(step2CK)DM 환자가 dehydration 에 의식소실? 운영자 / 2005-09-16 11:41:19
Nonketotic hyperosmolar coma
A 71-year-old Hispanic man from Honduras, with no known previous medical problems, was found unconscious by his friends.Although not responsive to verbal stimuli, he did respond to vigorous physical stimuli by eye opening and movement of extremities. There were no signs of physical trauma or evidence of possible toxic ingestion by the patient. He apparently had complained of a sore throat for one day. He was transported to the emergency room via emergency medical services. He had not seen a physician since his move to the United States two years earlier. The patient’s friends denied any history of medication use, past operations, or allergies. They stated that he did not smoke, drink alcohol, or use any illicit drugs.
Upon initial examination in the emergency room, the patient had spontaneous eye opening but did not answer questions or follow commands. His axillary temperature was 102.8° F, pulse 128/minute, respirations 60/minute, blood pressure 190/124mmHg, and oxygen saturation 100% on 100% oxygen by non-rebreather face mask. His pupils were equal and responsive to light, and extraocular movements were intact. His tonsils were edematous and pharynx erythematous but without an appreciable posterior oropharyngeal exudate. The patient was tachypneic but did not have any abnormal lung findings. His skin showed poor turgor.
Initial laboratory results revealed a significantly elevated blood glucose of 1,602 mg/dL with a blood urea nitrogen (BUN) of 116 mg/dL and a creatinine (Cr) of 5.9 mg/dL He had an increased anion gap of 28 with a decreased bicarbonate level of 19 mEq/L . His serum phosphorus was elevated at 6.1mg/dL (normal range 2.6-4.5 mg/dL) with a magnesium of 3.4 mg/dL (normal range 1.6-2.3 mg/dL). A complete blood count (CBC) yielded a white blood cell count of 19.9 normal hemoglobin and platelet count. Which is the most probable diagnosis?
Important features
Fever (low grade) ,Severe dehydration ,Decreased Level of Consciousness
Blood Glucose 600-2000 mg/dl
Serum Osmolarity >320 mOsm
BUN markedly elevated (70-90 mg/dl)
Treatment
Fluid
Normal saline 1 Liter/hour(Innitial)
Hypernatremia: 1/2NS(later)
300mOsm 이하일경우 5%d
Add 5% Dextrose to fluids when glucose < 300 mg/dl
Keep Serum Potassium >4.0 and <5.0
Insulin
Hold Insulin until Serum Potassium >3.3
Give IV bolus of 0.15 units/kg
Start 0.1 units/kg/hour Insulin Drip
