The document discusses two clinical cases involving patients with diabetes-related complications. The first case describes an 80-year-old patient diagnosed with hyperosmolar hyperglycaemic state (HHS) due to dehydration and hyperglycaemia, while the second case focuses on a 19-year-old with diabetic ketoacidosis (DKA) caused by skipped insulin injections during illness. Key management strategies are outlined for both conditions, emphasizing fluid replacement, insulin therapy, and monitoring for complications.

1. CASE DISCUSSION SESSION-3
#Clinical_PharmD_Cases
Dr. S P Srinivas Nayak,
PharmD, Rph, (MSc), (Dip.D)
Assistant Professor,
Dept of Pharmacy Practice
WATCH COMPLETE LECTURE IN U TUBE CHANNEL
‘DR SP NAYAK MED EASY’

2. CASE – 1. 94
• An 80-year-old patient with a history of Type II diabetes mellitus is admitted to
hospital after an episode of vomiting and diarrhoea, followed by increasing
confusion and drowsiness. His medication includes HYDROCHLORTHIAZIDE and
GLYMEPRIDE. On examination he has a reduced level of consciousness, is
dehydrated, and has a low blood pressure.
Biochemistry results are:
• Sodium - 158 mmol/L (136-145 mmol/L)
• Potassium - 4.6 mmol/L (3.5-5.5 mmol/L)
• Urea - 34 mmol/L (1.8 to 7.1 mmol/L)
• Creatinine - 250 μmol/L (65.4 to 119.3 μmol/L)
• RBS - 38 mmol/L (4.0 to 5.4 mmol/L)
Arterial blood gases on air:
• pH - 7.39
• pCO2 - 40 mm Hg
• Actual bicarbonate - 24 mmol/L
• pO2 – 89 mm Hg
QUESTION: What is the diagnosis and Give Management

3. • 1 mmol/L equals approximately 18.01 mg/dL
to convert from mg/dL to mmol/L, value needs
to be multiplied by 0.0555
• The formula to convert µmol/L to mg/dL is 1
Micromole per Liter = 0.0113096584483149
mg/dl

4. Ans: Hyperosmolar hyperglycaemic
state(HHS)
• Hyperglycaemia is the main cause leading to
dehydration due to osmotic diuresis which, if severe,
results in hyperosmolarity. In HHS, unlike diabetic
ketoacidosis, there is no significant ketone production
and therefore no severe acidosis.
• Hyperosmolarity may increase blood viscosity and the
risk of thromboembolism. Factors precipitating HHS are
infection, myocardial infarction, poor adherence with
medication regimens or medicines which cause diuresis
or impair glucose tolerance, for example,
glucocorticoids.

5. Diagnosis of HHS
• hyperglycaemia
• dehydration and hyperosmolarity.
• There may be a mild metabolic acidosis but without
marked ketone production.
• Conscious levels on presentation range from slight
confusion to coma. In some cases, seizures occur.
• Serum sodium and potassium levels are usually
normal but may elevate, and creatinine is high.
• The average fluid deficit is 10 L, so circulatory
collapse is common.

6. Treatment of HHS
• Treatment requires fluid replacement to stabilise
blood pressure and improve circulation and urine
output. Potassium may be added if required.
• Insulin treatment is started via intravenous infusion
but is not aggressive, since fluid replacement also
lowers serum glucose levels.
• Prophylaxis or treatment for thromboembolism
may also be required.

7. CASE - 2
• Miss Priya is a 19-year-old teenager recently
diagnosed type 1 DM. She has been admitted to
hospital with diabetic ketoacidosis (DKA), which
was precipitated by a diarrhoea and vomiting
Caused by an infection.
• On enquiry she says that she was vomiting and
not eating, hence she temporarily stopped
injecting her insulins Glargine and Glulisine
• She was normally well controlled on a basal bolus
insulin regimen comprising insulin glargine
(Lantus) at night and (Apidra) three times daily
with meals.

8. questions
1. What is DKA?
2. Why was it a mistake for Miss Priya not to
inject her insulin whilst she was not feeling well
enough to eat?
3. What are the initial management priorities
for patients admitted with diabetic
ketoacidosis?

9. 1. What is DKA?

10. Answer. 2
2. Why was it a mistake for Miss Priya not to inject her
insulin whilst she was not feeling well enough to eat?
• This is a common misunderstanding amongst patients
and sometimes even health care professionals. When a
person is unwell, their basal insulin requirements can
often increase, despite not eating. This is because of the
stress involved and the increase in the production of
counter-regulatory hormones which increase glucose
levels.
• Patients should be counselled on what are commonly
referred to as ‘sick day rules’ and adviced to monitor
Sugar levels and ketones.

11. Answer. 3
3. What are the initial management priorities for
patients admitted with diabetic ketoacidosis?
• Intravenous sodium chloride 0.9% should be
started as soon as possible. A fixed rate
intravenous insulin infusion should then be
started. Current recommendations are to begin
at a rate of 0.1 units/kg. Regular hourly
monitoring of blood glucose and ketones should
be undertaken and 2-hourly monitoring of serum
potassium for the first 6 h.

12. please
THANK YOU
‘Regular exercise, drug adherance and diet
maintenance is must to control DM,
Complication risk is high if any one is missed
from above’.
-- Dr S P Nayak med easy lectures