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Mary 23rd year old women brough in by ambulance from a music festival presenting with
drowsiness, slurred speech, dyspnea and has vomited three time. She has had two beers and
claims to not have taken any drugs. Mary has Type 1 Diabetes and has lost her insulin and blood
glucose monitor earlier today. For the past few years she has had a runny nose and cough
possibly due to viral infection and also a pruritic rash in her vulva region. The rash has not
resolved from antifungal cream.
Mary is a 23 year old women brought in by ambulance from a muscle festival presenting with
drowsiness, slurred specch, dyspnea at rest and vomiting on a background of Type 1 diabetes.
She reports of thirst polyuria but no pain on urination, has not vomited any blood or bile but has
intermittent abdominal cramps. She has had some food intake including 2 beers today but has
missed her previous evening insulin dose and her morning dose as well. She also has not
measured her BGL
She also complains of general unwellness over the last three days with running nose, sore throat,
cough in addition to a itchy vulva rash for the last 4 months with thick vaginal discharge. It has
been partially relief with topical clotrimazole cream.
Mary was diagnosed with diabetes at the age of 19 due to complants of urinary frequency. Initially
she was treated with twice daily injection of insulin and has difficult with regular meal and
carbohydrate intake complance due to work and social activities. She has had a number of
hypoglycaemic attacks before she stopped taking the insulin. During this period she experience
general unwellness with thirst, polyuria, blurred vision and vaginal irritation. The diabetes Centre
re-commence therapy with a lower insulin dose and her BGL and HbA1c stabalised.
Mary self tests her blood glucose and calculates her own insulin dose and does admit to irregular
insulin use and BGL testing.
She is concerned about her friends and colleages knowing about her diabetes due to social and
employment implications. She needs to maintain her drivers license to transport students. Only
her boyfriend knows about her diabetes as she has difficulties communicating this to her parents.
Mary is a social smoker starting at the age of 15 and has a quarter of a pack a week. She has 2-3
standard drinks on weekends only.
Upon examining Mary, she is tachycardic with increased respiratory rate. Her BMI is in the lowest
range of normal (18.3). Mary is orientated but slow ot answer questions and appear sleeping (GCS
of 14). She has dry skin and tongue with acetone breath suggestive of ketone acidosis.
Examination of the chest founds right basal crackles. Tis is consistent with a eryhtmatous pharynx
however no tonsiular exudate was present. Her CRT was delayed at 3 seconds but she had normal
peripheral sensation and equal pulses. Her retinal examination was unremarkable. Vaginal
examination found red scaly plaque on the labia and thick white vaginal discharge.
In summary, Mary is a 23rd female presenting with a possible hyperglycaemia and diabetic
ketoacidosis due to missing previous two insulin injections.
Hyperglycaemia ddx
Mechanism of diabetes
Mechanism of Type 1
-
Genetics
HLA complex Chromosome 6 involing MHC. Most indivudlas have HLA DR3 or DR4
However the risk of low for first degree relatives
Pathogenesis of DM1
-
DKA pathophysiology
-
Ketosis
-
DKA diagnosis
-
Treatment of DKA
IV fluid replacement and insulin therapy (haemodynamic stability and adequate urine
output)
o Use of short acting insulin
o Mild can use SC but IV insulin used for those with acidosis and metabolic unstability
If vomiting = nasogastric tube to prevent aspiration