Question 7 A 58-year-old homeless man with long-standing insulin-treated type 2 diabetes has been diagnosed with right lower extremity cellulitis. He has taken a prescribed oral antibiotic for the...

Question 7

A 58-year-old homeless man with long-standing insulin-treated type 2 diabetes has been diagnosed with right lower extremity cellulitis. He has taken a prescribed oral antibiotic for the past week but has not noticed much improvement. For the past 2 days, he has complained of intermittent fevers and chills, nausea with poor oral intake, and proximally spreading erythema over his right leg. On the evening of admission, a friend notices that he is markedly confused and calls 911. In the emergency room, he is oriented only to his name. The patient is tachypneic, breathing deeply at a rate of 24/min. He is febrile at 38.8°C. He is normotensive, but his heart rate is elevated at 112 bpm. On examination, this patient is a delirious, unkempt man with a fruity breath odor. His right lower extremity is markedly erythematous and exquisitely tender to palpation. Serum chemistries reveal a

glucose level of 488 mg/dL, potassium of 3.7 mEq/dL, and sodium of 132 mEq/L. Urine dipstick is grossly positive for ketones.

Questions

1. 
   A. Describe the precipitants of ketoacidosis in this diabetic patient.


2. 
   B. What is the cause of his altered mental status?


3. 
   C. Describe the patient’s respiratory pattern. What is the pathogenetic mechanism?


4. 
   D. What are important issues to consider in replacing electrolytes in this patient?