Diabetes Mellitus And Diabetic Ketoacidosis Case Studies

Diabetes Mellitus And Diabetic Ketoacidosis

Case 1: Benedict’S And Rothera’S Tests

A 15 years old boy diagnosed with diabetes was brought to the hospital in a semi-conscious state and had abnormal deep, rapid breathing. His plasma glucose was 623 mg/dl. Urine shows positive on Benedict’s and Rothera’s tests.

Diagnosis-Diabetic Ketoacidosis

• Mention the type in which it is common
• Type 1 DM (Insulin-dependent DM).

Read And Learn More: Biochemistry Clinical Case Studies With Answers

• Benedict’s test– for reducing sugar in the urine.
• Rothera’s test– for ketone bodies in urine (acetone and acetoacetate).

Diabetes Mellitus And Ketoacidosis Clinical Manifestation

1. Kussmaul breathing- deep and rapid respiration.
2. Low blood pressure.
3. Dehydration.
4. Vomiting, excessive urination, abdominal pain.
5. Confusion and loss of consciousness.

Diabetes Mellitus And Ketoacidosis Mechanism

• In a deficiency of insulin, blood glucose increases and appears in the urine. Glucose drags water with it due to the osmotic effect, which leads to increased urination.
• In DM, due to insulin deficiency or insulin resistance, glucose from the blood can’t enter the
  cells. The body can’t convert food into energy, which stimulates hunger centres, which leads to polyphagia.R
• Loss of water in urine stimulates the thirst centre which leads to polydipsia. Insulin deficiency causes excessive mobilization of free fatty acids and underutilization of chylomicrons and VLDL, leading to increased TG levels in the blood.
• The inability to use glucose in the absence of insulin makes them starved. Lipolysis occurs in insulin’s absence and leads to the generation of free fatty acids and glycerol. In beta-oxidation, fatty acids give acetyl CoA which is utilized for ketone body (beta-hydroxybutyrate and acetoacetate) synthesis.
• That causes ketosis, compensated by deep and rapid breathing (Kussmaul respiration).
• Increased loss through urine leads to dehydration. Fruity odour is due to the increased synthesis of ketone bodies (mainly acetone), which gives this specific odour to urine and breath.
• In DKA pH goes down and H+ ion concentration rises in ECF, in compensation K+ moves out of the cell in exchange with H+ to lower the H+ ion concentration in blood, but at the same time, hyperkalemia occurs.
• When insulin is given in treatment, due to insulin-dependent K+ channels, K+ moves into the cell and hypokalemia occurs. Hence, in DKA when insulin treatment is given, strict monitoring of K+ is required.

Diabetes Mellitus And Ketoacidosis Laboratory Investigations

1. Plasma Glucose- increased.
2. Urine shows positive tests for sugar and ketone bodies.
3. pH- decreased.

Diabetes Mellitus And Ketoacidosis Treatment

1. Insulin injection.
2. 4 fluids.
3. 4 Potassium is required for maintenance.

Case 2: Diagnosis- Diabetes Mellitus

An obese person came to the hospital with a chief complaint of frequent urination, polydipsia and polyphagia. His fasting plasma glucose was 378 mg/dl. Benedict’s test urine was positive.

Diagnosis- Diabetes Mellitus

Case 3: Diabetes mellitus

An obese person came to the hospital with complaints of:

1. Polyuria
2. Thirst
3. Weakness
4. Increased appetite

On investigation, random blood sugar was found to be 160 mg%

1. What is the probable diagnosis
2. Diabetes mellitus
3. What further investigations do you suggest to confirm the diagnosis

• • HbA1C (Glycosylated Hb).
  • Glucose tolerance test.
  • Urine sugar and ketone bodies.

Case 4: Untreated Diabetes Mellitus

A person presents with untreated diabetes mellitus. He is treated for acidosis.

Question 1. What is the type of acidosis?
Answer: Metabolic acidosis (DKA).

Question 2. What is the normal bicarbonate: Carbonic acid ratio? What will happen to the ratio in this patient?
Answer: Normal bicarbonate: Carbonic acid ratio is 20, ratio get decreased (< 20).

Question  3. How will compensation occur?
Answer: By hyperventilation, the lungs will blow out CO2. As the partial pressure of CO2 decreases, carbonic acid concentration goes down and reduces acidosis.

Question  4. What is the role of kidneys in correcting acidosis?
Answer: Renal mechanism– conservation of bicarbonate and excretion of H+ ions.

Case 5: Male Diabetic Semi-Comatose Condition

53 years old male diabetic is admitted in a semi-comatose condition. His fasting blood glucose level is 410 mg% with urine sugar +++ and urine ketone bodies positive.

Question  1. Name the clinical condition.
Answer: Diabetic ketoacidosis.

Question 2. What is the renal threshold for glucose?
Answer: A renal threshold is 180 mg/dl.

Question 3. Describe the test for urinary ketone bodies.
Answer:

Case 6: Old Man Semiconscious State Undue Thirst And Urinate

A 50-year-old man was admitted to the hospital in a confused and semiconscious state. Several days before admission, he was complaining of undue thirst and also started to get up several times during the night to urinate. His breath had a fruity odour. Following is the data from his laboratory investigations.

Question 1. What is the probable diagnosis?
Answer: Diabetic ketoacidosis.

Question 2. Describe the biochemical basis giving rise to the following conditions.
Answer:

1. Increased thirst.
2. Frequency of urination.
3. Fruity odour to the breath.

Case 7: Excessive Thirst And Polyuria Coma

A 17-year-old girl was admitted to hospital in a coma. Several days before, she complained of excessive thirst and polyuria. She was dehydrated, breathing was deep and breath had fruity
odour.

Question 1. Name the disease and mention its cause.
Answer: Diabetic ketoacidosis.

Question 2. Mention the major metabolic changes associated with this disease.
Answer:

Case 8: Untreated Diabetes Mellitus And Acidosis

• A person with untreated diabetes mellitus and acidosis was admitted to the hospital for treatment.
• A decrease in insulin levels or resistance to insulin causes accelerated lipolysis leading to more fatty acids in circulation. Simultaneously, gluconeogenesis increases and oxaloacetate level decreases.
• The acetyl CoA can be oxidized in the TCA cycle only when oxaloacetate is available. In DM, Acetyl CoA is utilized for ketone bodies synthesis due to a deficiency of intracellular Glucose.
• Ketone bodies are acidic in nature; bicarbonate is utilized for buffering of ketone bodies hence bicarbonate level decreases. The decrease in bicarbonate level is the primary defect in metabolic acidosis.

Case 9: Semi-Comatose State Laboratory Investigations

A 50-year-old man was admitted to the hospital in a confused and semi-comatose state. Several days before admission he was complaining of undue thirst and also used to get up several times during the night for urination. His breath had a fruity odour. Following is the data from his laboratory investigations.

• Blood glucose (random)– 480 mg/dl.
• Rothera’s test with urine– purple ring.
• Urine sugar– present (+++).

Question 1. Describe the biochemical basis of the following condition.
Answer:

1. Increased thirst and frequent urination.
2. Fruity odour to breathe.

Case 10: Routine Checkup Positive For Benedict’s Test.

An apparently healthy man, on routine checkup, was found to have a fasting blood glucose of 80 mg/dl, and urine showed no abnormal constituents. Two hours after a heavy breakfast his blood glucose was 185 mg/dl and his urine was positive for Benedict’s test.

Question 1. What is the probable diagnosis?
Answer:

Alimentary glycosuria- glucose level rises rapidly after a meal and spills over in urine.

Question 2. Enlist two conditions in which you find glucose in urine and why?
Answer:

• Diabetes mellitus.
• Renal glycosuria- renal threshold decreases in renal diseases.
• Alimentary glycosuria

Case 11: surgical OPD

• A 52-year-old male attended surgical OPD for an unhealed wound on his right toe. On his biochemical examination, his random plasma glucose concentration was reported to be 217 mg%.
• His blood samples for glucose estimation were repeated the next morning in fasting and two hours after meal and reported to be 173 mg% and 239 mg% respectively. Besides, he also complained of frequent passing of urine.

Question 1. What could be the reason for elevated levels of glucose in his blood?
Answer:

Decreased insulin secretion or increase resistance to insulin.

Question 2. What is the reason for persistent non-healing wounds?

• High blood sugar causes nerve damage called diabetic neuropathy. Because of loss of sensation, the individual is not able to feel the injuries hence damage worsens.
• Decrease in local immunity at the site. High blood glucose makes the vessels narrow due to atherosclerosis and a decrease in nitric oxide levels. This leads to a lack of nutrients and oxygen to the cells and delays wound healing.

Case 12: Male Obese Patient Admitted On Emergency Ward

A 46 years old male obese patient was brought to the hospital emergency ward. He was drowsy with deep and rapid breathing which had faintly fruity odour. On clinical examination was found dehydrated with dry skin, poor turgor, and low BP. The temperature was normal. His laboratory investigation report was as follows.

Biochemical test Results:

1. Blood glucose (Random)= 414 mg/dl
2. Blood urea = 42 mg/dl
3. Bicarbonate =12 mmol/L
4. Sodium= 136 mEq/L
5. Potassium= 5.3 mEq/L
6. Chloride = 102 mEq/L
7. pH = 7.1