So if I?m suspecting diabetes in a child.
Let?s say they all have the polys
and I want to check how can I make this diagnosis.
It?s not too hard.
We can obtain a random glucose
and really any random glucose over 200
with signs and symptoms consisting of Diabetes
will be likely to tell you
that this patient is having diabetes.
If you wish to be more accurate
we can obtain a 2-hour post-glucose challenge
and check the fasting glucose level.
Typically, people should have a level less than 126
if it?s been 2 hours after a glucose challenge
which is a fixed amount of glucose that they drink.
If it?s above this level, they probably have diabetes.
They don?t have enough insulin to pack away that sugar.
Another way to make the diagnosis
is by looking for long-term sequelae of having a low insulin level.
This would be your Hemoglobin A1C
which if over 6.5% indicates that this patient may have diabetes.
Diabetic Ketoacidosis is the emergence that we all fear.
This is when patients are getting so behind
in terms of their sugar levels and their buildup of ketones
because they don?t have insulin that they can get incredibly sick.
This is a picture of the same boy.
This is the boy when they came in with diabetic ketoacidosis
and then when he was feeling better.
These patients are cachexic, dehydrated,
they are profoundly tachypneic,
they are very sick and they can have brain damage as well.
So, in type 1 Diabetes, roughly a third of patients
when they first present will show up in DKA.
We define that as a serum pH of less than 7.3.
A glucose of more than 300 and a serum bicarbonate of less than 15.
These patients have D-Diabetes with a high glucose,
K-ketones in their urine and A-acidosis
which is the serum pH and the bicarb level.
Other tests we can usually get
if we wish to figure out exactly what?s going on
are a CHEM-7 and when we get a CHEM-7
keep in mind that these patients may have
what we call a ?pseudohyponatremia?.
Remember that for every 100 of glucose that is above normal,
there is a lowering of the sodium compensatorily
that allows for maintenance of the osmostat of the blood.
So a patient may have a glucose of a thousand and a sodium of 126
and this is actually a relatively normal level.
Patients can develop a high potassium.
This is initially mediated through a balancing of protons.
Remember that if I?m acidotic.
I?m gonna pack away my protons intracellularily
and in return, to maintain electrical neutrality,
will spit potassium out of the cell
thereby raising my levels of potassium.
A potassium level may be high in the blood
but the patient may actually have a low body potassium.
So we?re gonna keep an eye on this potassium as they continue to improve.
Patients will classically have an anion gap acidosis.
This is the ketones that are creating this anion gap.
You?ll see ketones in the blood if you wish to measure them.
We typically talk about the ketones AcAc and Bah
which your acetoacetate and Beta-Hydroxybutyrate.
We used to measure them, that?s not so important anymore
but we can check them if we wish
and certainly we will see the ketones
in the urine on a simple urine dipstick.
So we?re gonna get a urine on all these patients
and look for both glucose and ketones.
Patients with diabetic ketoacidosis may present with a mild pancreatitis.
It?s not so important that we track these illnesses
but if you see an elevated amylase and lipase,
don?t be surprised and usually this is transient
and it gets better as the patient recovers from DKA.
Rarely, patients can have abnormalities in their C-peptide
especially if this was not DKA
but rather was an example of medical child abuse or Munchausen by proxy.
Remember, a mother might be injecting her child with insulin
and that child?s presenting as if they?re in DKA
when in fact that?s not the diagnosis.