Diabetes
Hypotheses
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A 21 year old female, unconscious with cold extremities
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History
Ambulance has brought to
emergency an unconscious 21 y old female. The patient is
diaphoretic and has cold extremities. The patient smells
strongly of alcohol. Ambulance was called to the scene where
the patient has suddenly fell unconscious on the floor of a
bar while dancing. On arrival: blood pressure 110/70;
respiratory rate = 24/min; heart rate (HR) = 100 beats per
minute; T = 36(C. MedAlert bracelet: IDDM (Insulin Dependent
Diabetes Mellitus). Parents arrive and say that her diabetes
mellitus (DM) is usually very stable; the patient is a college
student and has an adequate understanding of her DM and
usually can recognize the forecoming symptoms of hypoglycemia
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Laboratory
findings
On arrival: blood pressure
110/70; respiratory rate = 24/min; heart rate (HR) = 100 beats
per minute; T = 36(C. MedAlert bracelet: IDDM (Insulin
Dependent Diabetes Mellitus). Parents arrive and say that her
diabetes mellitus (DM) is usually very stable; the patient is
a college student and has an adequate understanding of her DM
and usually can recognize the forecoming symptoms of
hypoglycemia
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Diagnosis
Acute hypoglycemia
caused by ethanol ingestion Differentiate the clinical
picture of alcohol intoxication and hypoglycemic crisis
(e.g., cold sweat in hypoglycemia vs. hot one in alcohol
intoxication)
In the fasting state,
ethanol administration does not alter basal insulin
secretion, but may induce hypoglycemia and enhance the
hypoglycemic response to exogenous insulin by inhibition of
gluconeogenesis. Acute ethanol administration may improve
glucose tolerance by enhancing the insulin response to a
glucose load. However, ethanol does not appear to directly
enhance peripheral glucose utilization.
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Intervention
- Discourage the
insulin-treated patient with DM from ingesting ethanol
in the fasting state. If ethanol is to be ingested in DM
patients, it should be done in moderation, along with
the usual meal, and the caloric value included in the
diet. Closer monitoring of blood glucose concentrations
during ethanol ingestion may be the best approach for
early identification and subsequent treatment of
hypoglycemia.
- Patients receiving
sulfonylureas should avoid ethanol intake in excess of
an occasional single drink. Ethanol may prolong, but not
augment, sulfonylureas-induced reductions in blood
glucose. It can delay their absorption and elimination.
Chronic use of ethanol may also decrease the 1/2-life of
sulfonylureas, more specifically tolbutamide. It does so
by decreasing the absorption of the active compound and
inducing a more rapid metabolism by the liver. Patients
receiving sulfonylureas should avoid ethanol intake in
excess of an occasional single drink.
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Development
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What is the likely reason for the patient's state?
- The patient's physical appearance is
inconsistent with his professional occupation. Chronic drug/substance
abuse should be suspected.
- The elevated transaminases suggest impaired liver function.
This is likely to be the result of his chronic alcohol abuse.
- He has well
developed tolerance to ethanol appearing "sober" in spite
of high blood alcohol concentration (BAC).
However, the patient's chief complaint is
acute abdominal pain, which require immediate attention:
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