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Clinical Skills Challenge - case study 2

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THE COMPETITION FOR THIS CASE STUDY IS NOW CLOSED. THE ANSWERS ARE AT THE BOTTOM OF THE PAGE.

On the following pages are details of a fictional patient, complete with context, case history and test results. Your job is to diagnose the condition and suggest treatment options. Follow the instructions at the bottom of the article to submit your entry. Winners will receive a free training course. We will also publish a detailed review of the case study with an interpretation of the results on nursingtimes.net.

Click here to download a printable PDF of this article (recommended)

This 27-year-old Type 1 Diabetic was found unconscious, lying on his bedroom floor. He has been generally unwell recently with a gastrointestinal upset. His flat-mate said that his blood glucose levels had been running quite high for a couple of weeks and that he had not always been taking his prescribed insulin. He had been to quite a few parties in the last 2 weeks and had been drinking quite heavily at these events.

On admission:

He is drowsy but rousable. He is tachypnoeic and there is a distinctive smell of ketones from his breath. He has peripheral cyanosis.

Social History:

He is separated from his wife. He has two young children. He lives with a flat mate in rather run down rented accommodation. He works full time as a mechanical engineer.

Table 1: Vital signs on admission

Blood Pressure

90 / 45 mmHg

Pulse rate

105 (regular)

Respiratory rate

40 per minute

Tympanic temperature

38.4 OC

SaO2

89% on 4 litres of oxygen

Random blood glucose

52.1. mmols/L

A 14FR gauge urinary catheter was inserted. He had about 100 mls of urine in his bladder.

A CVP line was inserted in his internal jugular vein. The initial recording was + 1mmHg

Table 2: Blood results

Test

Result

Reference range

U&E's

Sodium

136

136 - 144

Potassium

3.5

3.5 - 5.0

Chloride

100

95 - 105

Urea

18.6

3.0 - 8.3

Creatinine

105

80 - 130

Haematology

Haemoglobin

174

120 - 160

Mean Cell Volume

87

80 - 98

White Cell Count

25.6

4.0 - 11.0

Table 3: Results of arterial blood gas sample taken from radial artery

Test

Patient result

Reference range

pH

7.15

7.35 - 7.45

PCO2

2.9

4.65 - 6.0 kilopascals

Standard bicarbonate

10

24 - 32

PO2

8.9

11.5 - 14 kilopascals

Please see the PDF of this case study to view the AP chest x-ray taken in the A&E department.

Answer to this case study

This patient has Diabetic Ketoacidosis. His blood glucose confirms hyperglycaemia and his ABG shows a metabolic acidosis. His CO2 level is low as he is tachypnoeic and attempting to eliminate acid by the respiratory system.

He is however also hypoxic and this would not neccessarily be expected in DKA. His chest x-ray shows a patchy whiteness affecting both lungs but predominantly the right lung. He also has clinical signs of sepsis with a pyrexia and a raised white blood cell count. These signs suggest an aspiration pneumonia.

His Urea is elevatyed but his creatinine is normal suggesting dehydration.

The priorities for this yopung man are:

1. He requires oxygenation
2. IV fluids
3. IV Insulin infusion
4. Antibiotic
5. He may well require mechanical ventilation

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