Question

An unconscious patient, female, 15 yrs was brought to the ER by private vehicle. Her guardians reported that she has diabetes and have been dependent on insulin for the past 7 years. They also report that she's previously had several episodes of hypoglycemia and ketoacidosis and that she often forgets to take her insulin injections. Attending physician ordered the following labs:

Sodium (136-145 mmol/L)	145 mmol/L
Potassium (3.4-5.0 mmol/L)	5.8 mmol/L
Chloride (98-107 mmol/L)	87 mmol/L
Bicarbonate (22-29 mmol/L)	8 mmol/L
Glucose (70-99 mg/dL)	1,050 mg/dL
Urea Nitrogen (7-18 mg/dL)	35 mg/dL
Creatinine (0.5-1.3 mg/dL)	1.3 mg/dL
Lactate (0.5-2.2 mmol/L)	5 mmol/L
Osmolality (275-295 mOsm/kg)	385 mOsm/kg

pH (7.35-7.45)	7.11
pO2 (83-100 mmHg)	98 mmHg
pCO2 (35-45 mmHg)	20 mmHg

. What is the diagnosis?

2. Calculate the anion gap (please use the equation 16-10 on page 362 in your textbook... you have all 4 electrolytes, so no need to use the other equation that only requires 3). What is the significance of this result?  

3. Why are the patient's chloride and bicarbonate results decreased? What is the significance of the elevated potassium result?

4. What is the significance of the plasma osmolality?

Answer 1

1. Diabetic ketoacidosis is the diagnosis. Diabetic ketoacidosis often seen in type 1 DM were hyperglycemia, dehydration, acidosis and ketosis is the clinical feature.

2. Equation of Anion gap (Na+) + (K+) - (Cl-) - (HCO3-)

145 + 5.8 - 87 - 8 = 55.8

55.8 is the Anion gap

Normal Anion gap is 8 - 16 mEq/L

Elevation in Anion gap result in diabetic ketoacidosis.

3. Chloride and bicarbonate level decrease because of acidosis. As a compensatory mechanism. Elevation in potassium occur due to dehydration and acidosis were hyperglycemia cause polyuria, polyuria leads to dehydration.

4. Normal osmolality level is 275 - 295 mosm/kg, patient lab value indicates osmolality level of 385 mOsm / kg. Increase osmolality of plasma indicate dehydration