|
Diabetic ketoacidosis A
halvány szürke betük halkak, nem kell kiejteni az i színű betüt "áj"-nak kell ejteni emlékeztető: ahol nincs jelölve a hangsúly ott mindig az ELSŐ szótag hangsúlyos Name: Hospital-No.: Physician: Dr A. Date: Found unconscious at work by a coworker, brought to the hospital by ambulance.
HISTORY
HISTORY OF PRESENT ILLNESS: The patient is a 40 year old real-estate sales-agent who was found unconscious in the men's-room at work and brought to the hospital by ambulance. The history was obtained from a coworker, the patients wife, and office files.
He has not been seen in follow‑up for over six months by his private physician. His wife states that because of a busy schedule and the tensions of work, he has not been watching his diet and has on occasion forgotten to take his insulin. There is no history of any trauma, heart disease, drug or alcohol ingestion.
|
|
The patient had a cholecystectomy six years ago without sequels. He had been in apparent good health until this episode, except for his diabetes.
FAMILY HISTORY: The patient is married and has two sons, ages 10 and 12.
Head and neck: The patient has no history of ocular involvement due to his diabetes.
Cardiorespiratory: His wife states he has complained of some occasional dyspnea with mild exertion but no chest pain or orthopnea .
Gastrointestinal: His diet has been erratic for several months, without proper adherence to his prescribed diet. There is no history of indigestion, flatulence, melena, diarrhea, or hematemesis.
Genitourinary; No known hematuria, colic, or nocturia. He had one episode of prostatitis in the past, treated with ampicillin.
Musculoskeletal: No history of claudication. The patient was treated for a trophic ulcer over his left lateral malleolus two years ago.
Endocrine: His diabetes has been in good control when last seen in the office slightly more than six months ago. His fasting blood sugar was 120 milligrams percent at that time, and he was maintained on 40 units NPH insulin. He was also on a 2,200 calorie diet.
General: BP 100/60, pulse 136 and weak, temperature 102 degrees F. rectally, respirations labored and deep, 20 per minute.
Head and neck: Face symmetrical, tongue midline. Eyeballs soft, the fruity odor of acetone on his breath. Carotid pulses are equal. There is no venous distention. Sclera injected, no icterus. Pupils are equal and react to light. Fundoscopic exam reveals bilateral punctate retinal hemorrhages. A white fluffy exudate is noted near the macula of the left eye.
Thorax and lungs; Respirations deep, no rhonchi or rales. No evidence of consolidation on percussion.
Abdomen; Soft. There are no masses or organomegaly. The abdominal sounds are hypoactive. The femoral pulses are present.
Genitalia: Normal penis and testes.
Anus and rectum:, Anal sphincter tone lax. Prostate boggy, benign and not enlarged. Stool guaiac negative.
Neurological: Deep tendon reflexes hypoactive. No pathological reflexes present.
==========================================================
FROM: Dr Adams RE: Diabetes Hospital Number: 987654 Date:03/21/99 REASON FOR CONSULTATION: Apparent diabetic coma.
CONSULTANT'S REPORT Dr. Endocrinology March 21, 1999 The chart and pertinent physical findings have been reviewed. The blood sugar upon admission was 560 milligrams percent. The C02 was 18 volumes percent, and the urines upon catheterization, was 4+ positive for sugar and 3+ positive for acetone.
I agree with the diagnosis of diabetic coma and have initiated therapy with Ringer's lactate and regular insulin intravenously. We will put him on a broad‑spectrum antibiotic and carefully monitor his blood sugar, urinary output, and serum electrolytes.
I will follow the patient with you.
Thank you. Dr. E.
Name: Hospital No.: Physician: Date:
EXAMINATION: Chest x‑ray. March 26, 1999
The bony structures of the thorax are normal. The cardiac silhouette is slightly enlarged. The lungs are expanded. No lesions are noted.
IMPRESSION: Mild cardiac enlargement.
The plain film is normal. The psoas shadows are well visualized. After the injection of contrast material, there is prompt bilateral excretion in five minutes. The renal sizes and contours are normal. The pyelocalyceal collecting system is normal. There is no evidence of obstruction, or deviation of the ureters. An indwelling Foley catheter is noted within the bladder. '''
IMPRESSION: Normal IVP.
Name: Hospital No.: Date Date admitted: Date discharged:
DIAGNOSIS: 1. Diabetic coma. 2. Urinary tract infection.
SURGERY: None.
COMPLICATIONS: None.
SPECIAL PROCEDURES: None.
Dr. Endocrinology
This 40‑year‑old male with known diabetes mellitus was admitted to the hospital comatose after being found unconscious at work by a coworker. Preliminary evaluation demonstrated the presence of ketoacidosis, hyperglycemia with glycosuria in a comatose state. He was hyperpnoeic, febrile, mildly hypotensive, and his neurological reflexes were hypoactive.
His blood sugar was 560 milligrams percent, the C02 was 18 volumes percent. There was bacteriuria and pyuria, and a urine culture grew out E. coli in colony counts over 100,000. The white blood count was 18,000, with a shift to the left. The hemoglobin was 15.4 grams percent and the hematocrit 50 volumes percent.
He was started on Keflex intravenously. An indwelling Foley catheter was put in place and intake and outputs monitored. He was followed carefully with blood sugars and electrolytes. He responded to this regimen, and within eight hours he was awake but still somewhat obtunded. He continued to improve over the next 24 hours, during which time his blood sugars dropped to the 123‑150 milligrams percent range.
His Foley catheter was removed, and he was able to void without difficulty. During his hospitalization an IVP was done because of his urinary tract infection, and this was normal. He continued his convalescence and was discharged on July 13, 1991, on 60 units NPH insulin daily, oral antibiotics, and a 2,200 calorie diet. He was advised regarding frequent and careful follow-ups.
|
