_血糖控制不稳的问题_北京市东城区社区卫生服务管理中心远程会诊病历(1)

#全科医生诊室# =编者按 >本栏目如实记载了我国全科医生的临床实际工作, 并特邀美国 Un iversity o fW iscons in家庭医学系 Jona- than L1Tem te教授 (麦迪逊市W isconsin大学医学和公共卫生学院, 医学和公共卫生博士 ) 针对我国的病例进行, 从中对比中西方处理病例的和思维方式。希望能给我国的全科医生一定的启示和借鉴。在此感谢北京市东城区社 区卫生服务管理中心谢载纬医生 ( Dr1G ilbert Shia) 和美国W isconsin大学 Kushner教授 ( Ph1D1 Professo r Departm ent o f Fam ilyM edic ine) 给予的支持和帮助! /血糖控制不稳的问题 0 ) ) ) 北京市东城区社区卫生服务管理中心远程会诊病历 邓红月, 张 然, Jonathan L1Tem te =关键词 > 血糖; 糖尿病; 胰岛素 =中图分类号 > R 587. 1 =文献标识码 > B =文章编号 > 1007- 9572 ( 2010) 02- 0392- 02 1 基本信息 患者彭某某, 女, 65岁, 健康档案号 01000032 - A, 申 请会诊单位: 多福巷站, 申请会诊医生: 张然, 申请会诊科 别: 内分泌, 申请时间: 2008- 05- 08。 会诊时间: 2008- 05- 09, 会诊专家: 内分泌专家朱良湘。 2 病历摘要与诊断 主诉: 糖尿病十余年 现病史: 患者十年前因多饮、多食、消瘦, 在 /中医医 院 0 就诊, 当时空腹血糖 15 mm ol/L、尿糖 ( ++ ) , 确诊 /糖尿病 0, 给予 /迪沙 0、 /拜糖平 0 治疗, 空腹血糖控制在 7mm ol/L、餐后血糖控制在 8 mm ol/L左右。两年前空腹血糖 约 9mmol/L、餐后血糖约 10mm ol/L, 在隆福医院就诊, 开始 用胰岛素 (诺和灵 N ) 治疗, 每晚 8U, 1年后血糖控制不良, 胰岛素改为早晨 10U、晚上 6 U, 并用二甲双胍 015 g, 3次 / d, 阿卡波糖 50 m g, 3次 /d, 现空腹血糖 818 mm ol/L、餐后 血糖 17mm ol/L, 自感疲劳、腿软、视力下降, 间断头晕、胸 闷、四肢麻木, 并有口腔溃疡、口腔异味。无尿急、水肿等不 适, 足背痛温感觉良好。现在每日能坚持锻炼, 每日四餐, 每 餐约二两。 既往史: 高血压 3年, 现血压控制平稳。高脂血症 3年, 现血脂偏高, 类风湿关节炎 30年, 因服阿司匹林便血、停药。 查体: BP 130 /80mm H g, 一般状况可, 眼睑无水肿, 口 腔未见溃疡点, 咽不红, 双肺呼吸音清, 未闻及干湿罗音, 心 率 68次 /m in, 律齐, 各瓣膜听诊区未闻及病理性杂音, 腹软 无压痛, 肝、脾未触及, 双下肢无水肿, 浅表淋巴结无肿大。 双侧足部皮温正常, 皮肤无溃破, 双侧足背动脉可触及。神经 系统检查: 生理反射存在, 病理反射未引出。 实验室检查: 肝肾功能正常, 血脂偏高, 尿常规、血常规 正常, 心电图正常, 糖化血红蛋白未查。 3 需要会诊为患者解决的问题: 血糖控制不稳 4 会诊 ( 1) 饮食处方: 六餐法; 少喝粥; 早餐: 主食 1两; 蛋白质 1份; 凉菜; 上午 10B00: 加鸡蛋 1个 中餐: 主食 2两; 蛋白质 1 ~ 115份; 下午 3B00 ~ 4B00: 水果半两, 不吃香蕉、芒果、荔枝 晚餐: 主食 1两; 蛋白质 1份; 睡前: 加半两饼干半杯牛奶 ( 2) 药物处方: 中效胰岛素: 早 8~ 10U, 晚 7U; 选腹部注射 格华止: 早、晚各 250m g; 中餐 500mg 卡博平: 只在中餐加用 胰开 1~ 2片, 3次 /d; 弥可保 1 g, 3次 /d 血脂高加降血脂药物 口腔溃疡加用维生素 B1, 10m g, 3次 / d; 加胡萝卜 请美国家庭医生的会诊问题: 1 假若她在美国, 且是你的病人, 你将对如何管理她目前的糖尿病状况, 理由是什么? 2 你如何监测她的血糖, 如何选择检测空腹血糖、餐后血糖和糖化血红蛋白? 3 就饮食来讲, 对居住在美国的中国糖尿病病人, 你会给出怎样的建议? 美国W iscom sin大学 Jona than L1Tem te教授对病例的分析 此 65岁女性糖尿病病人的病情已进展至需用胰岛素治疗 的程度。这在糖尿病自然病史中极为常见。目前, 她的血糖已 达 818~ 17mm ol/L, 很明显, 需要加强对血糖的控制力度。 1 有关胰岛素的用量问题需要更多的信息 我会选择家庭用血糖议用于监测她的血糖。要获得早餐 前、中餐前、晚餐前及就寝前的相关数据。通常, 我会要求每 周 3~ 4天进行血糖检测, 每天 4次, 回诊所看病前, 要做 2 周这种监测。这样就诊时我会得到 24~ 32个血糖值。根据这 些血糖值, 我会为病人选择短效和长效 ( NPH, 中性鱼精蛋白 #392# 胰岛素 ) 胰岛素联合治疗, 比例为: 70%短效胰岛素和 30% 长效胰岛素。常规, 胰岛素应每日给 2次, 早餐前给剂量的 2 /3, 晚餐前给 1 /3。 2 糖尿病和其他代谢参数的监测 由于血糖呈波动状态, 所以需检测病人的糖化血红蛋白以 观察疗效。我会要求病人继续做好上面提到的 4次家庭监测。 我会给病人做尿微量清蛋白 (和尿微量清蛋白与尿肌酐比值 ) 检测, 用于糖尿病肾病的评估, 若升高, 用某种血管紧张素转 换酶 ( ACE ) 抑制剂做早期干预。密切观察血压的变化至关重 要, 若病人的血压 > 130 /80mm H g, 我会给病人用某种 ACE 抑制剂。密切注意血脂变化, 包括总胆固醇、低密度脂蛋白 ( LDL)、高密度脂蛋白 ( HDL) 和三酰甘油, 若血脂高应开始 用他汀类药物。最后, 应对足感觉缺失、皮肤硬结和出现的溃 疡做出评估, 应每年进行糖尿病视网膜病变检查。 3 提出饮食建议 为了能对饮食结构提出合理的建议, 有必要了解病人目前 的饮食状况。为了能产生好效果, 提高自我意识, 我更喜欢让 病人提供 3 d的饮食日志。就诊期间, 对其饮食、所建议的卡 路里摄入 (和摄入量 ) 目标做简要评诉、对食物的血糖指数 也要做评诉。我会表扬病人能每日做运动锻炼, 并鼓励其坚持 下去。 (中国石油中心医院 周淑新 译 ) 附英文原文: Jonathan L1T em te, MD /PhD; P rofessor of Fam ily M ed icine; Un iversity ofW isconsin; Schoo l ofM ed icine and Public H ealth; Departm ent of Fam ily M ed-i cine; M ad ison, W isconsin c/o poor glucose contro l H istory of p resen ting comp lain t 65 year old d iabeticw om an1 10 years ago presen ted w ith symptom s of polydip sia, cfeel ing hungry all th e t im ec, w e igh t loss1 She attended a Ch inesem ed icine hosp ital and her fas ting glucose was 13mmol/L, urine glucose + + 1Shewas prescribed gl ip iz ide and acarbose tab lets1Fast ing glucose have been con trolled at about 7 mmol/L and postp rand ial g lucose at 8mmol/L1 Two years ago her fast ing g lucose rose to about 9 mmol/L and pos tprand ial glucose o f abou t 10 mmol/L1She attended Long Hua hosp ital ( a d istrict hosp ital o f W estern m ed icine) 1She was in it iated on insu lin (Novol inN 8 un its at n igh t) 1A year later her glucose level becam e unstab le aga in and her insu lin was in- creased to 10 un its in them orn ing and 6 un its at n ight1She was also started on m etform in 015g three t im es a day and acrbose 50mg th ree tim es a day1H er latest fast ing b lood sugarw as 818mmol/L and postprand ial glucose of 17 mmol/L1 She said she feels t ired andcweak in the legsc, d izzy and light headed at t im es and chest d iscom for,t pares thesia in the extrem it ies1She also notedm ou th ulcers and fetor in herm ou th1She den ied any urinary urgency or f lu id retent ion1Has norm alw arm and pain sensation in her feet1Shem anages regu lar daily exercise and has 4 ligh tm eals a day1 Past medical h istory H yperten sion for 3 years and s table on m ed icat ion1 Ra ised choles terol for 3 years and s till raised1 Rheumatoid arthritis for 30 years1W as on asp irin but stopped due to m elena1 On exam ination Look well1N o edem a in the eyel ids and no m ou th u lcers noted1Throat not red1No en larged lymph nodes1 BP 130 /80 mmHg1P 68 /m in regu lar1N orm al heart sounds1No swelling in the low er l imbs1 Lung fields w ere clear1 Abdomen soft1No palpab le liver or sp leen1 Fee:t sk in feels w arm, no u lcers and pa lpab le foot pu lses1 Norm al neu rological reflexes1 Investigation Liver function, renal function, CBC, ECG, urine analys is: norma l B lood l ip ids: ra ised1 HbA 1 c: not tested Quest ions: If she was you r pat ien t in US 11How wou ld you manage her d iabetes now and why? 21How wou ld you mon itor her d iabetes, particu larly the choice of us ing fast ing glucose, postprand ial glucose andHbA1 c? 31How wou ld you give d ietary advice to a diabetic Ch inese patient inUS? Th is 65 year- o ld wom an has p rogressed in her d iabetes to the poin t of hav ing an insul in requ irem en t1Th is is very common in the natural h istory of d iabetes1At th is tim e, g iven that her b lood sugars are 818 to 17 mmol/L, cons ideration is needed to great ly im prove her contro l1 ( 1) Add itional in form ation is needed to ad just in su lin dosing1 I would have th is patien t check her b lood glucose us ing a hom e g lucom eter1Readings should be ob ta ined before b reakfas ,t b efore lunch, before dinner and at bed tim e1 I usually request 3- 4 read ings for each t im e each week and reques t th is be done for tw o weeks before seeing the patient back atm y clin ic1H ence, at the follow- up v is i,t Iw ill have 24- 32 blood glucose read ingsw ith wh ich tom ake decis ions1Based on the read ings, Iw ou ld start the patient on a comb inat ion of short- acting and long- acting insul in in a p roport ion of 70% short- act ing and 30% long- act ing (NPH ) insu lin1The in su lin shou ld be given tw ice a day w ith rough ly 2 /3 of the dose before b reak fast and 1 /3 before dinner1 ( 2) M on itoring of d iabetes and other m etabolic param eters1 Because of the tendency of blood glucose read ings to fluctuate, hem og lob in A1c levels shou ld be obtained to m on itor therapeut ic effect1 I wou ld have the patient cont inue hom emon itoring at the fou r tim es noted above1 Iw ou ld also check for urine m icroalbum in ( andm icroalbum in to urine creat in ine rat io) to assess for d ia- betic nephropathy and in tervene early w ith anACE inh ib itor if elevated1Carefu lm on itoring of BP s is essen tial and Iw ou ld use anACE inh ib itor ifBPs are greater than 130 /801Careful eva luation of the b lood l ip ids, includ ing total cholestero,l LDL, HDL and trig lyceride shou ld be perform ed and stat in therapy shou ld be in itiated for elevat ion s of lip ids1F inal ly, an assessm en t for sensory loss to feet and the presence of calluses and u lcers shou ld be perform ed rou tinely as shou ld an annual diabetic ret ina exam ination1 ( 3) Provid ing d ietary adv ice1 To prov ide sound advice on d ietary changes, it is necessary to understand the patien tcs curren t d iet1T o facil itate th is and provide self- awareness, I lik e to have the pat ien t record a 3- day food d iary1A brief rev iew o f food s, suggested calorie ( and quant ity) goals, and a review of the glycem ic index of foods is then cov- ered during the visit1 I w ou ld also comp lim ent th is pat ien t on her usual daily exercise and encou rage her to con tinue th is1 #393#