Clinicopathological Conference Decompensated Diabetes
نویسندگان
چکیده
The patient, a 48-year-old black man, was first admitted to the hospital in late February 1993 because of fatigue, polyuria, polydipsia, and nocturia. To lose weight, he had been on a liquid diet and vitamins since November 1992 and had lost about 4.5 kg. He had remained active, working as an automobile mechanic. For several weeks before admission, he had been tired and weak and had noticed polyuria. On the day of admission he collapsed. The patient had not had a recent infectious illness. A brother and an aunt have diabetes mellitus; both take insulin. On admission to the emergency department, the patient had a heart rate of 140 beats per minute, and his blood pressure was 81/53 mm Hg. Physical examination showed the patient to be obese (weight, 106 kg; height, 173 cm; body mass index, 35.5 kg/m2). Ears, nose, and throat were clear. There was a grade 2 midsystolic murmur along the left sternal border. The lungs were clear to auscultation. The abdomen was soft, with positive bowel sounds. The liver edge was palpable at the right costal margin. Liver span by percussion was 9 cm. There was no lesion of the extremities. The serum Na+ was 140 mmol/L, K' was 6.0 mmol/L, creatinine was 460 ,umol/L, urea nitrogen was 30 mmol/L, glucose was 102.1 mmol/L, and osmolality was 432 mmol/kg. Anti-islet cell antibodies were negative. Analysis of arterial blood gases revealed a pH of 7.11, HCO3 of 11 mmol/L, Paco2 of 34 mm Hg, and base excess of -17 mmol/L. A test for ketones was positive in a 1/64 dilution of serum. The patient was treated with intravenous fluids and infusion of insulin; his hyperglycemia promptly improved and the ketoacidosis resolved. At discharge in early March, he was advised to maintain a 2000-kcal/d diet for patients with diabetes and to take neutral protamine Hagedorn insulin twice daily. Four days later, on the first follow-up visit, the patient reported numbness and tingling in the left leg and complained of shortness of breath. He said he had
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