCs and/or due to poor kidney function.

BUN 65 mg/dl,        Creatinine 1.6 mg/dl,    Sodium: 150 mEq/l

Glucose 454 mg/ml       serum ketones 1.35 +   Potassium: 6.0 mEq/l

pH 7.25       pCO2       27 mEq/l      HCO3: 17 mEq/l

Hematocrit 56 %       WBC 18,000              HbA1C 8.0 mg/dl = elevated

a. The doctor says her kidneys are not normal, why, what are they not doing?

b. Analyze her acid/base status: pH _________, pCO2 __________ HCO3 __________

c. What is her condition? _____________________________________________________

d. What are Kussmal Respirations and how does her high rate “make sense” with her pH?

e. Potassium ions will diffuse out of the cell in exchange for Hydrogen ions when they are numerous. This can cause additional complications.

What can problems can high potassium cause? _________________________________________

f. What do her hematocrit, BUN, and sodium values suggest about her over-all body fluid level?

g. List at least 3 basic treatments should she receive for her conditions:

________________________ _______________________ ___________________________

3. At a check-up 3 months later with her doctor she says she feels much better. You note that she has had an additional treatment for cystitis in the intervening time. The patient’s values are now:

Temp 98.2 F, BP 125/ 65, Respiration 14, U/A Normal, Sp Grav. 1.025. Weight 117

BUN 22 mg/dl,        Creatinine 1.0 mg/dl,       Sodium: 141 mEq/l

Glucose 118 mg/ml       serum ketones 0          Potassium: 4.2 mEq/l

pH 7.38       pCO2       43 mEq/l      HCO3: 25 mEq/l

Hematocrit 42%       WBC 10,000              HbA1C 7.4 mg/dl = elevated

a. How is her acid/base status? ____________________

b. How is her kidney function? ____________________

c. How is her glucose level today? _________________

d. What does the glycosylated hemoglobin, HbA1C indicate? _______________________

e. How is her history of insulin/ serum glucose regulation? ________________________

f. What additional patient support would you offer?

4. Considering compartment volumes:

If there is hyperglycemia in the vascular space, (it is hypertonic)

a. What happens to normal fluid levels in the intracellular space? __________________

b. What happens to fluid levels in the vascular space (plasma volume)? _________________

c. What happens to blood pressure? _______________________

5. Cells everywhere in the body are affected by hyperglycemia, including the blood vessel endothelial cells, WBC cells, neurons and others.

List at least 3 complications that can occur ‘secondarily’ due to uncontrolled Diabetes Mellitus.

___________________________

___________________________

___________________________

Explanation / Answer

1) The woman is suffering from another episode of urinary tract infection (UTI).

a) Apart from UTI, the individual also has diabetes mellites type 1.

Type 1 diabetes mellites is caused by lack of insulin. So, the patient requires daily dose of insulin to maintain normal blood glucose levels.

b) There are three reasons for UTIs to occur more frequently in diabetics. They are,

c) Osmosis is the movement of solvent molecules across a semi permeable membrane from a region of lower concentration to a region of higher concentration. In diabetics, due to increased levels of glucose in urine, the water molecules diffuses into the collecting duct of nephron by means of osmosis. This is the cause of polyuria which occurs in diabetes patients.

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