M/49 Hyperosmolar Hyperglycaemic State

Submitted by Dr TAM Oi Yan on 6 April 2009
Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital
 
hypernatremia and hyperglycemia

A 49 year old man with schizophrenia and type 2 DM was admitted for decreased general condition. He was dull looking and refused to talk according to her mother. He had chills, mild flu-like symptoms and repeated vomiting with decreased oral intake for few days before admission. He had no fever, no abdominal pain. His usual medications included Metformin and Diamicron.

On arrival to AED, he was profoundly dehydrated and emaciated with clouded consciousness. His GCS was E4V4M6. He was running high fever and had tachycardia. Otherwise, his BP was stable. He was neither dyspneic nor in respiratory distress and was saturated in room air. Physical examination of the respiratory system and the abdomen was essentially normal. CXR was clear. Hstix was high and urine was not immediately available for dipstix analysis. The clinical diagnosis was hyperglycemia crisis. He was taken over to ICU for further management.

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M/34 Epigastric pain for 3 Weeks

Submitted by Dr LAU Chun Wing Arthur on 25 Feb 2009; Department of Intensive Care, PYNEH

M/34, social smoker + drinker; PHX: Diabetes mellitus, initially on insulin, later switched to oral hypoglycemic agents. Defaulted FU, on over-the-counter diabetic medications

Admitted to another hosptial for epigastric pain for 3 weeks, transferred to us for further care. We regarded that plasmapheresis was necessary for the treatment. 

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Plasma of patient obtained by the centrifugation method of plasmapheresis

 

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Plasma of another similar patient by the plasma filtration method of plasmapheresis

 

What is their common diagnosis?

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M/75 Skin abscess and persistent fever

Submitted by Dr LAU Chun Wing Arthur on 12 December 2008

Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital

 

History of Present Illness

A 75-year old man who was said to be of good past health presented with right lower limb skin abscess. After drainage, he still had persistent fever. CXR showed bilateral infiltrates. The patient was confused and septic looking despite treatment with tazocin. His skin condition was poor, upper limbs and lower limbs had similar lesions as shown in the figures.

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What is the underlying cause of the patient's presentation?

 

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F/22 A diabetic lady who missed insulin for fear of hair loss

Submitted by Dr LAU Chun Wing Arthur on 12 December 2008

Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital

 

History of Present Illness

A 22-year-old lady, non-smoker, social drinker

Type I DM diagnosed for one year, started on metformin and insulin

claimed to be using insulin regularly, but recently stopped because of hair loss which she attributed to the insulin, also patient defaulted FU and went to see herbalist

c/o presented this time with vomiting and colicky abd pain
noticed high H'stix with urine ketones ++++. RG 40+
therefore transferred to ICU for close monitoring of DKA

patient alert and stable
clinically dehydrated. not septic looking.
initially patient was soft
serum amylase 710 with upper abd tenderness
LFT normal
pulse 130, u/o good
no peritoneal sign
Investigations:
CXR no free gas
AXR: no dilated bowel
ABG: metabolic acidosis
LRFT normal
amylase710

Impression: no peritoneal sign at this moment, abdominal pain can be caused by DKA +/- acute pancreatitis
Ranson's score 2 (WCC and glu)
What else will you check?

CT abdomen confirmed acute pancreatitis
Triglyceride level was checked, level >19
in view of acute pancreatitis and hyperTG, plasmapheresis was performed
Estimated body weight ~ 55-60kg
Plasmapheresis 2400ml (~40ml/kg) by plasmafiltration method over 4hrs was done
Appearance of the plasmafiltrate is shown in the figure 

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Figure. Millky looking plasmafiltrate

TG was reduced to 5 after just one session of plasmafiltration.

Patient remained stable on discharge from ICU.