Johnny Suzuki
You just saw your last patient in continuity clinic, and hope to catch up on charts when your pager goes off. It’s the Emergency Department asking you to see a 14-year-old brought in by his Aunt unresponsive. Upon arrival in the ED, Aunty Clair tells you that Johnny has “sugar disease”. She does not know his medications, or the time of his last dose. The patient is unable to provide you with any history; however, you recognize him as a new patient from continuity clinic.
Physical Examination
Blood pressure:
120/82; heart rate: 124; respirations: 32; oral temperature: 34.8 °C; pulse
oximetry: 100% on room air.
General: An approximately 65 Kg, thin male who responds to simple questions with
moans; in general, he is only responsive to very loud or painful stimuli. Head
and neck are normal, except for his oropharynx, which demonstrates very dry
mucous membranes. His lungs are clear. His respiratory pattern is that of
rapid and deep breathing.
Abdomen exam is negative.
There are no other pathological findings on PE.
You decide on an intravenous infusion of normal saline with hydration rate of 200 cc/hr. A serum glucose determination (Accucheck) was "too high to read." A sample of the blood was sent to the lab for a definitive determination of the serum glucose level. You suspect diabetic ketoacidosis as Johnny has a history of DM Type II on insulin.
The patient was given a bolus of 10 units of regular insulin
IV while waiting for the lab results. The results came back shortly
thereafter, and showed an arterial blood gas pH of 6.92, CO2 of 9 and a bicarb
of 2. The WBC count was 8000/B5L, hemoglobin of 14.4 mg/dL, and
hematocrit of 43.5%. His chemistry panel demonstrated a serum sodium of
127, potassium 5.2, chloride of 87, CO2 of less than 5, BUN of 32 , creatanine
1.5, and a blood sugar of 1,582. The serum ketones were positive at a
dilution of
Johnny’s results show severe metabolic acidosis secondary to DKA.
Further history
Johnny’s mother arrives later; she does not know if, or when, he last
administered insulin. She tells you to
ask Aunty Clair.
You wonder about Johnny’s social situation, when you remember Dr. Derauf’s presentation on the ecological model and systems theory. Thinking this may help understand Johnny’s social situation, you give a call to Dr. Derauf.