Posted: July 3rd, 2022

A 19-year-old Marine was brought to the infirmary

Due June 30
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EDUCATING OUR COMMUNITY
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CASE 1
A 19-year-old Marine was brought to the infirmary after passing out during basic training. He had repeatedly complained of severe weakness, dizziness, and sleepiness during the preceding 4 weeks of boot camp. In a previous episode weeks earlier, he had drowsiness and generalized tiredness and was brought to the infirmary, where after IV administration of saline, he was returned to duty with the diagnosis of dehydration. Upon questioning, he reported unquenchable thirst, and the repeated need to urinate. Although he ate all of his rations as well as whatever he could get from his fellow trainees, he had lost 19 pounds. (Baseline body weight was 150 pounds, height 5’8″). On the last day, he complained of vague abdominal pain, which was worse on the morning of admission. He had vomited once. During the examination, he was oriented but tachypneic. He appeared pale, dehydrated with dry mucous membranes, and poor skin turgor. His respiratory rate was 36/minute with deep, laborious breathing; his heart rate was
138/minute regular, and his blood pressure was 90/60. His chest was clear, and his heart tones were normal. There was an ill-defined generalized abdominal tenderness, which was otherwise soft to palpation and showed no rebound. There was generalized muscular hypotonia; his deep tendon reflexes were present but very weak. Laboratory, on admission, showed glucose of 560 mg/dl, sodium 154, potassium 6.5, pH 7.25, bicarbonate 10 mM/liter, chloride 90, BUN 38 mg/dl, creatinine 2.5 mg/dl. (Normal values: glucose, 70-114 mg/dl; Na = 136-146; K, 3.5-5.3; Cl, 98-108; CO2, 20-32 [all in mM/I]; BUN, 7-22mg/di; creatinine, 0.7-1.5 mg/dl). A urine sample was 4+ for glucose and had “large” acetone. HbA1c was 14% (n=4-6.2%). Serum acetone was 4+ undiluted, and still positive at the 4th dilution. Beta-Hydroxybutyrate level was 20 millimoles/liter (normal=0.0-0.3 mM/I).

He was treated with insulin and saline I.V. By the 4th hour of treatment, potassium chloride was added to the IV at a rate of 15 mEq/hour. Sixteen hours later, he was active, alert, well-hydrated, and cheerful, indicating he felt extremely well. He requested that his IV be discontinued. His physician decided to switch his insulin to subcutaneous injections and start a liquid diet. He was later put on a diabetes maintenance diet and treated with one injection of Human Lente insulin in the morning. Although his blood sugars the next morning were 100-140 mg/dl, he had frequent episodes of hypoglycemia during the day, and his HbA1c was 9%. Eventually, he was put on 3 injections of regular insulin/day, and a bedtime intermediate duration (Lente) insulin.

Questions
1. Why did the patient improve after being given IV saline on his first admission?
2. Why was dyspnea his presenting symptom?
3. He was hyperkalemic on admission, and yet, why was potassium later added to the IV infusion?
4. What is the possible reason why a single injection of insulin in the morning failed to control his
diabetes without causing hypoglycemia?

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Sample Answer Writing Guide:
The patient improved after being given IV saline on his first admission because he was dehydrated. Dehydration can cause symptoms such as weakness, dizziness, and sleepiness, which were reported by the patient. The IV saline replenished his fluids and corrected his dehydration, leading to improvement in his symptoms.

Dyspnea was likely his presenting symptom due to the high levels of ketones in his blood, causing a metabolic acidosis. This can lead to increased respiratory rate and depth in an attempt to compensate for the acidosis by exhaling more carbon dioxide.

Although the patient was hyperkalemic on admission, potassium was later added to the IV infusion because insulin therapy can cause potassium to shift from the extracellular fluid into the cells, leading to hypokalemia. Therefore, adding potassium to the IV infusion helps prevent hypokalemia from occurring.

A single injection of insulin in the morning was not enough to control his diabetes because he likely had type 1 diabetes, which requires insulin to be given multiple times per day to maintain stable blood sugar levels. Additionally, the patient’s body may have developed insulin resistance due to the high levels of glucose in his blood before he was diagnosed and treated. This insulin resistance could have contributed to the frequent episodes of hypoglycemia despite the injection of insulin. Eventually, a more intensive insulin regimen was needed to manage his diabetes.