SITUATIONAL PROBLEM K002026

1. Diabetes mellitus type 1, HbA1C<6.5% Diabetic hypoglycemic coma.

2. The diagnosis of type 1 diabetes mellitus was made on the basis of the onset of the disease at a young age of the patient, the start of therapy with insulin, HbA1C<6.5% - since there are no severe macrovascular complications and the risk of severe hypoglycemia and young age.

The diagnosis of “hypoglycemic coma” was made on the basis of complaints (headache and trembling in the body, sweating), medical history (suffers from type 1 diabetes mellitus, receives insulin), identified syndromes: neuroglucopenic and hyperadrenergic, glycemia level – 2.2 mmol / l

The mechanism of development of syndromes.

The immediate cause of hypoglycemic conditions in diabetes mellitus is usually eating disorders, an overdose of hypoglycemic drugs (in this case, an insufficient amount of carbohydrates before physical activity).

Hypoglycemia is accompanied by a deficiency of glucose in the neurons of the brain (as a result of which there is a feeling of hunger, a decrease in mental and physical performance, inappropriate behavior, stupor, coma). First of all, the cerebral cortex suffers from hypoglycemia, then subcortical structures (accompanied by an increase in weakness, pallor of the skin, headache, dizziness), the cerebellum (manifested by disorientation, aggressiveness, a sharp increase in muscle tone with the development of tonic-clonic convulsions resembling an epileptic seizure) and later – the medulla oblongata (marks the onset of coma). Hypoglycemia stimulates the sympathetic-adrenal system – catecholamines are released into the blood. For a compensatory increase in blood glucose, contra-insular hormones are released into the blood: glucagon, cortisol, somatotropin.

Symptoms of a hypoglycemic state appear when the blood glucose is below 2.78-3.33 mmol / l.

3. KShChS (normal), protein in daily urine (normal), electromyography of the lower extremities (normal or decreased conduction of a nerve impulse along motor fibers), examination of the fundus (presence of retinopathy or its absence, since the duration of diabetes is short), MAU (presence of or no – short duration of diabetes), creatinine and GFR (normal – short duration of diabetes, but may be reduced GFR or increased creatinine), AST and ALT. Bilirubin (assess liver function – with such a duration of diabetes, as a rule, it is normal).

4. Intravenous administration of 40% Glucose solution 20-100 ml until full recovery of consciousness; in the absence of recovery of consciousness, they switch to intravenous drip administration of 5% Glucose solution; s / c or / m administration of 1 mg of Glucagon, Prednisolone 30 mg / m (contrinsular hormones, increase the level of glycemia). With a protracted course of coma – the introduction of osmotic diuretics: Mannitol or Urea 0.5 g / kg (for the prevention and treatment of cerebral edema);

after the restoration of consciousness, the patient should be fed with carbohydrate foods (bun, bread, potatoes) to prevent the recurrence of a hypoglycemic state.

5. The prognosis is favorable with adequate treatment of coma and diabetes. After stopping this condition, strict control over food intake, dosage of hypoglycemic drugs and physical activity is required. With inadequate treatment, the coma is fatal. With inadequate treatment of diabetes, the occurrence of severe complications that disable the patient and shorten his life.

Situational task 208 [K002027]

Instructions: READ THE SITUATION AND GIVE DETAILED ANSWERS TO THE QUESTIONS

Main part

Patient P., 24 years old, lost consciousness at home, relatives called an ambulance. Anamnesis of the disease: it is known that dry mouth, thirst appeared a month ago (drank up to 8.0 l / day), polyuria, weakness, lost 10 kg. Didn’t go to doctors. The last 3 days have been disturbed by gradually increasing pulling pains in the abdomen, diffuse in nature, lack of appetite, nausea, the day before there was 2-fold vomiting.

This morning she became indifferent to what is happening around, with difficulty answering questions. Gradually she began to lose consciousness, breathing became rapid, deep, noisy.

Objectively: the patient’s condition is grave. The position is passive (lying on the bed), consciousness is absent. Nutrition reduced, hypotrophy of the subcutaneous fat, muscle layer.

Height – 154 kg, weight – 33 kg. The skin and visible mucous membranes are pale, cold, dry, turgor is reduced, cyanosis of the lips. Facial features are sharpened. Striae, no hirsutism. In the lungs with percussion – a clear pulmonary sound. Breathing is deep, noisy, a sharp smell of acetone in the exhaled air, respiratory rate – 32 per minute. Vesicular breathing in the lungs, no wheezing. The boundaries of relative cardiac dullness: right – the right edge of the sternum, the top – the upper edge of the III rib, the left – 1 cm medially from the midclavicular line, heart rate – 110 beats per minute. The tones are rhythmic, muffled, there is no noise, 110 per minute. The pulse is rhythmic, small filling, 110 per minute, blood pressure – 90/50 mm Hg. Art. Tongue dry, red. The abdomen is swollen, does not participate in the act of breathing, is tense on palpation in all departments, peritoneal symptoms are negative, the liver is +2 cm from under the costal arch. The spleen is not palpable, the kidneys are not palpable, the effleurage syndrome is negative.

The thyroid gland is not enlarged on palpation, elastic, nodular formations are not determined. There is no lactorea.

survey data. Complete blood count: erythrocytes – 3.7 × 1012 / l, hemoglobin – 124 g / l, leukocytes – 10.2 × 109 / l, eosinophils – 4%, basophils – 1%, stab neutrophils – 7%, segmented neutrophils – 62%, lymphocytes – 17%, monocytes – 8%.

ESR – 24 mm/h.

Urinalysis: color – yellow, specific gravity – 1032, protein – 0.376 g/l, sugar – 10%, acetone – 4++++, epithelium – 0-1 in the field of view, leukocytes – 3-5 in the field of view , erythrocytes

– 3-5 in sight.

Biochemical blood test: total protein – 67 g / l, creatinine – 135 μmol / l, urea – 12.7 mmol / l, sugar – 35.6 mmol / l, AST – 24 U / l, ALT – 28 U / l , Na+ – 131.3 mmol/l, K+

– 3.2 mmol/l, Fe2+ – 17.3 µmol/l. KShchS: pH – 7.23, BE – 8.3.

ECG: rhythm – sinus, heart rate – 110 per minute, atrial extrasystoles (3). EOS – right. Metabolic changes in the myocardium.

Questions:

1. Suggest the most likely diagnosis.

2. Justify your diagnosis.

3. Draw up and justify a plan for an additional examination of the patient.

4. Draw up and justify a treatment plan.

5. Assess the prognosis for the patient. follow-up strategy.

Be First to Comment

Leave a Reply

Your email address will not be published.