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Acute Diabetes Case B

Acute Diabetes Case B. By: Abdullah Osman Christine Tanzil Ayse Togac. Jack (51 years) was admitted to hospital with a 24 hour history of drowsiness. Medical History. Cardiomyopathy with aortic and mitral regurgitation Hypertension Ischaemic heart disease. Medications.

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Acute Diabetes Case B

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  1. Acute DiabetesCase B By: Abdullah Osman Christine Tanzil Ayse Togac

  2. Jack (51 years) was admitted to hospital with a 24 hour history of drowsiness.

  3. Medical History • Cardiomyopathy with aortic and mitral regurgitation • Hypertension • Ischaemic heart disease

  4. Medications • Frusemide 40mg MANE • A loop diuretic indicated for hypertension. • Lisinopril 20mg DAILY • An angiotensin converting enzyme inhibitor indicated for hypertension. • Aspirin 100mg DAILY • An anti-platelet drug indicated for secondary prevention in ischaemic heart disease. • Glyceryl trinitrate 600mcg SL PRN • A nitrate indicated for angina (IHD)

  5. On examination to the hospital he was: • Unconscious • Hyperventilating • Dehydrated • BP = 80/40 • Pulse = 120

  6. Vigorous rehydration, electrolyte replacement and insulin therapy were administered. Urinalysis was positive for glucose but negative for ketone bodies. A diagnosis of NKHC was suspected.

  7. What is NKHC?PART 1

  8. What is NKHC? • Non-ketotic Hyperosmolar Coma • A syndrome characterized by hyperglycaemia, extreme dehydration, and hyperosmolar plasma leading to impaired consciousness, sometimes accompanied by seizures. • Non-ketotic hyperosmolar coma (NKHC) is a complication of type II DM and has a mortality rate of over 50%.

  9. What are the signs and symptoms? • In some patients, an infection, particularly pneumonia or gram-negative sepsis, is an initiating event; but NKHC can also occur when patients with undiagnosed or neglected type II DM receive drugs that impair glucose tolerance (e.g., Glucocorticoids) or increase fluid loss (e.g., diuretics).

  10. Diagnostic features of NKHC • The consistent and diagnostic features of NKHC are CNS alterations, extreme hyperglycaemia, dehydration and hyperosmolarity, mild metabolic acidosis without marked hyperketonemia, and pre-existing chronic renal failure

  11. Continued….. • The state of consciousness at presentation varies from mental cloudiness to coma. The plasma glucose is usually in the range of 55.5 mmol/L. The calculated serum osmolality on admission is about 400 mmol/L, whereas the normal level is around 280mmol/L. • The mean fluid deficit is about 22% of the total body water, or about 10 L, and acute circulatory collapse is a common terminal event in NKHC

  12. Do the results support the diagnosis?PART II

  13. JACK’S RESULTS

  14. SIGNS OF NON-KETOTIC HYPEROSMOLAR COMA • CNS alterations • Increased HR • Dehydration • Decreased BP • Increased temp • Thirst

  15. DIAGNOSING NKHC • BGL >50mmol/L • pH >7.3 • Bicarbonate slightly decreased • Na and K basically normal • Large increase in BUN • Serum Osmolality > 320mmol/l

  16. JACK’S RESULTS • Unconscious • Hyperventilating • Dehydrated • BP of 80/40 • Pulse Rate of 120 i.e. indicative of NKHC

  17. JACK’S RESULTS

  18. What are the other acute presentations of diabetes apart from NKHC?PART III

  19. Diabetic Ketoacidosis (DKA) • Mainly occurs in type I diabetics. • Ketosis is a condition that is characterised by an elevated serum level of ketone bodies. The ketone bodies are generally found in blood, urine and tissues. • Occurs where there are high levels of blood glucose and glucagon levels. • high glucagon levels result in an increased production of ketones. • Occurs where there are low levels of insulin. • Low insulin levels result in increased ketone production. • The patients generally present with impaired consciousness, dehydration, hyperventilation, low pH, hyperkalemia, potassium deficiency, hyperphosphatemia and phosphate depletion and sodium depletion. • K+ and Phosphate depletion due to urinary loss • The acidosis is partly compensated by hyperventilation. • Occurs where there are any changes in hormones (adrenaline, cortisol and growth hormone) result in a mobilisation of free fatty acids from adipose tissue and result in an increase in ketone body production in the liver.

  20. Hypoglycaemic Coma • Glucose levels are generally <2.5mmol/L • Insulin levels are elevated or normal and therefore there are generally no ketone bodies present. • Patients present with symptoms of anxiety, fainting, hunger, sweating and headache. • Hypoglycaemia may be caused by fasting or by other medications such as insulin, sulphonylureas, salicylates and alcohol consumption.

  21. Insulinoma • There are generally low blood glucose levels. • Male < 55mg/dL • Female <35mg/dL • There are generally elevated insulin levels. • Therefore generally there are no ketone bodies present. • Diagnosis is confirmed by an elevated plasma insulin levels of >15mU/L and proinsulin levels of >40fmol/L. • Levels of insulin may be mimicked by too much use of oral sulfonylurea's or insulin use.

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