1. January 29, 2012 Cruz, C., Cruz, M., Medieta

2. OBJECTIVES  Identify pertinent findings from the history and physical examination that would contribute to the diagnosis of diabetic ketoacidosis  Provide a systematic approach in diagnosing patients with diabetes mellitus and its complications  Learn how to manage patients with diabetes mellitus

3. Patient Profile  R.E.  28-year-old male  Single, Filipino, Roman Catholic  From Quezon City  Admitted for the first time at UERMMMCI on June 26, 2012

4. Patient Profile  Doesn’t drink alcoholic beverages  Non-smoker

5. Chief Complaint  Vomiting few hours PTA Source and Reliability  The patient himself, his sister and parents with fair reliability

6. HISTORY OF PRESENT ILLNESS  7 hours prior to admission  7 episodes of vomiting  Palpitations  Generalized body weakness  Increased flatulence  No fever, headache, abdominal pain, changes in BM

7. Past Medical History  Hypertension - 2006 Usual BPs: 80-110/50-80 Highest BP - 170/90 On Metoprolol 50 mg BID (am, pm)  Diabetes Mellitus Type 1 - 2006 On Insulin HN 25 ‘u’ SC OD No regular follow-up check-up with physician

8. Past Medical History  Atrophic Kidney (2006)  S/P appendectomy at 10 years old

9. Family History  Hypertension, Diabetes Mellitus and asthma – maternal

10. Review of Systems Organ System Symptoms General (-) significant weight loss Skin (-) lumps, (-) sores, (-) itching, (-) changes in color; (-) changes in hair or nails, (-) changes in size or color of moles Head (-) headache, (-) head injury, (-) dizziness and (-) light-headedness Eyes (-) icteric sclerae, (-) pale palpebral conjunctivae Ears (-) discharge, (-) hearing loss, (-) tinnitus Nose (-) frequent colds,(-) discharge, (-) itching, (-) nosebleed Mouth/Throat (-) dentures, (-) hoarseness,(+) dry oral mucosa, (-) frequent sore throats Neck (-) swollen glands, (-) no thyroid enlargement, lumps, (-) pain and stiffness Respiratory (-) cough, (-) hemoptysis, (-) dyspnea, (-) wheezing, CVS (-) dyspnea, (-) orthopnea, (+) palpitations GIT (-) dysphagia, (-) nausea, (+) vomiting, (-) melena, (-) jaundice, (-) indigestion, (-) fatty food intolerance, (-) acholic stool, (-) changes in bowel movement GUS (-) dysuria, (-) polyuria, (-) nocturia; (-) hematuria, (-) retention, (-) bleeding

11. Organ System Symptoms Reproductive (-) menorrhagia, (-) dyspareunia, (-) PCB Musculoskeletal (-) ankle pain, (-) swelling, (-) redness, (-) no history of trauma Psychiatric (-) nervousness, (-) tension, (-) mood changes, (-) depression, (-) memory change Neurologic (-) change in sensorium, (-) memory loss Hematologic (-) pallor, (-) easy bruising or bleeding Endocrine (-) excessive sweating, (-) excessive thirst or hunger Review of Systems

13. Admitting Physical Examination General Appearance Awake, conscious, coherent and in distress Vital SignsBP = 140/100 mmHg; HR = 130 bpm; RR = 18 cpm; Temperature = 36.4C; BMI =

14. Admitting Physical Examination Head and Neck Anicteric sclerae, pink palpebral conjunctivae, dry oral mucosa, breath - fruity smell, no tonsillopharyngeal congestion, no cervical lymphadenopathy Ophthalmologic examination:

15. Admitting Physical Examination Chest and LungsSymmetric chest expansion, no retractions, clear breath sounds CardiovascularAdynamic precordium, tachycardic, regular rhythm, distinct S1 S2, no murmurs appreciated

16. Admitting Physical Examination AbdomenFlat, normoactive bowel sounds, soft, severe diffuse abdominal pain, no organomegaly ExtremitiesFull and equal pulses,no cyanosis, no edema NeurologicEssentially normal with slight difficulty in understanding and answering questions

18. Salient Features  28-year-old male  Diabetic and hypertensive  Vomiting  Palpitations  Generalized body weakness  Decreased appetite  Increased flatulence  Dry oral mucosa, breath with fruity smell  Severe diffuse abdominal pain  No changes in BM

20.  Diabetic Ketoacidosis; DM Type 1, uncontrolled; Hypertension

21. Salient Features  Diabetic  Nausea and vomiting  Palpitations  Generalized body weakness  Decrease in appetite  Breath with fruity smell  Tachycardia  Severe diffuse abdominal pain  Difficulty in understanding and answering questions

22. Diabetic Ketoacidosis  Acute complication  Nausea and vomiting  Abdominal pain  Hyperglycemia  Kussmaul respirations and a fruity odor on the patient’s breath  Lethargy and central nervous system depression

23. Diabetic Ketoacidosis  Absolute insulin deficiency  Counterregulatory hormone excess  Ketosis  Metabolic acidosis

24. CBG  At the ER: 391

25. Arterial Blood Gas Panels (At Room Air)12.03.11 HD1 pH7.08 pCO215 pO2135 HCO34.04 Base Excess (ECF)-25.6 Oxygen Saturation98% Total Carbon Dioxide4.90 Metabolic acidosis

26. Urinalysis ColorYellow Turbidity Reaction Specific Gravity1.030 ProteinNegative Sugar+++ RBC0-1-/hpf WBC0-1/hpf CastsNone BacteriaRare Epithelial cellsFew Mucus ThreadsNone CrystalsNone Yeast CellsNone

27. Serum Ketones Panels06.26 DOA BUN19 Creatinine140 ECC kg31.43@32kg ml/min Serum Chemistries  Positive

28. Diabetes Mellitus  Diabetes mellitus (DM) comprises a group of common metabolic disorders that share the phenotype of hyperglycemia

29. National Kidney Foundation: K/DOQI Guidelines Diagnosis  Symptoms of diabetes plus random blood glucose concentration >/= 11.1mmol/L (200mg/dL)  Fasting plasma glucose >/= 7.0mmol/L (126mg/dL) or  2-hour plasma glucose >/= 11.1mmol/L (200mg/dL) during an oral glucose tolerance test

30. Risk Factors:  Family history of diabetes (i.e., parent or sibling with type 2 diabetes)  Obesity (BMI 25 kg/m 2 )  Habitual physical inactivity  Race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander)  Previously identified IFG or IGT  History of GDM or delivery of baby >4 kg (>9 lb)

31. Risk Factors:  Hypertension (blood pressure 140/90 mmHg)  HDL cholesterol level 250 mg/dL (2.82 mmol/L)  Polycystic ovary syndrome or acanthosis nigricans  History of vascular disease

32. Diabetes Mellitus  Type 1 1A- Autoimmune beta cell distruction which leads to insulin deficiency 1B – develop insulin deficiency by unknown mechanisms and are ketosis prone Harrison’s Principles of Internal Medicine (17 th ed.)

33. Effects of Insulin:

34. Diabetes Mellitus  Type 2 Variable degrees of insulin resistance, impaired insulin secretion and increased glucose production Harrison’s Principles of Internal Medicine (17 th ed.)

35. Diabetes Mellitus Type 2 Risk Factors Harrison’s Principles of Internal Medicine (17 th ed.)

36.  MODY Autosomal dominant Early onset of hyperglycemia Impairment of insulin secretion

37. Acute Complications of Diabetes Mellitus

38. Diabetic Ketoacidosis

39. Chronic Complications of Diabetes Mellitus