低血糖竟误诊为脑血管病 Why?

2017-09-07 曾昭耆 刘凤奎 顾复生 专家临床笔录丛书.内科分册

男60岁,多次出现发作性意识障碍,因发做次数较多,到医院就诊,对于这样的病症医生应如何询问病史?又应如何进行诊断治疗?

男60岁,多次出现发作性意识障碍,因发做次数较多,到医院就诊,对于这样的病症医生应如何询问病史?又应如何进行诊断治疗?

患者,男性,60岁,因2天来发作性意识障碍入院。患者2天来无任何诱因出现发作性意识障碍,共发作3~4次,表现为突然头晕,心悸,继而出现意识不清,昏迷不醒,伴有小便失禁,无抽搐,立即就近医疗,给予输液后很快缓解,缓解后如同常人。本次因半小时前又出现上述症状而来急诊。既往有高血压,脑血管病史多年,但无类似发作史。

查体 浅昏迷状态,体温36.2℃血压160/100mmHg,脉搏100次/分,皮肤略显苍白,发凉,瞳孔等大等圆,光反射存在,心率100次/分,律齐,各瓣膜区未闻杂音,两肺正常,腹平软,肝脾未及,无病理反射。

辅助检查 血红蛋白110g/L,白细胞4.6 ×109/L,血小板180 ×109/L,尿常规正常,胸部X线片正常,心电图显示左室高电压,轻度ST‐T改变,肝肾功能正常,血糖6.9mmol/L,血清总胆固醇7.4mmol/L,血清甘油三酯1.8mmol/L,高密度脂蛋白1.26mmol/L,低密度脂蛋白3.4mmol/L,颅脑CT,显示右侧丘脑可疑少量出血。

诊治经过 入院诊为高血压病、脑出血?而给予输液(葡萄糖盐水)及甘露醇治疗,输液后10分钟患者清醒,清醒后如同常人,由于食欲好,未再继续输液治疗,按一般高血压治疗,后在住院过程中又有两次类似发作,最后一次发作时查血糖为10mg%,而确诊为低血糖昏迷。追问病史,患者有糖尿病史多年,一直服用苯乙双胍(降糖灵),最近加用格列苯脲(优降糖)治疗,在住院过程中,患者一直自服这些药物,后经停用格列苯脲治疗后,继续观察两周,患者未再发生上述问题。

误诊原因及教训

1﹒老年病人,有高血压,脑血管病史,此次因昏迷入院,颅脑CT提示脑出血,故误诊为脑血管病。本病人表现为发作性意识障碍,可以考虑是短暂性脑缺血发作(TI A),但此种疾病常常自然缓解,而病人每次发作时都必须输液才能缓解,这点不符合TI A,也更不像脑出血,CT检查结果必须紧密结合临床才能得出正确的诊断

2﹒TI A是常见的脑血管病,其特征是发作突然、发作短暂、可完全恢复,但可反复发作,CT检查往往有腔隙性脑梗死,可发展至严重的脑血管病,故应给以积极的治疗。

3﹒老年人的糖尿病易合并脑血管病,虽然CT显示脑出血,但输液后很快清醒,此点不符合脑出血的临床过程,脑出血昏迷时间一般较长,应仔细观察临床过程。

4﹒病史采集要细致,要详细询问起病的诱因、症状发展的经过、治疗的经过、既往的病史、家族史等。医生在诊治过程中未问及患者有糖尿病史,这是误诊的主要原因。有糖尿病史者,必须详细了解服药和饮食情况,格列苯脲常引起低血糖反应,必须给予注意,该病人完全是由于服用降糖药引起的低血糖,由头晕发展到昏迷。

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  2. [GetPortalCommentsPageByObjectIdResponse(id=1644590, encodeId=282f164459028, content=<a href='/topic/show?id=e3eb89e17fb' target=_blank style='color:#2F92EE;'>#血管病#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=24, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=89717, encryptionId=e3eb89e17fb, topicName=血管病)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=64bb23195917, createdName=Luyuxie_17, createdTime=Thu Jan 25 09:38:00 CST 2018, time=2018-01-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=242597, encodeId=b2da24259e91, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=57, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/wTPEmeh1VLGa54PRuiaGX8E3QqB8qLLytvK7BYGA0cVIZPeOpOOTEjpIJOVLrGnoBEmWicKw3xojHhkdR2QHW3mg/0, createdBy=65d42140522, createdName=183****1900, createdTime=Sun Sep 10 19:50:27 CST 2017, time=2017-09-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=242139, encodeId=352a24213982, content=好文.值得点赞!认真学习了.把经验应用于实践.为患者解除病痛., beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo7s7ZCKOmmbBTD6nE7gcd5OZpvyGEzkxBP3S275k5ZJVrsPkotZhBglRHM9rKvcj1OgkssqhcnoPw8zIaMZTF8c/0, createdBy=4c441942088, createdName=ylzr123, createdTime=Sat Sep 09 10:25:16 CST 2017, time=2017-09-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=242050, encodeId=013d242050e9, content=糖尿病的急诊观察, beContent=null, objectType=article, channel=null, level=null, likeNumber=57, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/ajNVdqHZLLCclExeQ6LOGMD4dTsia4Ty4HtZCxRmG5vO5XIKfKX3a3vusfhHSej4Iib517vmhFW7RQgh7bpDp1yw/0, createdBy=50951609779, createdName=baihao215, createdTime=Sat Sep 09 07:06:41 CST 2017, time=2017-09-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=241546, encodeId=5c73241546f1, content=今天刚接了个椎基底动脉供血不足的患者.引以为戒., beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTJhib37iaEv5GFHrIJJiaqVySknMXp7Xxz3HXMD4SibafaQBP7M780Eb3MRzC7tIeb9a9kjGDzgakQpicg/0, createdBy=ec642100654, createdName=蒙娜丽, createdTime=Thu Sep 07 22:20:47 CST 2017, time=2017-09-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=241481, encodeId=3252241481aa, content=谢谢.学习一下, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160718/IMG578C993D395567540.jpg, createdBy=59b81918946, createdName=flysky120, createdTime=Thu Sep 07 16:31:26 CST 2017, time=2017-09-07, status=1, ipAttribution=)]
    2017-09-10 183****1900

    学习了

    0

  3. [GetPortalCommentsPageByObjectIdResponse(id=1644590, encodeId=282f164459028, content=<a href='/topic/show?id=e3eb89e17fb' target=_blank style='color:#2F92EE;'>#血管病#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=24, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=89717, encryptionId=e3eb89e17fb, topicName=血管病)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=64bb23195917, createdName=Luyuxie_17, createdTime=Thu Jan 25 09:38:00 CST 2018, time=2018-01-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=242597, encodeId=b2da24259e91, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=57, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/wTPEmeh1VLGa54PRuiaGX8E3QqB8qLLytvK7BYGA0cVIZPeOpOOTEjpIJOVLrGnoBEmWicKw3xojHhkdR2QHW3mg/0, createdBy=65d42140522, createdName=183****1900, createdTime=Sun Sep 10 19:50:27 CST 2017, time=2017-09-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=242139, encodeId=352a24213982, content=好文.值得点赞!认真学习了.把经验应用于实践.为患者解除病痛., beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo7s7ZCKOmmbBTD6nE7gcd5OZpvyGEzkxBP3S275k5ZJVrsPkotZhBglRHM9rKvcj1OgkssqhcnoPw8zIaMZTF8c/0, createdBy=4c441942088, createdName=ylzr123, createdTime=Sat Sep 09 10:25:16 CST 2017, time=2017-09-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=242050, encodeId=013d242050e9, content=糖尿病的急诊观察, beContent=null, objectType=article, channel=null, level=null, likeNumber=57, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/ajNVdqHZLLCclExeQ6LOGMD4dTsia4Ty4HtZCxRmG5vO5XIKfKX3a3vusfhHSej4Iib517vmhFW7RQgh7bpDp1yw/0, createdBy=50951609779, createdName=baihao215, createdTime=Sat Sep 09 07:06:41 CST 2017, time=2017-09-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=241546, encodeId=5c73241546f1, content=今天刚接了个椎基底动脉供血不足的患者.引以为戒., beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTJhib37iaEv5GFHrIJJiaqVySknMXp7Xxz3HXMD4SibafaQBP7M780Eb3MRzC7tIeb9a9kjGDzgakQpicg/0, createdBy=ec642100654, createdName=蒙娜丽, createdTime=Thu Sep 07 22:20:47 CST 2017, time=2017-09-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=241481, encodeId=3252241481aa, content=谢谢.学习一下, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160718/IMG578C993D395567540.jpg, createdBy=59b81918946, createdName=flysky120, createdTime=Thu Sep 07 16:31:26 CST 2017, time=2017-09-07, status=1, ipAttribution=)]
    2017-09-09 ylzr123

    好文.值得点赞!认真学习了.把经验应用于实践.为患者解除病痛.

    0

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    2017-09-09 baihao215

    糖尿病的急诊观察

    0

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    2017-09-07 蒙娜丽

    今天刚接了个椎基底动脉供血不足的患者.引以为戒.

    0

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    2017-09-07 flysky120

    谢谢.学习一下

    0

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