Infirmary After Passing Out During Basic Training

Infirmary After Passing Out During Basic Training

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Infirmary After Passing Out During Basic Training

Due June 30

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EDUCATING OUR COMMUNITY

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CASE 1

A 19-year-old Marine was brought to the infirmary after passing out during basic training. He had repeatedly complained of severe weakness, dizziness, and sleepiness during the preceding 4 weeks of boot camp. In a previous episode weeks earlier, he had drowsiness and generalized tiredness and was brought to the infirmary, where after IV administration of saline, he was returned to duty with the diagnosis of dehydration. Upon questioning, he reported unquenchable thirst, and the repeated need to urinate. Although he ate all of his rations as well as whatever he could get from his fellow trainees, he had lost 19 pounds. (Baseline body weight was 150 pounds, height 5’8″). On the last day, he complained of vague abdominal pain, which was worse on the morning of admission. He had vomited once. During the examination, he was oriented but tachypneic. He appeared pale, dehydrated with dry mucous membranes, and poor skin turgor. His respiratory rate was 36/minute with deep, laborious breathing; his heart rate was

138/minute regular, and his blood pressure was 90/60. His chest was clear, and his heart tones were normal. There was an ill-defined generalized abdominal tenderness, which was otherwise soft to palpation and showed no rebound. There was generalized muscular hypotonia; his deep tendon reflexes were present but very weak. Laboratory, on admission, showed glucose of 560 mg/dl, sodium 154, potassium 6.5, pH 7.25, bicarbonate 10 mM/liter, chloride 90, BUN 38 mg/dl, creatinine 2.5 mg/dl. (Normal values: glucose, 70-114 mg/dl; Na = 136-146; K, 3.5-5.3; Cl, 98-108; CO2, 20-32 [all in mM/I]; BUN, 7-22mg/di; creatinine, 0.7-1.5 mg/dl). A urine sample was 4+ for glucose and had “large” acetone. HbA1c was 14% (n=4-6.2%). Serum acetone was 4+ undiluted, and still positive at the 4th dilution. Beta-Hydroxybutyrate level was 20 millimoles/liter (normal=0.0-0.3 mM/I).

He was treated with insulin and saline I.V. By the 4th hour of treatment, potassium chloride was added to the IV at a rate of 15 mEq/hour. Sixteen hours later, he was active, alert, well-hydrated, and cheerful, indicating he felt extremely well. He requested that his IV be discontinued. His physician decided to switch his insulin to subcutaneous injections and start a liquid diet. He was later put on a diabetes maintenance diet and treated with one injection of Human Lente insulin in the morning. Although his blood sugars the next morning were 100-140 mg/dl, he had frequent episodes of hypoglycemia during the day, and his HbA1c was 9%. Eventually, he was put on 3 injections of regular insulin/day, and a bedtime intermediate duration (Lente) insulin.

Questions

1. Why did the patient improve after being given IV saline on his first admission?
2. Why was dyspnea his presenting symptom?
3. He was hyperkalemic on admission, and yet, why was potassium later added to the IV infusion?
4. What is the possible reason why a single injection of insulin in the morning failed to control his

Diabetes without causing hypoglycemia?

RUBRIC
Excellent Quality 95-100%	Introduction 45-41 points The background and significance of the problem and a clear statement of the research purpose is provided. The search history is mentioned.		Literature Support 91-84  points The background and significance of the problem and a clear statement of the research purpose is provided. The search history is mentioned.			Methodology 58-53 points Content is well-organized with headings for each slide and bulleted lists to group related material as needed. Use of font, color, graphics, effects, etc. to enhance readability and presentation content is excellent. Length requirements of 10 slides/pages or less is met.
Average Score 50-85%	40-38 points More depth/detail for the background and significance is needed, or the research detail is not clear. No search history information is provided.		83-76  points Review of relevant theoretical literature is evident, but there is little integration of studies into concepts related to problem. Review is partially focused and organized. Supporting and opposing research are included. Summary of information presented is included. Conclusion may not contain a biblical integration.			52-49  points Content is somewhat organized, but no structure is apparent. The use of font, color, graphics, effects, etc. is occasionally detracting to the presentation content. Length requirements may not be met.
Poor Quality 0-45%	37-1 points The background and/or significance are missing. No search history information is provided.		75-1 points Review of relevant theoretical literature is evident, but there is no integration of studies into concepts related to problem. Review is partially focused and organized. Supporting and opposing research are not included in the summary of information presented. Conclusion does not contain a biblical integration.			48-1 points There is no clear or logical organizational structure. No logical sequence is apparent. The use of font, color, graphics, effects etc. is often detracting to the presentation content. Length requirements may not be met
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