邓红月,张 然,Jonathan L.Temte

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”就诊,当时空腹血糖 15 mmol/L、尿糖 (++),确诊“糖尿病”,给予 “迪沙”、“拜糖平”治疗,空腹血糖控制在7 mmol/L、餐后血糖控制在 8 mmol/L左右。两年前空腹血糖约 9 mmol/L、餐后血糖约 10 mmol/L,在隆福医院就诊,开始用胰岛素 (诺和灵 N)治疗,每晚 8 U,1年后血糖控制不良,胰岛素改为早晨 10 U、晚上 6 U,并用二甲双胍 0.5 g,3次/d,阿卡波糖 50 mg,3次/d,现空腹血糖 8.8 mmol/L、餐后血糖 17 mmol/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 130/80 mm Hg,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/min,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 会诊意见

(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 10∶00:加鸡蛋 1个

中餐:主食 2两;蛋白质 1～1.5份;下午 3∶00～4∶00: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 8～10 U,晚 7 U;选腹部注射

格华止:早、晚各 250 mg;中餐 500 mg

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 B1,10 mg,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 Wiscomsin大学 Jonathan L.Temte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 8.8～17 mmol/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 ＞130/80 mm Hg,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。

附英文原文:

Jonathan L.Temte,MD/PhD;Professor of Family Medicine;University of Wisconsin;School of Medicine and Public Health;Department of Family Medicine;Madison,Wisconsin

c/o poor glucose control

History of presenting complaint

65 year old diabetic woman.

10 years ago presented with symptoms of polydipsia,′feeling hungry all the time′,weight loss.

She attended a Chinese medicine hospital and her fasting glucose was 13 mmol/L,urine glucose++.Shewasprescribed glipizide and acarbose tablets.Fasting glucose have been controlled at about 7 mmol/L and postprandial glucose at 8 mmol/L.

Two years ago her fasting glucose rose to about 9 mmol/L and postprandial glucose of about 10 mmol/L.She attended Long Hua hospital(a district hospital of Western medicine).She was initiated on insulin(Novolin N 8 units at night).A year later her glucose level became unstable again and her insulin was increased to 10units in the morning and 6 units at night.She was also started on metformin 0.5g three times a day and acrbose 50mg three timesa day.Her latest fasting blood sugar was 8.8 mmol/L and postprandial glucose of 17 mmol/L.

She said she feelstired and′weak in the legs′,dizzy and light headed at times and chest discomfort,paresthesia in the extremities.She also noted mouth ulcers and fetor in her mouth.She denied any urinary urgencyor fluid retention.Has normal warmand pain sensation in her feet.She managesregular daily exercise and has 4 light mealsa day.

Past medical history

Hypertension for 3 yearsand stable on medication.

Raised cholesterol for 3 yearsand still raised.

Rheumatoid arthritisfor 30 years.Wason aspirin but stopped due to melena.

On examination

Look well.No edema in the eyelidsand no mouth ulcers noted.Throat not red.No enlarged lymph nodes.

BP 130/80 mmHg.P 68/min regular.Normal heart sounds.No swelling in the lower limbs.

Lung fields were clear.

Abdomen soft.No palpable liver or spleen.

Feet:skin feels warm,no ulcers and palpable foot pulses.

Normal neurological reflexes.

Investigation

Liver function,renal function,CBC,ECG,urine analysis:normal

Blood lipids:raised.

HbA1c:nottested

Questions:

If she was your patient in US

1.How would you manage her diabetesnow and why?

2.How would you monitor her diabetes,particularly the choice of using fasting glucose,postprandial glucose and HbA1c?

3.How would you give dietary advice to a diabetic Chinese patient in US?

This 65 year-old woman has progressed in her diabetes to the point of having an insulin requirement.Thisis very common in the natural history of diabetes.At this time,given that her blood sugars are 8.8 to 17 mmol/L,consideration isneeded to greatly improve her control.

(1)Additional information isneeded to adjust insulin dosing.

I would have thispatient check her blood glucose using a home glucometer.Readings should be obtained before breakfast,before lunch,before dinner and at bedtime.Iusually request 3-4 readingsfor each time each week and request this be done for two weeksbefore seeing the patient back at my clinic.Hence,at the follow-up visit,I will have 24-32 blood glucose readings with which to make decisions.Based on the readings,Iwould start the patient on a combination of short-acting and long-acting insulin in a proportion of 70%short-acting and 30%long-acting(NPH)insulin.The insulin should be given twice a day with roughly 2/3 of the dose before breakfast and 1/3 before dinner.

(2)Monitoring of diabetesand other metabolic parameters.

Because of the tendency of blood glucose readingsto fluctuate,hemoglobin A1c levelsshould be obtained to monitor therapeutic effect.Iwould have the patient continue home monitoring at the four times noted above.Iwould also check for urine microalbumin(and microalbumin to urine creatinine ratio)to assessfor diabetic nephropathy and intervene early with an ACEinhibitorif elevated.Careful monitoringof BPs isessential and Iwould use an ACEinhibitor if BPs aregreater than 130/80.Careful evaluation of the blood lipids,including total cholesterol,LDL,HDL and triglyceride should be performed and statin therapy should be initiated for elevationsof lipids.Finally,an assessment for sensorylossto feet and the presence of calluses and ulcersshould be performed routinely asshould an annual diabetic retina examination.

(3)Providing dietary advice.

To provide sound advice on dietary changes,it is necessary to understand the patient′scurrent diet.Tofacilitate this and provide self-awareness,Ilike to have the patient record a 3-day food diary.A brief review of foods,suggested calorie(and quantity)goals,and a review of the glycemic indexof foods isthen covered during the visit.Iwould also compliment this patienton her usual daily exercise and encourage her to continue this.