病史和体格检查
患者通常会有多尿、多饮、多食、无力和体重减轻的表现。[7]Umpierrez GE, Smiley DD. Complications. In: Fonseca V, ed. Clinical diabetes. Philadelphia, PA: Elsevier; 2006:101-8. 入院时,患者常有意识状态改变,[2]Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009 Jul;32(7):1335-43.
http://care.diabetesjournals.org/content/32/7/1335.long
http://www.ncbi.nlm.nih.gov/pubmed/19564476?tool=bestpractice.com
并且与高血糖严重程度和血清渗透压相关。昏迷是 HHS 非常罕见的症状。一般情况下,昏迷与血清渗透压>330-340 mmol/kg (>330-340 mOsm/kg) 相关,并且性质上最常为高血钠性昏迷,而非高血糖性昏迷。
在患者既往病史或现病史中,需要注意的重要因素包括:改变或者遗漏胰岛素治疗、近期感染以及近期或者既往发生了 MI 或卒中,因为这些可能是 HHS 的触发因素或者危险因素。[1]Kitabchi AE, Umpierrez GE, Murphy MB, et al. Management of hyperglycemic crises in patients with diabetes. Diabetes Care. 2001 Jan;24(1):131-53.
https://care.diabetesjournals.org/content/24/1/131.long
http://www.ncbi.nlm.nih.gov/pubmed/11194218?tool=bestpractice.com
[15]Kitabchi AE, Umpierrez GE, Murphy MB, et al. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. 2006 Dec;29(12):2739-48.
http://care.diabetesjournals.org/content/29/12/2739.long
http://www.ncbi.nlm.nih.gov/pubmed/17130218?tool=bestpractice.com
查看完整的药物史十分重要,尤其是检查近期皮质类固醇、戊烷脒、去羟肌苷、拟交感神经药或者噻嗪类利尿剂,或者二代(非典型)抗精神病药的使用记录,因为这些能影响碳水化合物代谢并且可能促进高血糖危象的发展。[1]Kitabchi AE, Umpierrez GE, Murphy MB, et al. Management of hyperglycemic crises in patients with diabetes. Diabetes Care. 2001 Jan;24(1):131-53.
https://care.diabetesjournals.org/content/24/1/131.long
http://www.ncbi.nlm.nih.gov/pubmed/11194218?tool=bestpractice.com
[7]Umpierrez GE, Smiley DD. Complications. In: Fonseca V, ed. Clinical diabetes. Philadelphia, PA: Elsevier; 2006:101-8.[15]Kitabchi AE, Umpierrez GE, Murphy MB, et al. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. 2006 Dec;29(12):2739-48.
http://care.diabetesjournals.org/content/29/12/2739.long
http://www.ncbi.nlm.nih.gov/pubmed/17130218?tool=bestpractice.com
血容量缺失的体征包括粘膜干燥、皮肤弹性差、心动过速、低血压,严重时出现休克。在老年患者中,皮肤不够充盈可能难以评估血容量缺失。对这些患者颊粘膜干燥程度评估可获取更多信息。[2]Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009 Jul;32(7):1335-43.
http://care.diabetesjournals.org/content/32/7/1335.long
http://www.ncbi.nlm.nih.gov/pubmed/19564476?tool=bestpractice.com
[8]Trence DL, Hirsch IB. Hyperglycemic crises in diabetes mellitus type 2. Endocrinol Metab Clin North Am. 2001 Dec;30(4):817-31.
http://www.ncbi.nlm.nih.gov/pubmed/11727401?tool=bestpractice.com
因为外周血管舒张,某些患者可能会有轻微的体温过低。[1]Kitabchi AE, Umpierrez GE, Murphy MB, et al. Management of hyperglycemic crises in patients with diabetes. Diabetes Care. 2001 Jan;24(1):131-53.
https://care.diabetesjournals.org/content/24/1/131.long
http://www.ncbi.nlm.nih.gov/pubmed/11194218?tool=bestpractice.com
[2]Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009 Jul;32(7):1335-43.
http://care.diabetesjournals.org/content/32/7/1335.long
http://www.ncbi.nlm.nih.gov/pubmed/19564476?tool=bestpractice.com
[8]Trence DL, Hirsch IB. Hyperglycemic crises in diabetes mellitus type 2. Endocrinol Metab Clin North Am. 2001 Dec;30(4):817-31.
http://www.ncbi.nlm.nih.gov/pubmed/11727401?tool=bestpractice.com
严重的体温过低往往提示预后不良。[1]Kitabchi AE, Umpierrez GE, Murphy MB, et al. Management of hyperglycemic crises in patients with diabetes. Diabetes Care. 2001 Jan;24(1):131-53.
https://care.diabetesjournals.org/content/24/1/131.long
http://www.ncbi.nlm.nih.gov/pubmed/11194218?tool=bestpractice.com
[2]Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009 Jul;32(7):1335-43.
http://care.diabetesjournals.org/content/32/7/1335.long
http://www.ncbi.nlm.nih.gov/pubmed/19564476?tool=bestpractice.com
[8]Trence DL, Hirsch IB. Hyperglycemic crises in diabetes mellitus type 2. Endocrinol Metab Clin North Am. 2001 Dec;30(4):817-31.
http://www.ncbi.nlm.nih.gov/pubmed/11727401?tool=bestpractice.com
[15]Kitabchi AE, Umpierrez GE, Murphy MB, et al. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. 2006 Dec;29(12):2739-48.
http://care.diabetesjournals.org/content/29/12/2739.long
http://www.ncbi.nlm.nih.gov/pubmed/17130218?tool=bestpractice.com
腹痛在 HHS 中不常见,但在糖尿病酮症酸中毒 (DKA) 中频率较高 (>50%)。[2]Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009 Jul;32(7):1335-43.
http://care.diabetesjournals.org/content/32/7/1335.long
http://www.ncbi.nlm.nih.gov/pubmed/19564476?tool=bestpractice.com
[7]Umpierrez GE, Smiley DD. Complications. In: Fonseca V, ed. Clinical diabetes. Philadelphia, PA: Elsevier; 2006:101-8. 因此,对于高血糖急症患者,如果存在无法解释的腹痛,医生应该考虑 DKA 而不是 HHS 的诊断。[7]Umpierrez GE, Smiley DD. Complications. In: Fonseca V, ed. Clinical diabetes. Philadelphia, PA: Elsevier; 2006:101-8. HHS 患者偶尔可能表现出局灶性神经系统体征(偏盲和轻偏瘫)和癫痫发作(局灶性或全身性)。[2]Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009 Jul;32(7):1335-43.
http://care.diabetesjournals.org/content/32/7/1335.long
http://www.ncbi.nlm.nih.gov/pubmed/19564476?tool=bestpractice.com
[7]Umpierrez GE, Smiley DD. Complications. In: Fonseca V, ed. Clinical diabetes. Philadelphia, PA: Elsevier; 2006:101-8.[8]Trence DL, Hirsch IB. Hyperglycemic crises in diabetes mellitus type 2. Endocrinol Metab Clin North Am. 2001 Dec;30(4):817-31.
http://www.ncbi.nlm.nih.gov/pubmed/11727401?tool=bestpractice.com
这种表现经常被误以为是急性卒中。然而,通过液体和胰岛素治疗纠正高血糖,可以快速消除 HHS 患者的这些体征。[7]Umpierrez GE, Smiley DD. Complications. In: Fonseca V, ed. Clinical diabetes. Philadelphia, PA: Elsevier; 2006:101-8.[8]Trence DL, Hirsch IB. Hyperglycemic crises in diabetes mellitus type 2. Endocrinol Metab Clin North Am. 2001 Dec;30(4):817-31.
http://www.ncbi.nlm.nih.gov/pubmed/11727401?tool=bestpractice.com
在 HHS 的早期阶段,持续性不全癫痫发作是癫痫发作的一种不常见形式,仅发生在 6% 的 HHS 患者中。[40]Harden CL, Rosenbaum DH, Daras M. Hyperglycemia presenting with occipital seizures. Epilepsia. 1991 Mar-Apr;32(2):215-20.
http://www.ncbi.nlm.nih.gov/pubmed/2004625?tool=bestpractice.com
与 HHS 中高血糖相关的癫痫发作通常耐抗癫痫治疗,且苯妥英可能会进一步加剧 HHS。[8]Trence DL, Hirsch IB. Hyperglycemic crises in diabetes mellitus type 2. Endocrinol Metab Clin North Am. 2001 Dec;30(4):817-31.
http://www.ncbi.nlm.nih.gov/pubmed/11727401?tool=bestpractice.com