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February 26, 2019

Diagnosis and Symptoms

Question from Colombia:

Niña en urgencias de 2 años y 11 meses, cuadro febril y vómito de 48 horas de evolución.
Examen físico: Decaimiento, aliento cetónemico, pruebas de orina: glucosa +++, cuerpos cetónicos ++, leucocitos +++, nitritos ++, glucemia capilar 220 mg/dl, leucocitosis con desviación izquierda y aumento de PCR, al día siguiente persiste febril, glucemia de 166 mg/dl, esta pálida, ojerosa, cansada, realizamos nuevamente examen presentando leucocitosis con desviación izquierda, ↑↑PCR y procalcitoninca e Hiperglucemia.

1. ¿Por qué tiene aliento cetónemico? ¿Esta relacionado con los lipidos?

2. ¿Qué estilo de vida saludable debo recomendarle? ¿Son importantes sus antecedentes familiares?

3. ¿Qué cuidados de enfermería especificos le puedo brindar a mi paciente?

4. Sospecho que tiene hiperglucemia de estrés o hiperglucemia infantil ¿Qué opinan respecto a esto?

Two-year, 11-month-old little girl in emergency care, fever and vomiting over the past 48 hours. Physical exam: Lethargic, ketone breath, urine tests: glucose +++, ketonic bodies ++, leukocytes +++, nitrites ++, blood sugar 220 mg/dl, leukycytosis with left deviation, and elevated CRP. The next day the fever persisted, blood sugar of 166 mg/dL; she’s pale, haggard, tired. We did another exam where she presented with leukocytosis with left deviation, raised CRP and procalcitonin and hyperglycemia.

1. Why does she have ketotic breath? Is this related to the lipids?

2. What lifestyle should I recommend them? Is it important to know family history?

3. What type of nursing care or specific recommendations should I offer to my patient?

4. My suspicion is that this patient has hyperglycemia from stress or infantile hyperglycemia. What do you think about it?


From: Penelope Pauley, MD

1. Probablemente al no estar comiendo y consumiendo calorías en cuerpo comienza a quemar grasa y proteínas y como respuesta a esta oxidación, se liberan cuerpos ketonicos, lo que da ese olor característico. No directamente, pero si hay oxidación de grasas.

2. Aquí al parecer la enfermedad/infección de base es la que aparentaría estar dirigiendo el cuadro, incluyendo la hiperglicemia. Definitivamente es importante saber los antecedentes familiares así como saber de enfermedades autoimmunes en la familia.

3. Hidratación sería lo número uno y tratar la infección de base.

4. En ausencia de pérdida de peso, polyuria, polydipsia, y en presencia de fuente infecciosa, es lo más probable. Que paso el día de la glucemia de 200 mg/dl? Recibió líquidos? Se fue a la casa? Está admitida?

English Translation:
1. Probably as she’s not eating she is developing starvation ketosis because the body is trying to burn fat and protein given the fact that the patient is not eating calories. As a byproduct of fatty acid oxidation the body releases ketone bodies which gives that characteristic smell. Not necessarily but it is because of fatty acid oxidation.

2. It is always important to know if family history because there is a correlation between diabetes and autoimmune conditions.

3. As mentioned above I think the main thing will be to take care of the dehydration and the infection.

4. I do not have all the data that I wish in order to give a more accurate assessment however in absence of weight loss, polyuria, polydipsia, as well as having an infection that can induce hyperglycemia I would lean more towards hyperglycemia of the illness or stress.

Now I would like to know what happen when glucose was 200 and then the next day it went down to 166? Was the patient rehydrated it? Was the patient discharged home? is the patient in the hospital?