Case Study: Hyperglycemia, concern for diabetic ketoacidosis, and type 1 diabetes

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The patient presented to the emergency room with hyperglycemia and possible diabetic ketoacidosis after not taking his insulin for 3 days.
The patient presented to the emergency room with hyperglycemia and possible diabetic ketoacidosis after not taking his insulin for 3 days.

History of present illness

The patient is a 36-year-old man who has had type 1 diabetes for 15 years. He presents to the emergency room with hyperglycemia and concern for possible diabetic ketoacidosis after not taking his insulin for 3 days. The patient reports that he is currently homeless and has lost his supply of insulin, syringes, glucose meter, and related glucose testing supplies. 

Diabetes-related comorbidities/complications

Hypertension, hyperlipidemia, retinopathy, and bipolar disorder

Diabetes related history

The patient states that at the time of his initial diagnosis with type 1 diabetes, he was hospitalized, with a glucose value >1000 mg/dL, and he was experiencing polyuria, polydipsia, and polyphagia. He reports that he has been on insulin since the time of his diagnosis, and he has never been prescribed oral agents for diabetes management. He recalls that glutamic acid decarboxylase  (GAD) antibodies and a C-peptide level have been previously evaluated. GAD antibodies were positive, and C-peptide value was low, helping to confirm the diagnosis of type 1 diabetes.

Most recently, he has been using insulin glargine 55 units once daily, and insulin aspart per correction doses 3 times daily. There was an imbalance when comparing his basal and bolus insulin doses. When asked about meal doses of insulin aspart, the patient relates that he is currently homeless and eats when food is available, often snacking on bits of food throughout the day. He was not using a meal dose of insulin aspart, but he would use this insulin to correct for hyperglycemia.

The patient has had previous episodes of diabetic ketoacidosis, for which he was hospitalized. With this episode of hyperglycemia, he is not experiencing any nausea, vomiting, or abdominal discomfort, and he appears well. The patient has no recent concerns for hypoglycemia. He reports that with past episodes of hypoglycemia, he experienced sweatiness and shakiness, for which he treated with juice or food.

Laboratory values on admission

  • A1c: 11.3%
  • Creatinine: 0.9 mg/dL with eGFR >60 mL/min
  • Aspartate aminotransferase (AST): 17 U/L
  • Alanine aminotransferase (ALT): 14 U/L
  • Beta-hydroxybutyrate: 0.1 mmol/L
  • Bicarbonate: 25 mEq/L
  • Anion Gap: 14 mEq/L

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