Transcript Diabetic emergencies

Diabetic emergencies
Dr Esther Tsang
August 2011
Case 1
 40 year old lady with history of diabetes mellitus for the past
5 years.
 Presented with fever, severe epigastric pain, vomiting and
breathlessness.
 What other information from history taking do you need?
 She was rather confused when you are speaking to her, but
managed to tell you that her toe was painful and foul
smelling.
 Why is she confused?
 What are the differential diagnoses for severe epigastric pain
and vomiting?
 Why is she breathless?
 You decide to ask the nurse to check the patient’s vital signs.
 T 39°C
 BP 90/60
 HR 120
 Reflo 20.0 mmol/L
 What could possibly be wrong with her?
 What physical signs would you look for?
 What are the physical signs of shock?
 What are the physical signs of infection to look for?
 You look at her toe and it is foul smelling, with greenish pus
extending upwards towards the ankle.
 The soft tissue is grossly inflammed with crepitus on
palpation.
 What is the diagnosis?
 What blood tests would you do?
 How do you tell the difference between DKA and HHS?
 ABG
 pH 6.8
 pCO2 3.5 kPa
 pO2 12 kPa
 HCO3 10.0 mmol/L
 Interprete this blood gas.
 BUSE :
 Urea 12
 Creat 150
 K 5.2
 Na 140
 FBC
 TWC 22
 Hb 10g/dL, MCV 80
 Plt 450
 RBS 18.8
 LFT
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TP 60
Alb 23
Bilirubin 5
ALT 33
ALP 20
 ECG showed sinus tachycardia.
 Interprete the results.
 How do you calculate the serum osmolality?
 Why did this patient end up with this complication of
diabetes?
 What are the precipitants of DKA or HHS?
 Her relatives brings the patient’s medications :
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Aspirin 150mg OD
Perindopril 4mg OD
Amlodipine 5mg OD
Simvastatin 40mg OD
Gliclazide 80mg BD
Metformin 1g BD
S/C Insulatard 20 units ON
 What do you do to these medications? Which do you continue,
which do you withhold?
 How would you manage this patient?
 Is IV sodium bicarbonate indicated?
 What parameters must be monitored?
 When would the patient be fit for discharge?
 State your antibiotic of choice and why.
 Give examples of classes of antibiotics and examples of
antibiotics.
Case 2
 70 year old man admitted for seizure and drop in GCS.
 Reflomet in casualty was 2.5mmol/L
 He was given Dextrose 20% 1 pint in casualty.
 Now, reflomet is 6.0 mmol and he is alert and consious.
 Comment on the management in casualty department.
 Why did he have a seizure?
 What further history would you want to take?
 What are the causes of hypoglycaemia?
 He tells you that he has not been feeling too well, and has not
been eating much. He took his medications as usual.
 He has a productive cough with greenish sputum and a fever.
 His medications are as follows :
 Glibenclamide 10mg BD
 Metformin 1g BD
 Acarbose 100mg TDS
 Perindopril 4mg
 What physical signs would you look for?
 What would his diagnosis be?
 What tests would you order?
 How would you treat his hypoglycaemia? State the rational of
treatment.
 What would you do to his medications?
 How would you treat his fever with cough?