Patient Case Questions: Endocrine 1. Diabetic Ketoacidosis, Hyperglycemic Hyperosmolar State, and Thyroid Storm

Questions 1-3 rely on the following case information: Patient AP is a 46 year old male presenting to the emergency department with a chief complaint of lethargy. AP has a past medical history consisting of type II diabetes, hypertension, and osteoarthritis. Initial glucometer check upon arrival simply reads “HIGH”, with notable subsequent labs as follows:

CHEMISTRY: Sodium 125mEq/L, Glucose 745mg/dL, Chloride 101mEq/L, Potassium 3.0mEq/L, SCr 1.6mg/dL, BUN 18mg/dL, HCO₃ 9mEq/L, Albumin 3.3g/dL

CBC: WBC 8.2 x 10³ cells/μl, Hgb 13.5g/dL, Hct 41.6%, Platelets 210,000/μl

URINALYSIS: RBC(-), WBC(-), LE(-), Ketones(+), Glucose (++)

ARTERIAL BLOOD GAS: pH 7.122

Question 1: Based on the laboratory values in the Chemistry panel, what is AP’s calculated anion gap?

Questions 1-3 rely on the following case information: Patient AP is a 46 year old male presenting to the emergency department with a chief complaint of lethargy. AP has a past medical history consisting of type II diabetes, hypertension, and osteoarthritis. Initial glucometer check upon arrival simply reads “HIGH”, with notable subsequent labs as follows:

CHEMISTRY: Sodium 125mEq/L, Glucose 745mg/dL, Chloride 101mEq/L, Potassium 3.0mEq/L, SCr 1.6mg/dL, BUN 18mg/dL, HCO₃ 9mEq/L, Albumin 3.3g/dL

CBC: WBC 8.2 x 10³ cells/μl, Hgb 13.5g/dL, Hct 41.6%, Platelets 210,000/μl

URINALYSIS: RBC(-), WBC(-), LE(-), Ketones(+), Glucose (++)

ARTERIAL BLOOD GAS: pH 7.122

Question 2: AP has been diagnosed with diabetic ketoacidosis based on the elevated glucose level of 745mg/dL, urinalysis which is positive for ketones, elevated anion gap, and acidotic pH of 7.122. Based on the above lab values and your knowledge of this disease state, what is the most important laboratory abnormality to correct first and with which medication regimen?

Questions 1-3 rely on the following case information: Patient AP is a 46 year old male presenting to the emergency department with a chief complaint of lethargy. AP has a past medical history consisting of type II diabetes, hypertension, and osteoarthritis. Initial glucometer check upon arrival simply reads “HIGH”, with notable subsequent labs as follows:

CHEMISTRY: Sodium 125mEq/L, Glucose 745mg/dL, Chloride 101mEq/L, Potassium 3.0mEq/L, SCr 1.6mg/dL, BUN 18mg/dL, HCO₃ 9mEq/L, Albumin 3.3g/dL

CBC: WBC 8.2 x 10³ cells/μl, Hgb 13.5g/dL, Hct 41.6%, Platelets 210,000/μl

URINALYSIS: RBC(-), WBC(-), LE(-), Ketones(+), Glucose (++)

ARTERIAL BLOOD GAS: pH 7.122

Question 3: With a documented weight of 140kg, what is an appropriate dosing and monitoring regimen of IV insulin to treat AP’s diabetic ketoacidosis?

Question 4: The team instituted your recommendations, and the patient appears to be getting clinically better. At the end of your shift, a new chemistry panel for AP shows the following:

CHEMISTRY: Sodium 136mEq/L, Glucose 187mg/dL, Chloride 104mEq/L, Potassium 4.2mEq/L, SCr 1.2mg/dL, BUN 14mg/dL, HCO₃ 20mEq/L

What is the next step for medication therapy and when will your medication therapy end?

Questions 5-7 rely on the following case information: After taking your above recommendations, the team has managed to resolve AP’s diabetic ketoacidosis. AP was discharged on insulin glargine 10u once a day (at bedtime), along with metformin 1000mg twice daily and insulin aspart used with meals on a sliding scale. However, AP forgot to pick up his prescription. Two weeks later, AP is once again presenting to the ER with a chief complaint of lethargy. He states that the past two weeks he has been using a friend’s insulin pen, but cannot describe how much insulin he uses or how often he uses it. Shortly after obtaining this information, AP becomes unresponsive to verbal stimuli – only responding with moans to a deep sternal rub. Notable labs upon presentation are as follows:

CHEMISTRY: Sodium 131mEq/L, Glucose 1588mg/dL, Chloride 106mEq/L, Potassium 4.2mEq/L, SCr 2.1mg/dL, BUN 33mg/dL, HCO₃ 21mEq/L, Plasma Osmolality (pOsm) 330mOsm/kg

CBC: WBC 6.1 x 10³ cells/μl, Hgb 13.7g/dL, Hct 43.6%, Platelets 225,000/μl

URINALYSIS: RBC(-), WBC(-), LE(-), Ketones(-), Glucose (++)

ARTERIAL BLOOD GAS: pH 7.423

Question 5: Based on AP’s laboratory values, which calculation reveals his current disease state, and what is its calculated value?

Questions 5-7 rely on the following case information: After taking your above recommendations, the team has managed to resolve AP’s diabetic ketoacidosis. AP was discharged on insulin glargine 10u once a day (at bedtime), along with metformin 1000mg twice daily and insulin aspart used with meals on a sliding scale. However, AP forgot to pick up his prescription. Two weeks later, AP is once again presenting to the ER with a chief complaint of lethargy. He states that the past two weeks he has been using a friend’s insulin pen, but cannot describe how much insulin he uses or how often he uses it. Shortly after obtaining this information, AP becomes unresponsive to verbal stimuli – only responding with moans to a deep sternal rub. Notable labs upon presentation are as follows:

CHEMISTRY: Sodium 131mEq/L, Glucose 1588mg/dL, Chloride 106mEq/L, Potassium 4.2mEq/L, SCr 2.1mg/dL, BUN 33mg/dL, HCO₃ 21mEq/L, Plasma Osmolality (pOsm) 330mOsm/kg

CBC: WBC 6.1 x 10³ cells/μl, Hgb 13.7g/dL, Hct 43.6%, Platelets 225,000/μl

URINALYSIS: RBC(-), WBC(-), LE(-), Ketones(-), Glucose (++)

ARTERIAL BLOOD GAS: pH 7.423

Question 6: AP is correctly diagnosed with being in a hyperglycemic hyperosmolar state (HHS). With his glucose of 1588mg/dL and a potassium within normal limits, the team would like to start insulin. Which insulin formulation, route, and dosing is most appropriate for AP?

Questions 5-7 rely on the following case information: After taking your above recommendations, the team has managed to resolve AP’s diabetic ketoacidosis. AP was discharged on insulin glargine 10u once a day (at bedtime), along with metformin 1000mg twice daily and insulin aspart used with meals on a sliding scale. However, AP forgot to pick up his prescription. Two weeks later, AP is once again presenting to the ER with a chief complaint of lethargy. He states that the past two weeks he has been using a friend’s insulin pen, but cannot describe how much insulin he uses or how often he uses it. Shortly after obtaining this information, AP becomes unresponsive to verbal stimuli – only responding with moans to a deep sternal rub. Notable labs upon presentation are as follows:

CHEMISTRY: Sodium 131mEq/L, Glucose 1588mg/dL, Chloride 106mEq/L, Potassium 4.2mEq/L, SCr 2.1mg/dL, BUN 33mg/dL, HCO₃ 21mEq/L, Plasma Osmolality (pOsm) 330mOsm/kg

CBC: WBC 6.1 x 10³ cells/μl, Hgb 13.7g/dL, Hct 43.6%, Platelets 225,000/μl

URINALYSIS: RBC(-), WBC(-), LE(-), Ketones(-), Glucose (++)

ARTERIAL BLOOD GAS: pH 7.423

Question 7: AP was admitted to the ICU after initiating insulin, and you come back the next day to follow-up with the patient. AP’s calculated osmolality is now approaching normal limits, and while he is still on an insulin drip, AP is now much more alert than he was yesterday. Since AP is still on an insulin drip for HHS, which of the following electrolyte abnormalities would be most common to see in a patient with DKA/HHS who has been fluid resuscitated and is on an insulin drip?

Questions 8-10 rely on the following case information: JY is a 38 year old female presenting to your emergency department with a chief complaint of rapid heart rate and fever. JY has a past medical/surgical history of Grave’s Disease, colon polyps, Crohn’s disease, and psoriasis. JY states this has been going on for about 4 days, but became acutely worse today. Further, JY tells you she recently lost her job and her insurance, and ran out of all of her medications, which include: Methimazole 5mg PO daily, budesonide 9mg PO daily, and Larin Fe 1/20 PO daily. JY looks very anxious, is profusely diaphoretic, and reports hearing voices throughout your interview with her. Vitals and notable labs are as follows:

VITALS: Heart rate 144bpm, BP 88/67mmHg, Temp 104.1F, RR 18 with O2 saturation of 96%

CHEMISTRY: Sodium 138mEq/L, Glucose 214mg/dL, Chloride 103mEq/L, Potassium 4.5mEq/L, SCr 1.0mg/dL, BUN 16mg/dL, HCO₃ 24mEq/L, Calcium 10.8mg/dL

CBC: WBC 11.4 x 10³ cells/μl with 65% neutrophils, Hgb 12.7g/dL, Hct 39.6%, Platelets 295,000/μl

THYROID PANEL: TSH<0.1IU/mL (undetectable), Free T4 7.2ng/dL, Free T3 1,510pg/dL

Question 8: Based on JY’s laboratory studies and physical exam findings, the ER attending assumes a working diagnosis of thyroid storm. Of JY’s diagnoses in her past medical history, which of the following is contributing to this emergent issue and which laboratory finding confirms the diagnosis of thyroid storm?

Questions 8-10 rely on the following case information: JY is a 38 year old female presenting to your emergency department with a chief complaint of rapid heart rate and fever. JY has a past medical/surgical history of Grave’s Disease, colon polyps, Crohn’s disease, and psoriasis. JY states this has been going on for about 4 days, but became acutely worse today. Further, JY tells you she recently lost her job and her insurance, and ran out of all of her medications, which include: Methimazole 5mg PO daily, budesonide 9mg PO daily, and Larin Fe 1/20 PO daily. JY looks very anxious, is profusely diaphoretic, and reports hearing voices throughout your interview with her. Vitals and notable labs are as follows:

VITALS: Heart rate 144bpm, BP 88/67mmHg, Temp 104.1F, RR 18 with O2 saturation of 96%

CHEMISTRY: Sodium 138mEq/L, Glucose 214mg/dL, Chloride 103mEq/L, Potassium 4.5mEq/L, SCr 1.0mg/dL, BUN 16mg/dL, HCO₃ 24mEq/L, Calcium 10.8mg/dL

CBC: WBC 11.4 x 10³ cells/μl with 65% neutrophils, Hgb 12.7g/dL, Hct 39.6%, Platelets 295,000/μl

THYROID PANEL: TSH<0.1IU/mL (undetectable), Free T4 7.2ng/dL, Free T3 1,510pg/dL

Question 9: Now that JY has a confirmed diagnosis of thyroid storm, the attending physician would like to start treatment as soon as possible. Since JY is markedly tachycardic, which oral pharmacologic agent would be best to control her heart rate?

Questions 8-10 rely on the following case information: JY is a 38 year old female presenting to your emergency department with a chief complaint of rapid heart rate and fever. JY has a past medical/surgical history of Grave’s Disease, colon polyps, Crohn’s disease, and psoriasis. JY states this has been going on for about 4 days, but became acutely worse today. Further, JY tells you she recently lost her job and her insurance, and ran out of all of her medications, which include: Methimazole 5mg PO daily, budesonide 9mg PO daily, and Larin Fe 1/20 PO daily. JY looks very anxious, is profusely diaphoretic, and reports hearing voices throughout your interview with her. Vitals and notable labs are as follows:

VITALS: Heart rate 144bpm, BP 88/67mmHg, Temp 104.1F, RR 18 with O2 saturation of 96%

CHEMISTRY: Sodium 138mEq/L, Glucose 214mg/dL, Chloride 103mEq/L, Potassium 4.5mEq/L, SCr 1.0mg/dL, BUN 16mg/dL, HCO₃ 24mEq/L, Calcium 10.8mg/dL

CBC: WBC 11.4 x 10³ cells/μl with 65% neutrophils, Hgb 12.7g/dL, Hct 39.6%, Platelets 295,000/μl

THYROID PANEL: TSH<0.1IU/mL (undetectable), Free T4 7.2ng/dL, Free T3 1,510pg/dL

Question 10: After implementing your previous recommendation, JY now has a heart rate of 95bpm and a BP of 105/72mmHg. The attending physician has started propylthiouracil (PTU) at 200mg Q4Hours. The first does of PTU has been given 55 minutes ago, and the attending physician believes we need to give another agent exactly 1 hour after starting PTU. What agent is the attending physician referring to?