<Case History>
A 46 years old male patient was quite healthy before. He
suffered from polyuria, polydipsia and polyphagia since 6
months ago. Progressive body weight loss (12 Kg within 6
months) and generalized malaise were also noted during this
period. He did not pay any attention to it until cough with
yellowish sputum and high fever occurred 3 days ago. Other
associated symptoms including dyspnea, abdominal pain and
nausea. No vomiting or diarrhea was noted. Because of
worsening of dyspnea and fever, he was sent to our Emergency
Room for help.
On physical examinations, this patient appeared very
ill-looking and tachypnea. His consciousness was clear and
oriented. The blood pressure was 165/98 mmHg, body temperature
was 39.60C, pulse rate was 118 /min, and respiratory rate was
28/min. The body height was 168 cm, body weight was 76 Kg, and
BMI was 26.9 Kg/m2. The head was normal. The conjunctivae were
not pale and the sclerae were not icteric. The neck was supple
without lymphadenopathy. The jugular veins were not engorged.
The thyroid was not enlarged. The heart sounds were regular
without murmur. Inspiratory crackles and wheezing were found
over right lung field. The abdomen was soft and flat, diffuse
tenderness was noted but without rebound tenderness. The liver
and spleen were not palpable. The extremities moved freely
without edema.
<Laboratory Data>
CBC
WBC K/μL |
RBC K/μL |
Hb g/dL |
Hct % |
MCV fL |
MCH pg |
MCHC g/dL |
PLT K/μL |
Seg % |
Eos % |
Baso % |
Lym % |
19.3 |
4900 |
15.5 |
45.6 |
98 |
30.8 |
37 |
258 |
89.8 |
2.7 |
1.3 |
6.2 |
Biochemestry
Alb g/dL |
Glo g/dL |
T-Bil mg/dL |
D-Bil mg/dL |
AST U/L |
ALT U/L |
ALP U/L |
LDH U/L |
BUN mg/dL |
Crea mg/dL |
3.9 |
3.0 |
0.6 |
0.2 |
32 |
26 |
134 |
385 |
35.2 |
1.3 |
UA mg/dL |
Na Meq/L |
K Meq/L |
Cl Meq/L |
(T)Ca mg/dL |
Sugar mg/dL |
CRP μg/ml |
HbA1c % |
Lipase IU/L |
Osmo mOsm/Kg |
5.2 |
130 |
4.2 |
102 |
8.9 |
485 |
183 |
14.2 |
48 |
295 |
Arterial blood gas (room
air)
PH |
PaCO2 mmHg |
PaO2 mmHg |
HCO3- Meq/L |
SaO2 % |
7.253 |
26 |
112 |
9.8 |
99.6 |
Urine analysis
Ketone |
Sugar mg/dL |
WBC /HPF |
RBC /HPF |
3+ |
>1.0 |
0-2 |
0-2 |
Imaging
Studies:
*Chest PA: Air-space lesions over right lung *Plain
abdomen film: no positive findings *12 leads EKG: Sinus
tachycardia
<病情分析>
糖尿病是一種血糖代謝異常的疾病,造成血糖升高的原因包括:胰島素分泌減少、血糖利用減少或是血糖生成增加,一般分成四種type:type
1
(因βcell受破壞導致胰島素生成減少)、type
2(因胰島素生成功能異常或是有insulin
resistance)、other
type(βcell或是胰島素的gene突變、胰臟發炎或是胰臟手術引起、藥物)以及GDM(妊娠高血糖)。
糖尿病急性併發症是指胰島素缺乏導致對生命有立即威脅的代謝異常,一般常見的是糖尿病酮酸血症(DKA)和高血糖高滲透壓非酮體性症候群(HHNK);糖尿病酮酸血症好發於胰島素生成減少的type1
DM,當胰島素分泌不足或壓力荷爾蒙分泌過度時,血液中的葡萄糖會因來源增加和利用減少導致濃度升高,此時脂肪組織釋放脂肪酸的速度增加,再加上肝臟將脂肪酸轉換成酮體的功能亢進,使得血液中酮體濃度上昇,造成代謝性酸中毒。
典型DKA的臨床表徵為:發病前數日有多喝多尿的症狀,而且常伴隨著厭食、噁心、嘔吐等表徵,有時以腹痛為主要表現;實驗室檢查的發現主要為高血糖、高酮血症和酸中毒。
DKA的治療目標在於抑制肝臟葡萄糖釋放和促進週邊組織葡萄糖利用、校正酮酸血症,因此要注意胰島素的使用以及水分和電解質的補充;此外要避免因治療導致之併發症,水分補充、胰島素使用以及酸血症的校正均會造成血中鉀離子濃度下降,因此治療中須仔細的檢視血中鉀離子濃度並補充適當的鉀離子以防止低血鉀的發生,而且當血糖低於250mg/dl時,須補充適當的葡萄糖以防止低血糖和腦水腫的發生。
高血糖高滲透壓非酮體性症候群是指血液中葡萄糖濃度升高、滲透壓升高,同時沒有明顯的酮體;臨床徵狀常出現脫水、體液不足和意識障礙等現象,易發生於年老type2
DM患者,治療上和上述DKA的治療相似;在HHNK常併發致死的梗塞症,特別是在低血壓、高滲透壓、脫水、血液濃縮和高黏性導致局部循環不足時較易發生,故在HHNK治療時須特別注意梗塞正並予以適當治療。
糖尿病慢性併發症包括小血管病變以及大血管病變,小血管病變是指視網膜病變、神經病變和腎病變,而大血管病變是指冠狀動脈、腦血管以及週邊血管疾病;其中大血管病變往往是病人死亡的主要原因。
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