Positive and Negative Findings
Positive findings in the patient assessment include:
- Dizziness, nausea, inability to get out of bed for 4 days;
- Excessive urine production;
- Increased thirst;
- History of diabetes mellitus, hypertension, coronary artery disease;
- Excessive blood sugar (405), excessive blood pressure (190/101), tachycardia (102), increased respiratory rate (20);
- The patient missed taking insulin (Lantus) and metformin.
Negative findings in the patient assessment include:
- No headaches, no blurry vision;
- No abdominal pains;
- No vomiting.
Differential Diagnosis
It is most likely that the patient is suffering from diabetic ketoacidosis, the suspicion for which arises from the history of diabetes mellitus; missed insulin and metformin; nausea; excessive thirst and urine production; exceptionally high sugar levels (Perry, Petersen, & Shulman, 2016).
When creating ddx while suspecting diabetic ketoacidosis, some of the potential adverse health conditions that should be considered include (Hamdy, 2017):
- Acute pancreatitis: this condition is unlikely, for the patient does not suffer from abdominal pain, diarrhea, or vomiting.
- Alcoholic ketoacidosis: highly unlikely, for the patient has high blood sugar and is not known to be suffering from alcoholism.
- Appendicitis: highly improbable, for the patient does not report abdominal pain (in the right lower quadrant), nor vomiting, anorexia, diarrhea, or constipation.
- Hypophosphatemia: might be possible due to increased respiration rate, muscle weakness, and the patient’s inability to stand dizziness. It is needed to check the phosphate concentration in the blood to confirm or exclude hypophosphatemia (White, Hum, & Econs, 2014).
- Lactic acidosis: might be possible because of such symptoms as nausea, increased respiratory rate, and muscle weakness. It is possible to test for this using the arterial blood gas test (Kraut & Madias, 2014).
- Metabolic acidosis is unlikely, for the symptoms and signs such as seizures, coma, stupor, arrhythmia are absent; hypertension is present instead of hypotension.
- Hyperosmolar hyperglycemic state: might be possible due to the presence of such symptoms and signs as dizziness, nausea, inability to stand up from bed (potentially decreased blood pressure when standing), increased thirst, etc. Might be worth checking serum osmolarity, serum pH, etc. (Maletkovic & Drexler, 2013).
To confirm the diagnosis of diabetic ketoacidosis, it is needed to additionally check for blood pH, and the presence of ketoacids in urine or blood; it is already known that the patient has high blood sugar levels (Wolfsdorf et al., 2014)
Medication Regimen
If the diagnosis of diabetic ketoacidosis is confirmed, it is recommended to treat the patient with insulin and intravenous blood fluids; the sugar levels in the patient need to be constantly checked (Perry et al., 2016). After discharge, the patient should keep his current medication regimen and continue taking insulin (e.g., Lantus) and metformin. The patient should immediately undergo his disability check so as to be able to afford the refill. He may also apply for such programs as Medicaid or Medicare if he cannot get the medications in any other way (National Institute of Diabetes and Digestive and Kidney Diseases [NIDDK], 2014).
Priority Concerns
Diagnostic Studies
To confirm or deny diabetic ketoacidosis, the presence of ketoacids in urine or blood, and the levels of pH in the blood should be checked (Perry et al., 2017). To confirm or exclude hypophosphatemia, the phosphate concentration in blood should be studied (White et al., 2014). To exclude lactic acidosis, the arterial blood gas test can be run (Kraut & Madias, 2014). To exclude hyperosmolar hyperglycemic state, serum pH and osmolarity should be checked (Maletkovic & Drexler, 2013).
Medications
If the diabetic ketoacidosis is confirmed, then, as was noted above, insulin (intravenously or under the skin) and additional intravenous fluids can be used (Perry et al., 2017). The levels of blood sugar should be regularly checked during the therapy.
Education
The patient ought to be told that his condition is, most likely, caused by his negligence for his prescribed medications, which led to extremely high blood sugar and to his current condition. It should be explained that the patient must comply with his prescriptions for insulin and metformin after the discharge, for the consequences may be dire (e.g., stroke, myocardial infarction, etc.), and potentially lethal if not addressed in a timely manner (Perry et al., 2017). The patient should also be told to avoid eating carbohydrates, such as sugar in his tea unless the levels of sugar in his blood reach extremely low levels.
Health Promotion
The patient should be advised on his diet; he should avoid taking excessive levels of carbohydrates. It is also pivotal to do physical exercise to achieve or preserve normal body weight (depends on the current weight of the patient).
Developmental Stages
There are three main stages of diabetic ketoacidosis: mild, moderate, and severe. In the mild stage, the patient remains alert; in the moderate stage, they may suffer from drowsiness, dizziness, etc.; in the severe stage, they may suffer from coma or stupor (Perry et al., 2016; Perry et al., 2017). Apparently, the patient has the second stage of diabetic ketoacidosis, for he experiences dizziness and inability to stand from the bed while retaining awareness.
Follow Up
After stabilizing the patient’s condition, it will be needed to find out what triggered the event (e.g., confirm that not taking insulin and metformin served as the trigger). After the diabetic ketoacidosis is treated, the patient should visit the medic regularly to check his diabetes status (Perry et al., 2017).
Referrals
The patient should also be referred to a specialist in cardiology to address his tachycardia and hypertension, and control his CAD and the influences of CVA.
The Impact of Comorbid Diagnoses (Hypertension, Coronary Artery Disease, and Stroke) on the Current Symptoms
Hypertension possibly causes high blood pressure, even though in diabetic ketoacidosis the pressure is usually lowered due to dehydration, or normal if there is no dehydration yet. Coronary artery disease may result in additional dizziness or weakness if the blood flow is not enough due to the malfunction of the heart. The cerebrovascular accident may exacerbate the dizziness, and add to the difficulty of walking.
The Influence of the Patient’s Health Beliefs, Culture, and Behaviors on the Potential Outcomes
The patient’s health beliefs, culture, and behaviors apparently have had an adverse impact on his condition: he did not take adhering to his medication regimen seriously, so he behaved irresponsibly and did not have his disability check to enable himself to afford insulin. The patient also waited for four days prior to going to the primary care clinic, and, apparently, consumed carbohydrates (such as sweet tea). If the patient persists in his behaviors, the outcomes of the disease may be highly adverse, even lethal (Wolfsdorf et al., 2014). Thus, it is paramount for the patient to change his behaviors and to comply with his medication prescriptions.
References
Hamdy, O. (2017). Diabetic ketoacidosis differential diagnoses. Web.
Kraut, J. A., & Madias, N. E. (2014). Lactic acidosis. New England Journal of Medicine, 371(24), 2309-2319.
Maletkovic, J., & Drexler, A. (2013). Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Endocrinology and Metabolism Clinics, 42(4), 677-695.
National Institute of Diabetes and Digestive and Kidney Diseases. (2014). Financial help for diabetes care. Web.
Perry, R. J., Peng, L., Abulizi, A., Kennedy, L., Cline, G. W., & Shulman, G. I. (2017). Mechanism for leptin’s acute insulin-independent effect to reverse diabetic ketoacidosis. The Journal of Clinical Investigation, 127(2), 657-669.
Perry, R. J., Petersen, K. F., & Shulman, G. I. (2016). Pleotropic effects of leptin to reverse insulin resistance and diabetic ketoacidosis. Diabetologia, 59(5), 933-937.
White, K. E., Hum, J. M., & Econs, M. J. (2014). Hypophosphatemic rickets: revealing novel control points for phosphate homeostasis. Current Osteoporosis Reports, 12(3), 252-262.
Wolfsdorf, J. I., Allgrove, J., Craig, M. E., Edge, J., Glaser, N., Jain, V.,…Hanas, R. (2014). Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatric Diabetes, 15(S20), 154-179.