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Don’t Judge a Book by Its Cover: A Complex Twist in a Patient with Diabetic Ketoacidosis

STsHere was a 45-year-old Type 1 diabetic who presented to the emergency department in a near coma with diabetic ketoacidosis. The diagnosis seemed clear as day, with some of the classic presenting signs: polyuria, polydipsia, hyperglycemia, high anion gap, low serum bicarbonate and presence of ketones in the urine. She was admitted and treated appropriately. Once she was stabilized, the human interaction and history-taking began, which proved to be far more convoluted.

She thoroughly explained her history that started with a diabetes diagnosis in her early 20s. At that time, she presented to the emergency department with a bout of viral gastroenteritis that presumably triggered the initial episode of diabetic ketoacidosis.

Her social history was far more complex. She admitted to alcoholism reluctantly yet openly talked about her recent cocaine and methamphetamine abuse, and made a few subtle yet poignant remarks hinting towards domestic violence at home. She talked about a daughter that hated her, a mother that abandoned her, and a diagnosis that limited her. Although her immediate assessment and plan were straightforward and successful, something unexpected happened the following night.

Her sugars dropped to the mid-40s. She was immediately given orange juice and sugar tablets. She was stabilized and slept comfortably through the night. I saw her the following morning during breakfast and observed her enjoying her coffee with three sugar packets and her pancakes with molasses syrup.

This patient seemed to demonstrate an awareness of her condition and an avoidance of another hypoglycemic state. Perhaps our insulin regimen was aggressive—and likely too aggressive—for our medium-sized lady. The following day, her sugar began to creep into the 200s. Then we saw a 300, then a 400, then a 500. What were we doing or what was happening in her body to account for such dramatic changes in blood sugar? We weren’t entirely sure, but were told by the patient that these fluctuations are consistent with her home readings. She said that she rarely goes down to the 70s and has adequate hypoglycemic awareness, but regularly yet inexplicably reaches the 500 mark on a weekly basis.

Her outpatient endocrinologist, who was not affiliated with our hospital, confirmed the story and told our team that this was a difficult-to-control Type 1 diabetic. He was certainly right; in a matter of 48 hours, her sugars had initially presented at 800, stabilized at 140, dropped to 70, went up to 500 and now had yet another episode of 80.

After a very eventful and painstaking week that involved additional sugar swings, patient-nurse and patient-physician confrontations and support from social work, the truth came out. The patient was found to have insulin pens (needles and syringes) in her room that she was using to cause the hypoglycemic episodes. The how was finally explained. But the why was dicey.

She admitted to using the pens and even stated that she had done so in the past. However, she tearfully explained her reasoning. She was explicitly told three months ago that she was a pancreas transplant candidate but would never be eligible because of her alcoholism. Although she attempted to quit multiple times, her handle of vodka became increasingly more appealing as her husband’s aggressive and verbal behavior worsened.

Quiet, somber and openly questioning the point of life, she simply told us that she wanted to remain in the hospital to avoid her home life. If she stopped drinking (a reasonable assumption while being in the hospital), she would soon get a pancreas transplant. If she went home, she would continue drinking and make herself vulnerable to further domestic abuse.

Although it may be easy to assume this patient is surreptitiously injecting insulin due to her current history of drug use and former profession as a nurse, it is very difficult to think her actions all along were to avoid alcoholism and domestic violence.

This patient taught me a difficult lesson and opened my eyes as to why people may do the things they do. This experience will always remain with me because although her actions are not acceptable, here was a clear opportunity to change this patient’s life. Her diagnosis of diabetes ketoacidosis brought her in the hospital, but she was later transferred to the inpatient psychiatry and rehab unit in an effort to cleanse her life. It is premature to say this is the last twist in this patient’s life, but it was certainly a story in mine.


Patients are the true storytellers. They come in with pathology, we interpret physiology and prescribe pharmacology, but their stories are what we remember. They shape our experiences and how we practice medicine.

Manik Aggarwal Manik Aggarwal (7 Posts)

Columnist Emeritus

Texas A&M Health Science Center College of Medicine

Hi! I am an Internal Medicine resident at Georgetown University Hospitals. I graduated medical school from Texas A&M Medical School and Baylor University Medical Center in Dallas, TX. I went to Case Western Reserve University where I did my bachelor's in medical anthropology and a masters in public health. Life is good. I am an inherent optimist who simply enjoys life. Avid Dallas Cowboys fan! In all my free time (ha ha), I enjoy traveling and spending time with friends and family.


Patients are the true storytellers. They come in with pathology, we interpret physiology and prescribe pharmacology, but their stories are what we remember. They shape our experiences and how we practice medicine.