鄧紅月,張 然,Jonathan L.Temte

1 基本信息

患者彭某某,女,65歲,健康檔案號 01000032-A,申請會診單位:多福巷站,申請會診醫(yī)生:張然,申請會診科別:內(nèi)分泌,申請時(shí)間:2008-05-08。

會診時(shí)間:2008-05-09,會診專家:內(nèi)分泌專家朱良湘。

2 病歷摘要與診斷

主訴:糖尿病十余年

現(xiàn)病史:患者十年前因多飲、多食、消瘦,在 “中醫(yī)醫(yī)院”就診,當(dāng)時(shí)空腹血糖 15 mmol/L、尿糖 (++),確診“糖尿病”,給予 “迪沙”、“拜糖平”治療,空腹血糖控制在7 mmol/L、餐后血糖控制在 8 mmol/L左右。兩年前空腹血糖約 9 mmol/L、餐后血糖約 10 mmol/L,在隆福醫(yī)院就診,開始用胰島素 (諾和靈 N)治療,每晚 8 U,1年后血糖控制不良,胰島素改為早晨 10 U、晚上 6 U,并用二甲雙胍 0.5 g,3次/d,阿卡波糖 50 mg,3次/d,現(xiàn)空腹血糖 8.8 mmol/L、餐后血糖 17 mmol/L,自感疲勞、腿軟、視力下降,間斷頭暈、胸悶、四肢麻木,并有口腔潰瘍、口腔異味。無尿急、水腫等不適,足背痛溫感覺良好?，F(xiàn)在每日能堅(jiān)持鍛煉,每日四餐,每餐約二兩。

既往史:高血壓 3年,現(xiàn)血壓控制平穩(wěn)。高脂血癥 3年,現(xiàn)血脂偏高,類風(fēng)濕關(guān)節(jié)炎30年,因服阿司匹林便血、停藥。

查體:BP 130/80 mm Hg,一般狀況可,眼瞼無水腫,口腔未見潰瘍點(diǎn),咽不紅,雙肺呼吸音清,未聞及干濕羅音,心率 68次/min,律齊,各瓣膜聽診區(qū)未聞及病理性雜音,腹軟無壓痛,肝、脾未觸及,雙下肢無水腫,淺表淋巴結(jié)無腫大。雙側(cè)足部皮溫正常,皮膚無潰破,雙側(cè)足背動(dòng)脈可觸及。神經(jīng)系統(tǒng)檢查:生理反射存在,病理反射未引出。

實(shí)驗(yàn)室檢查:肝腎功能正常,血脂偏高,尿常規(guī)、血常規(guī)正常,心電圖正常,糖化血紅蛋白未查。

3 需要會診為患者解決的問題:

血糖控制不穩(wěn)

4 會診意見

(1)飲食處方:

六餐法;少喝粥;

早餐:主食 1兩;蛋白質(zhì)1份;涼菜;上午 10∶00:加雞蛋 1個(gè)

中餐:主食 2兩;蛋白質(zhì) 1～1.5份;下午 3∶00～4∶00:水果半兩,不吃香蕉、芒果、荔枝

晚餐:主食1兩;蛋白質(zhì) 1份;睡前:加半兩餅干半杯牛奶

(2)藥物處方:

中效胰島素:早 8～10 U,晚 7 U;選腹部注射

格華止:早、晚各 250 mg;中餐 500 mg

卡博平:只在中餐加用

胰開 1～2片,3次 /d;彌可保 1 g,3次 /d

血脂高加降血脂藥物

口腔潰瘍加用維生素 B1,10 mg,3次/d;加胡蘿卜

請美國家庭醫(yī)生的會診問題:

1 假若她在美國,且是你的病人,你將對如何管理她目前的糖尿病狀況,理由是什么?

2 你如何監(jiān)測她的血糖,如何選擇檢測空腹血糖、餐后血糖和糖化血紅蛋白?

3 就飲食來講,對居住在美國的中國糖尿病病人,你會給出怎樣的建議?

美國 Wiscomsin大學(xué) Jonathan L.Temte教授對病例的分析

此 65歲女性糖尿病病人的病情已進(jìn)展至需用胰島素治療的程度。這在糖尿病自然病史中極為常見。目前,她的血糖已達(dá) 8.8～17 mmol/L,很明顯,需要加強(qiáng)對血糖的控制力度。

1 有關(guān)胰島素的用量問題需要更多的信息

我會選擇家庭用血糖議用于監(jiān)測她的血糖。要獲得早餐前、中餐前、晚餐前及就寢前的相關(guān)數(shù)據(jù)。通常,我會要求每周 3～4天進(jìn)行血糖檢測,每天 4次,回診所看病前,要做 2周這種監(jiān)測。這樣就診時(shí)我會得到 24～32個(gè)血糖值。根據(jù)這些血糖值,我會為病人選擇短效和長效 (NPH,中性魚精蛋白胰島素)胰島素聯(lián)合治療,比例為:70%短效胰島素和 30%長效胰島素。常規(guī),胰島素應(yīng)每日給 2次,早餐前給劑量的2/3,晚餐前給 1/3。

2 糖尿病和其他代謝參數(shù)的監(jiān)測

由于血糖呈波動(dòng)狀態(tài),所以需檢測病人的糖化血紅蛋白以觀察療效。我會要求病人繼續(xù)做好上面提到的 4次家庭監(jiān)測。我會給病人做尿微量清蛋白 (和尿微量清蛋白與尿肌酐比值)檢測,用于糖尿病腎病的評估,若升高,用某種血管緊張素轉(zhuǎn)換酶 (ACE)抑制劑做早期干預(yù)。密切觀察血壓的變化至關(guān)重要,若病人的血壓 ＞130/80 mm Hg,我會給病人用某種 ACE抑制劑。密切注意血脂變化,包括總膽固醇、低密度脂蛋白(LDL)、高密度脂蛋白 (HDL)和三酰甘油,若血脂高應(yīng)開始用他汀類藥物。最后,應(yīng)對足感覺缺失、皮膚硬結(jié)和出現(xiàn)的潰瘍做出評估,應(yīng)每年進(jìn)行糖尿病視網(wǎng)膜病變檢查。

3 提出飲食建議

為了能對飲食結(jié)構(gòu)提出合理的建議,有必要了解病人目前的飲食狀況。為了能產(chǎn)生好效果,提高自我意識,我更喜歡讓病人提供 3 d的飲食日志。就診期間,對其飲食、所建議的卡路里攝入 (和攝入量)目標(biāo)做簡要評訴、對食物的血糖指數(shù)也要做評訴。我會表揚(yáng)病人能每日做運(yùn)動(dòng)鍛煉,并鼓勵(lì)其堅(jiān)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.