Unexpectedly, it is impossible to make a clear diagnosis, but the doctor did not do this!

For an unknown diagnosis , in order to be clear, the first thing to do is to do the following elements:

Medical history, physical examination and auxiliary examinations

And it is indispensable

Don't worry, take your time

Introduction

Chief Complaint: Change of mind for half a day

History of present illness: The patient was due to a change in consciousness without obvious incentive half a day ago

Past history: a history of hypertension , systolic blood pressure up to 180mmHg many times, long-term drug treatment, specific unknown, no regular blood pressure monitoring

Family History: No family history of diabetes or related hypoglycemic disorders

The above medical history was described by the family members, and the patient's two grandchildren were accompanied by the patient when he was admitted to the hospital

Physical examination:

Body temperature: 36.

Seeing this, everyone must have guessed that this patient should be due to a change in consciousness caused by hypoglycemia

Auxiliary examination

▲Relevant laboratory tests

▲Main imaging findings

Except for the above-mentioned positive results, the rest of the tests were all negative, which will not be listed here for the time being

For the above-mentioned relevant laboratory test results, the main diagnosis is clear: hypoglycemia

▲ Blood glucose monitoring value (unit: mmol/L)

(Considering that there are many monitoring times and the table is difficult to make, here is temporarily

4 The above part of the blood sugar display)

After admission, the blood sugar basically fluctuated between 1.

Long-term hypoglycemia is particularly damaging to the nervous system of the body, and at the same time, it will also cause varying degrees of damage to the heart and other vital organs of the human body

▲Hypoglycemia treatment process (from literature)

When severe hypoglycemia occurs, the hypoglycemia cannot be corrected even after the use of hypertonic glucose and after eating, and glucocorticoid therapy should be initiated in time to use the powerful properties of hormones to antagonize insulin and increase blood sugar

Under the above treatment, the patient's blood sugar has been significantly improved

Since the patient's family insists on denying that the patient has no history of diabetes, in the search for the cause, priority should be given to the non-diabetic hypoglycemia, including fasting and postprandial hypoglycemia

fasting hypoglycemia

(1) Islet β-cell tumor (benign, malignant and hyperplastic);

(2) Decreased secretion of hormones that antagonize insulin (hypopituitarism, decreased secretion of catecholamines or glucagon);

(3) Decreased hepatic glucose output (various severe liver damage);

(4) Extrapancreatic malignant tumor;

(5) Immune diseases of insulin or insulin receptor autoantibodies ;

(6) hypoglycemic drugs: insulin or sulfonylurea drugs;

(7) severe malnutrition;

(8) Other drugs: propranolol, salicylic acid,
etc.

Point 6 was preferentially excluded due to no history of diabetes
.
Compared with the above-mentioned relevant examination results, the patient did not have any abnormal conditions such as malignant tumor, β-cell hyperplasia, severe liver damage, and severe malnutrition, which was basically excluded
.

Autoimmune insulin receptor disease (AIR), also known as type B insulin resistance (TBIR), is a rare disease caused by insulin receptor autoantibodies (IRAs).
Immune diseases, etc.
, a small number of patients will have hypoglycemia, and lupus is more common among many comorbidities
.
However, in the above physical examination, no signs similar or consistent with the disease were found, and because it was a rare disease, it was directly excluded
.

In the last drug use, the patient's family denied the use of this type of drug, and the drug factor was not considered for the time being
.
The second point is that due to the special examination, the patient has drowsiness at present, which is temporarily considered as a factor
.

Postprandial hypoglycemia:

(1) Functional hypoglycemia;

(2) Nourishing hypoglycemia (after gastrectomy and gastrojejunostomy);

(3) Early diabetic reactive hypoglycemia;

(4) Alcoholic hypoglycemia;

(5) Hereditary fructose intolerance;

(6) Idiopathic hypoglycemia
.

In fact, compared with fasting blood sugar, postprandial hypoglycemia is more likely to occur in real life, and it is also some factors that we need to consider this time
.
Among them, (2) and (4) are external human factors, which will basically not be considered after the family members deny it
.
In life, hereditary fructose intolerance is relatively rare.
After all, the most common diseases are considered first, so the disease is temporarily put aside, and the other three reasons are focused on
.

It is said that "sickness is easy to cure and difficult to cure", but just looking for the cause of low blood sugar makes me devastated
.
It made me frown all day
.
The patient's consciousness is not very good, and we can only continue to maintain blood sugar stability with the above-mentioned treatment methods
.

Although the family members of the patient are also very anxious at this moment, fortunately, all the vital signs of the patient are stable
.

I was caught off guard by the turning point

The next day, the patient woke up
.

Moreover, he can clearly recognize his two grandchildren, and he also knows that he is in the hospital, and his response is relatively quick and relevant
.

Knowing this, I jumped up in excitement and rushed to the bedside to see the patient.
I still had to ask the patient about some things
.

to the bed
.

The patient stared at me with wide eyes and said with a smile, "The doctor is here"
.

I nodded
.

I asked a question directly, which is also the most crucial sentence to solve the puzzle: "Old man, did a doctor tell you that you have diabetes before?"

The old man said unequivocally: "Yes, at the clinic in the countryside, the doctor told me that my blood sugar was high and gave me some medicine
.
"

My family and I were shocked!

And this is also a very important part of uncovering the cause, and it will even directly overturn all previous speculations
.

It's just that the patient can't remember what medicine he was taking, so he can only ask his family to go back and look for it
.

After a long wait, we finally got what the patient said about the medicine
.

Glipizide tablets!

Why is glipizide easy to cause hypoglycemia?

All types of hypoglycemic drugs currently on the market are as follows:

▲Classification of hypoglycemic drugs

The drugs that are likely to cause hypoglycemia in diabetic patients are mainly:

▲ Common types of drugs that are prone to hypoglycemia

Glipizide is a second-generation sulfonylurea hypoglycemic agent with lipid-lowering and anticoagulant effects
.
Its hypoglycemic effect is rapid and strong, and its mechanism of action is to stimulate the beta cells of the pancreatic islets to increase the secretion of insulin, and at the same time, it also stimulates the islet alpha cells to inhibit the secretion of hyperglycemia
.
It is not difficult to explain why the C-peptide value of the above-mentioned patients is so high
.

Combined with the effect of its drug half-life, 97% of the drug can be excreted within 24h, and it can be completely eliminated within 3 days (72h)
.
Therefore, some patients can effectively control blood sugar up to 24h by taking a single dose
.

All sulfonylurea hypoglycemic agents can cause severe hypoglycemia
.
Elderly, frail and malnourished patients, as well as patients with adrenal or pituitary insufficiency are all susceptible to hypoglycemic response to hypoglycemic drugs
.

In the follow-up treatment, after the half-life of the drug was exhausted, the patient's blood sugar basically returned to normal, and no hypoglycemic cerebral changes were found in the re-examination of the cranial MRI
.

After the patient is discharged from the hospital, whether the follow-up diagnosis of diabetes is made, it is recommended that the patient can go to the outpatient clinic for OGTT test to confirm the diagnosis after the patient's condition is stable
.

The collection of medical history is a very important link.
In many cases, the medical history provided by family members is very different from that provided by the patient himself
.
In clinical practice, it is necessary to make a clear screening in the collection of medical history
.
Even if the patient denies, at some point, we should question the validity of the denial, and perhaps uncover the truth behind the disease
.

References and information:

Diabetes Society of Chinese Medical Association.
Guidelines for Prevention and Treatment of Type 2 Diabetes in China (2020 Edition) [J].
Chinese Journal of Diabetes, 2021, 13(4): 315-409.
DOI: 10.
3760/cma.
j.
cn115791-20210221-00095.

Be alert to the danger of hypoglycemia, Community Health Service Center, Zhenjiang Road Street, Shibei District, Qingdao, doi: 10.
3969/j.
issn.
1007-614x.
2018.
20.
001

Glipizide Instructions

Professor Xu Jing - Diagnosis and Treatment of Hypoglycemia

For an unknown diagnosis , in order to be clear, the first thing to do is to do the following elements:

diagnosis

Medical history, physical examination and auxiliary examinations

Medical history, physical examination and auxiliary examinations

And it is indispensable
.
It is said that seeing, hearing, asking, and hearing in Chinese medicine is as important as sight, touch, percussion and hearing in Western medicine, and even runs through the entire diagnosis and treatment
.
But if we have done all the above three elements, but still can't find the root cause, what is the reason?

Don't worry, take your time
.

Introduction

Introduction

Chief Complaint: Change of mind for half a day
.

History of present illness: The patient was due to a change in consciousness without obvious incentive half a day ago
.
During the onset of the disease, he was found at home by his family and was urgently sent to the emergency department of our hospital for treatment.
The emergency blood glucose monitoring showed 2.
2 mmol/L, and after bolus injection of 50% glucose injection, he was admitted to our department for " hypoglycemia "
.

Hypoglycemia

Past history: a history of hypertension , systolic blood pressure up to 180mmHg many times, long-term drug treatment, specific unknown, no regular blood pressure monitoring
.
He denied any history of chronic diseases such as diabetes and coronary heart disease
.

high blood pressure diabetes

Family History: No family history of diabetes or related hypoglycemic disorders
.

The above medical history was described by the family members, and the patient's two grandchildren were accompanied by the patient when he was admitted to the hospital
.

Physical examination:

Body temperature: 36.
8°C Pulse: 120 beats/min Breathing: 21 beats/min Blood pressure: 151/74mmHg
.
Cardiopulmonary examination showed no obvious abnormality
.
The abdominal examination was unable to cooperate, and the remaining examinations were unable to cooperate
.

Seeing this, everyone must have guessed that this patient should be due to a change in consciousness caused by hypoglycemia
.

Auxiliary examination

Auxiliary examination

▲Relevant laboratory tests

▲Main imaging findings

Except for the above-mentioned positive results, the rest of the tests were all negative, which will not be listed here for the time being
.

For the above-mentioned relevant laboratory test results, the main diagnosis is clear: hypoglycemia
.
Other diagnoses are not listed
.
A normal person is defined as hypoglycemia when it is less than 2.
9mmol/L
.
The results of dynamic monitoring of blood glucose after admission are as follows:

▲ Blood glucose monitoring value (unit: mmol/L)

(Considering that there are many monitoring times and the table is difficult to make, here is temporarily

4 The above part of the blood sugar display)

After admission, the blood sugar basically fluctuated between 1.
3-7.
0 mmol/L, and it was maintained by a hypertonic glucose pump, but the patient continued to suffer from hypoglycemia, and the patient's consciousness changed and he could not eat
.
Despite the indwelling gastric tube and the injection of food, the blood sugar was still difficult to rise
.

Long-term hypoglycemia is particularly damaging to the nervous system of the body, and at the same time, it will also cause varying degrees of damage to the heart and other vital organs of the human body
.
Glucose is the main source of energy for the brain.
When glucose is deficient, it will lead to brain dysfunction.
Long-term hypoglycemia can lead to irreversible damage and death of nerve cells
.

▲Hypoglycemia treatment process (from literature)

When severe hypoglycemia occurs, the hypoglycemia cannot be corrected even after the use of hypertonic glucose and after eating, and glucocorticoid therapy should be initiated in time to use the powerful properties of hormones to antagonize insulin and increase blood sugar
.

Under the above treatment, the patient's blood sugar has been significantly improved
.
But this is only a temporary treatment, not a long-term solution, the key is to clarify: what is the cause of hypoglycemia, and why the patient's blood sugar has not been able to rise
.

Since the patient's family insists on denying that the patient has no history of diabetes, in the search for the cause, priority should be given to the non-diabetic hypoglycemia, including fasting and postprandial hypoglycemia
.

fasting hypoglycemia

fasting hypoglycemia

(1) Islet β-cell tumor (benign, malignant and hyperplastic);

(2) Decreased secretion of hormones that antagonize insulin (hypopituitarism, decreased secretion of catecholamines or glucagon);

(3) Decreased hepatic glucose output (various severe liver damage);

(4) Extrapancreatic malignant tumor;

(5) Immune diseases of insulin or insulin receptor autoantibodies ;

immunity

(6) hypoglycemic drugs: insulin or sulfonylurea drugs;

(7) severe malnutrition;

(8) Other drugs: propranolol, salicylic acid,
etc.

Point 6 was preferentially excluded due to no history of diabetes
.
Compared with the above-mentioned relevant examination results, the patient did not have any abnormal conditions such as malignant tumor, β-cell hyperplasia, severe liver damage, and severe malnutrition, which was basically excluded
.

Autoimmune insulin receptor disease (AIR), also known as type B insulin resistance (TBIR), is a rare disease caused by insulin receptor autoantibodies (IRAs).
Immune diseases, etc.
, a small number of patients will have hypoglycemia, and lupus is more common among many comorbidities
.
However, in the above physical examination, no signs similar or consistent with the disease were found, and because it was a rare disease, it was directly excluded
.

In the last drug use, the patient's family denied the use of this type of drug, and the drug factor was not considered for the time being
.
The second point is that due to the special examination, the patient has drowsiness at present, which is temporarily considered as a factor
.

Postprandial hypoglycemia:

Postprandial hypoglycemia:

(1) Functional hypoglycemia;

(2) Nourishing hypoglycemia (after gastrectomy and gastrojejunostomy);

(3) Early diabetic reactive hypoglycemia;

(4) Alcoholic hypoglycemia;

(5) Hereditary fructose intolerance;

(6) Idiopathic hypoglycemia
.

In fact, compared with fasting blood sugar, postprandial hypoglycemia is more likely to occur in real life, and it is also some factors that we need to consider this time
.
Among them, (2) and (4) are external human factors, which will basically not be considered after the family members deny it
.
In life, hereditary fructose intolerance is relatively rare.
After all, the most common diseases are considered first, so the disease is temporarily put aside, and the other three reasons are focused on
.

It is said that "sickness is easy to cure and difficult to cure", but just looking for the cause of low blood sugar makes me devastated
.
It made me frown all day
.
The patient's consciousness is not very good, and we can only continue to maintain blood sugar stability with the above-mentioned treatment methods
.

Although the family members of the patient are also very anxious at this moment, fortunately, all the vital signs of the patient are stable
.

I was caught off guard by the turning point

I was caught off guard by the turning point

The next day, the patient woke up
.

Moreover, he can clearly recognize his two grandchildren, and he also knows that he is in the hospital, and his response is relatively quick and relevant
.

Knowing this, I jumped up in excitement and rushed to the bedside to see the patient.
I still had to ask the patient about some things
.

to the bed
.

The patient stared at me with wide eyes and said with a smile, "The doctor is here"
.

I nodded
.

I asked a question directly, which is also the most crucial sentence to solve the puzzle: "Old man, did a doctor tell you that you have diabetes before?"

The old man said unequivocally: "Yes, at the clinic in the countryside, the doctor told me that my blood sugar was high and gave me some medicine
.
"

My family and I were shocked!

And this is also a very important part of uncovering the cause, and it will even directly overturn all previous speculations
.

It's just that the patient can't remember what medicine he was taking, so he can only ask his family to go back and look for it
.

After a long wait, we finally got what the patient said about the medicine
.

Glipizide tablets!

Why is glipizide easy to cause hypoglycemia?

All types of hypoglycemic drugs currently on the market are as follows:

▲Classification of hypoglycemic drugs

The drugs that are likely to cause hypoglycemia in diabetic patients are mainly:

▲ Common types of drugs that are prone to hypoglycemia

Glipizide is a second-generation sulfonylurea hypoglycemic agent with lipid-lowering and anticoagulant effects
.
Its hypoglycemic effect is rapid and strong, and its mechanism of action is to stimulate the beta cells of the pancreatic islets to increase the secretion of insulin, and at the same time, it also stimulates the islet alpha cells to inhibit the secretion of hyperglycemia
.
It is not difficult to explain why the C-peptide value of the above-mentioned patients is so high
.

Combined with the effect of its drug half-life, 97% of the drug can be excreted within 24h, and it can be completely eliminated within 3 days (72h)
.
Therefore, some patients can effectively control blood sugar up to 24h by taking a single dose
.

All sulfonylurea hypoglycemic agents can cause severe hypoglycemia
.
Elderly, frail and malnourished patients, as well as patients with adrenal or pituitary insufficiency are all susceptible to hypoglycemic response to hypoglycemic drugs
.

In the follow-up treatment, after the half-life of the drug was exhausted, the patient's blood sugar basically returned to normal, and no hypoglycemic cerebral changes were found in the re-examination of the cranial MRI
.

After the patient is discharged from the hospital, whether the follow-up diagnosis of diabetes is made, it is recommended that the patient can go to the outpatient clinic for OGTT test to confirm the diagnosis after the patient's condition is stable
.

The collection of medical history is a very important link.
In many cases, the medical history provided by family members is very different from that provided by the patient himself
.
In clinical practice, it is necessary to make a clear screening in the collection of medical history
.
Even if the patient denies, at some point, we should question the validity of the denial, and perhaps uncover the truth behind the disease
.

References and information:

References and information:

Diabetes Society of Chinese Medical Association.
Guidelines for Prevention and Treatment of Type 2 Diabetes in China (2020 Edition) [J].
Chinese Journal of Diabetes, 2021, 13(4): 315-409.
DOI: 10.
3760/cma.
j.
cn115791-20210221-00095.

Diabetes Society of Chinese Medical Association.
Guidelines for the Prevention and Treatment of Type 2 Diabetes in China (2020 Edition) [J].
Chinese Journal of Diabetes, 2021, 13(4): 315-409.
DOI: 10.
3760/cma.
j.
cn115791-20210221-00095.
guide

Be alert to the danger of hypoglycemia, Community Health Service Center, Zhenjiang Road Street, Shibei District, Qingdao, doi: 10.
3969/j.
issn.
1007-614x.
2018.
20.
001

Be alert to the danger of hypoglycemia, Community Health Service Center, Zhenjiang Road Street, Shibei District, Qingdao, doi: 10.
3969/j.
issn.
1007-614x.
2018.
20.
001

Glipizide Instructions

Glipizide Instructions

Professor Xu Jing - Diagnosis and Treatment of Hypoglycemia

Professor Xu Jing - Diagnosis and treatment of hypoglycemia Leave a

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