The patient had nausea and vomiting without any precipitating cause. Upon examination, it was because of diabetes...

*Only for medical professionals to read for reference.
If you see nausea and vomiting, will you go to the endocrinology department? If you encounter a patient who complains of nausea and vomiting, you will tell the TA which department to go to for treatment? Gastroenterology? Or spleen and stomach? In fact, in clinical patients who have nausea and vomiting without an inducement, the cause is not so obvious, so you must not miss the following cause! Case Courier Yu, male, 28 years old
.
The main complaint was
"nausea and vomiting for 10 days
.

" He was admitted to the hospital at 18:55:55 on July 26, 2021
.

▌ History of present illness: The patient had nausea, vomiting, and anorexia 10 days ago without obvious inducements, no discomforts such as abdominal pain, bloating, acid reflux, heartburn, etc.
, the amount of food consumed was significantly reduced, and the symptoms continued without improvement
.

For further treatment, he went to the emergency department of our hospital for treatment
.

Randomly measured high blood glucose and low sodium, the emergency department planned to admit "electrolyte imbalance, hyponatremia" to the gastroenterology department of our hospital
.

Since the onset of the onset, the patient has a clear mind, good spirits, reduced diet, good sleep, no abnormalities in urine and bowels, and a weight loss of 10kg
.

▌ Past history: Normally healthy, denying history of diabetes, hypertension, coronary heart disease, tuberculosis, hepatitis, no history of major surgery, trauma, no history of blood transfusion and blood donation, no history of medicine and food allergies, history of vaccination depends on the locality
.

▌ Physical examination: T: 36.
0℃, P: 95 beats/min, R: 18 beats/min, BP: 125/97mmHg Physical examination: clear, good spirit, clear breath sounds in both lungs, no smell and dry or wet Sound, heart rhythm, no pathological murmur in the auscultation area of ​​each heart valve, soft abdomen, no tenderness and rebound pain, normal bowel sounds, no edema in both lower limbs
.

▌ Admission examination: biochemical examination: glucose (GLU) 27.
81mmol/L; aspartate aminotransferase (AST) 53U/L; potassium (K+) 4.
43mmol/L; sodium (Na+) 122.
2mmol/L; chlorine (Cl-) 90.
3mmol /L; Calcium (Ca2+) 2.
5mmol/L; ▌ Preliminary diagnosis: 1.
Vomiting to be investigated; 2.
Hyponatremia; 3.
Diabetes? Nausea, vomiting, why the blood sugar is still high? The patient’s diet is reduced, but the blood sugar is high, which makes the gastroenterologist very confused, shouldn’t there be any problem? So immediately asked whether the patient has a history of diabetes? "No, the blood sugar measured a month ago was normal, and I am still losing weight recently, and I don't even eat much food
.

Could it be related to my frequent consumption of sugary drinks?" The patient immediately replied
.

"Is there any diabetes in my family?" The patient casually replied: "My mother has diabetes
.

" The patient's blood glucose level was high when admitted to the hospital, and it was accompanied by nausea and vomiting.
The gastroenterologist considered whether it was diabetic ketoacid.
Nausea and vomiting caused by poisoning, right? Immediately perform fingertip blood sugar and blood ketone examinations on the patient, and at the same time improve blood gas analysis
.

Fortunately, these results came out very quickly
.

The patient's random blood glucose was 27.
5mol/L, blood ketone body was 4.
9mol/L, blood gas analysis: pH 7.
21, HCO3- 7.
2mol/L, BE 18.
2mol/L, diabetic ketoacidosis did not run away
.

So I immediately called the endocrinologist for an emergency consultation.
The on-duty doctor simply decided, "This is diabetic ketosis, transfer to the department! By the way, the patient is low in sodium, so you didn't make it up.
This is caused by lack of water.
I can’t replenish a large amount of concentrated sodium
.

” After discussing with his family, he was transferred to the endocrinology specialist that night, and the case was followed up.
The patient had type 2 diabetes, diabetic ketoacidosis, and electrolyte imbalance
.

After professional diagnosis and treatment in the Department of Endocrinology, treatment of ketone elimination, hypoglycemia, correction of acidosis, etc.
, the patient improved and was discharged
.

Easy to be misdiagnosed, easy to miss.
.
.
how to break? Due to the rapid onset and rapid progress of diabetic ketoacidosis, but the symptoms are lack of specificity, it is easy to be misdiagnosed or missed
.

If the patient’s random blood glucose and blood ketone body indicators were not tested at the time, and ketoacidosis was treated as a common electrolyte disorder and hyponatremia in the gastroenterology department, the consequences would really be unimaginable
.

 Therefore, we cannot rashly diagnose the patient in clinical practice, but we must find out the cause of each symptom that the patient has, so as to avoid misdiagnosis or missed diagnosis
.

 Doubtful point analysis 1: Why does the patient have nausea and vomiting? Before solving this doubt, let's review the cause of vomiting
.

Vomiting is divided into central vomiting and reflex vomiting
.

Central vomiting refers to the central excitement of vomiting caused by the stimulation of the central nerve chemoreceptor trigger area
.

Reflex vomiting refers to vomiting caused by impulses from peripheral nerves that stimulate the vomiting center
.

The center of vomiting is located in the medulla oblongata and has two functional areas: one is the vomiting center (neural reflex center), which is located on the back of the lateral medulla reticular structure and receives transmission from the digestive tract, cerebral cortex, inner ear vestibule, coronary arteries, and chemoreceptors.
Impulse directly controls the action of vomiting; the second is the chemoreceptor trigger zone, located on the underside of the fourth ventricle of the medulla, which accepts various foreign chemicals or drugs (such as opioids, morphine, digitalis, etc.
) and endogenous metabolites (such as infections).
, Ketosis, uremia, etc.
), which triggers nerve impulse, which is transmitted to the vomiting center and then causes vomiting
.

In this case, we considered that the patient’s nausea and vomiting were due to elevated blood ketones, which caused nerve impulses to be transmitted to the vomiting center
.

Doubtful analysis 2: What is diabetic ketoacidosis? Diabetic ketoacidosis (DKA) is one of the severe metabolic acute complications of diabetes.
It is caused by a lack of insulin in the body but an increase in the counter-regulatory hormones of the insulin, causing sugar, fat and protein metabolism disorders, and high blood sugar and high ketone blood.
The main manifestations of the clinical syndromes are the disease and metabolic acidosis.
The disease is dangerous and the mortality rate is high.
If the diagnosis cannot be timely and effectively diagnosed and the correct and effective treatment and care are not available, the patient’s recovery and prognosis will be affected.
Timely and reasonable treatment can improve the patient.
Quality of life and reduction of fatality rate
.

Clinical manifestations: The symptoms of "three more and one less" aggravated in the early stage.
After the acidosis is decompensated, the condition rapidly deteriorated, including fatigue, nausea, vomiting, loss of appetite, polyuria, dry mouth, headache, lethargy, deep and fast breathing; It is manifested as severe water loss, decreased urine output, sunken eye sockets, dry skin and mucous membranes, decreased blood pressure, increased heart rate, and cold limbs.
In the late stage, there may be varying degrees of consciousness disturbance, slow reflexes, disappearance, and coma
.

Laboratory tests generally showed strong positive urine glucose and positive urine ketones
.

Blood glucose is generally 16.
7-33.
3mol/L, the normal value of blood ketone body is less than 0.
6mol/L, greater than 1.
0mol/L is high blood ketone, and greater than 3.
0mol/L indicates acidosis
.

What should I pay attention to when treating diabetic ketoacidosis? What should I do once I find a patient with diabetic ketoacidosis? What should I pay attention to? The principle of treatment of diabetic ketoacidosis is to replenish fluids as soon as possible to restore blood volume, reduce blood sugar, correct dehydration, electrolyte disturbances and acid-base balance disorders, and actively seek and eliminate incentives, prevent complications, and reduce mortality
.

Rehydration therapy is very important for patients with DKA.
It can not only correct water loss and restore renal perfusion, but also help reduce blood sugar and eliminate ketone bodies
.

Normally, normal saline is supplemented first, and 5% dextrose or dextrose saline is supplemented in the second stage
.

The rehydration rate is fast and then slow.
If there is no heart failure, enter 1000～2000mL within 2 hours
.

After that, the infusion volume and the infusion speed are determined according to the blood pressure, heart rate, urine output per hour and the state of the surrounding circulation
.

In the 3rd to 6th hours, enter 1000～000mL
.

Generally, the total amount of infusion in the first 24h is 4000-6000mL, and severe water loss can reach 6000-8000mL, so patients should be encouraged to drink water at this time
.

During ketoacidosis, short-acting insulin was given continuous intravenous infusion
.

At the beginning, 0.
1U/(kg·h) insulin was added to physiological saline for continuous intravenous infusion.
The blood glucose was 4mmol/L per hour, and the subsequent intravenous infusion rate decreased
.

At the same time, blood glucose is measured every 1 to 2 hours, and the amount of insulin is adjusted according to the decrease in blood glucose
.

When the blood sugar drops to 14mmol/L, transfer to the second stage of treatment
.

After the urinary ketone turns negative, the usual treatment can be resumed
.

Doctors have something to say that patients who encounter nausea and vomiting clinically will usually be admitted to the gastroenterology department or spleen and stomach department for treatment
.

However, diseases are often very cunning, which will bring many difficulties to our clinical diagnosis and treatment
.

As a specialist, we should not only be limited to the study and research of individual specialized diseases, but also strengthen our understanding of other diseases, so that we can make timely and accurate diagnosis after asking the patient’s medical history in detail.
Avoid misdiagnosis and missed diagnosis
.

References: [1] Lu Zaiying, Zhong Nanshan.
Internal Medicine.
Seventh Edition, People's Medical Publishing House, 2010-02.
[2] Chen Jianling, Li Hongwei, Analysis of 8 misdiagnosed cases of diabetic ketoacidosis with acute abdominal pain as the main manifestation.
Chinese Journal of Misdiagnosis, 2010.
10 (27).
6699.