CASE STUDY #4: CLINICAL HISTORY: Santo G., a 47 year old Hispanic man with a long history of obesity and type 2 diabetes

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CASE STUDY #4:
CLINICAL HISTORY: Santo G., a 47 year oldHispanic man with a long history of obesity and type 2
diabetes of recent onset, required daily insulin injections. Hiswife brought him to the emergency room
early in the morning because he was confused, breathing rapidly,and having to urinate far more often
than normal. "He's having one of those acid attacks," she said,"when everything gets out of balance."
She further revealed that he had not been careful about hisdiet--- the night before he had gorged on
pizza and ice cream and had consumed 8 to 10 bottles of beer,becoming so inebriated that he went to
sleep without taking his insulin.
PHYSICAL EXAMINATION AND OTHER DATA: Vitalsigns included temperature 39 C (102.2 F), heart rate
96 beats per minute(normal 72), and blood pressure 90/60(normal120/80). Respirations were noted to
be "fast and hard," and his breath had an unusual "paint thinneror nail polish remover" odor. Santo was
5 ft 9 in. tall and weighed 285 lb. He was drowsy and confusedabout time and place. Lab tests revealed abnormally high bloodglucose and low (acidic) blood pH. His urine was also unusuallyacidic and contained large amounts of glucose and ketonebodies, neither of which should normally be present. He also hadhigh blood osmolarity (indicating increased blood solutes), lowblood bicarbonates, and low blood partial pressure of CO2. Hisurine also had a very high specific gravity.
CLINICAL COURSE: The emergency room physicianmade a diagnosis of diabetic ketoacidosis and
admitted Santo to the hospital. He was given insulin injectionsand large volumes of intravenous
electrolyte solution containing bicarbonate. Further studiesfailed to find infection or any other
underlying cause of his fever. Within 24hrs, Santo was doingmuch better. He was discharged on the third hospital day.
QUESTIONS: (5 questions - 6.67 points each)
1. Santo's blood volume is decreased and his osmolarityincreased. How will these changes affect ANP,
ATll, ALDOSTERONE, and ADH production?
2. Santo was administered intravenous bicarbonate. Would thismedical intervention have increased or
decreased the production of carbonic acid, and what would havebeen the effect on his blood pH?
3. Santo is a type 2 diabetic meaning he suffers from
diabetes mellitus type 2.What is the problem here and what isthe significance of insulin to him?.
4. Alcohol inhibits ADH production. Remember that Santo drankabout 10 beers the night before. Would
you expect his urine to be more concentrated or lessconcentrated than normal, simply as a result of his
alcohol consumption?
5. Would a cortisol injection worsen or improve Santo's elevatedblood glucose?