Dr Esther Tsang August 2011 Diabetic emergencies

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 HCO 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 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 : 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?