病 案
TCM Case:Xiāo kě syndrome
Mr Zhang，53 years old.
Main Complaint:Thirst with excessive drinking and eating，profuse urine and weakness for over 3 years.
Mecical History:The patient experienced severe thirst that could not be quenched by excessive drinking for 2 months，urgent hunger，frequent and profuse urination and weakness.His symtoms were slightly relieved by taking some Chinese medicinals.The patient took blood pressure medication for over 8 years.Three days ago，he drank a large amount of fluid which aggravated his symptoms.He had no history of externally-contracted febrile disease，diarrhea，vomiting and other internal disease.
Presenting Symtoms:Severe thirst，excessive drinking，dry mouth，profuse urine，rapid digestion，mental fatigue，lack of strength，a red tongue tip and edges with a thin and yellow coating and thin and rapid pulse.He lost 6 kg in the past 2 months and had no lumbar and knee weakness，vertigo，tinnitus1),aversion to cold or cold limbs.
Physical Examination:The patient was conscious and had red facial complexion，without abnormal findings in the heart and lung，the abdomen was flat and soft without tenderness and masses，and the liver and spleen could not be palpated below the ribs.There was an open and pus filled abscess on his back the size of 1cm× 2cm，which had not healed for a long time.
Laboratory Test:FBG2) 8.6 mmol/L，PBG3) 15.5mmol(2 h after meals)，Urine Glucose(+++)，Urine Ketone(-)
Pattern Differentiation
These symptoms of thirst and excessive drinking with dry mouth，profuse urine，rapid digestion，red tongue tip and edges，thin and yellow coating，and rapid pulse belong to stomach heat imparing the body fluid demonstrating as Xiāo kě syndrome of upper and middle energizer.The lung governs qi and is the upper sourse of water，which distributes fluids through out the body.Due to the impairment of the lung by pathogenic dryness and heat,it fails to distribute the body fluid properly manifesting in the symptoms of severe thirst with excessive drinking.Since there is distribution disorder，the liquid moves downwards quickly and manifests as profuse urine.The Xiāo kě syndrome of the middle energizer manifests as rapid digestion with urgent hunger and dry stool.This case does not demonstrate any Xiāo kě of the lower energizer，since there is no lumbar and knee weakness，vertigo，and tinnitus.
This case is a combination of root yin deficiency with a pathogenic dry heat excess affecting both the upper and middle energizer.The pathogenic dry heat has entered the blood level causing blood heat and stasis binding with phlegm heat manifesting as the pus filled boil.In addition，since the qi and yin are impaired,the healthy qi fails to drain toxins and regenerate tissues,leading to delay in the healing.
Diagnosis
TCM Diagnosis:Xiāo kě of the upper and Middle Energizer due to lung and stomach dry and heat with qi deficiency and blood stasis.
Western medicine diagnosis:Diabetes
Treatment
This is a case of Xiāo kě of the upper and Middle Energizer affected with pathogenic dry and heat in the lung and stomach with qi deficiency and blood stasis.
Principles:
·Clear heat and resolve toxins
·Tonify qi and nourish yin
·Invigorate blood and unblock collaterals
Formula:Modified Xiāo kě Fāng(Wasting-Thirst Formula),Bái Hǔ Jiā Rén Shēn Tāng combined with Wǔ Wèi Xiāo Dú Yǐn
注释：
1）tinnitus耳鸣
2）fasting blood glucose（FBG）空腹血糖
3）postprandial blood glucose（PBG）餐后血糖
Case discussion of Diabetes and Cerebrovascular Diseases（病案讨论：糖尿病与脑血管病变）
In the Doctor’s Office
Chief Resident：Good morning，everybody.Today is Monday and Chief Physician Wang will give us a teaching ward round（教学查房）.Our topic today is a case with diabetes and cerebrovascular disease.To begin with，let’s have the history presented by Dr.Shi.
Intern A:OK.The 58-year-old woman was admitted because of 3 years’ recurrent fatigue，headache，and word-finding difficulties，as well as 1-day confusion and right-sided weakness.Three years before admission，she began a sudden episode of word-finding difficulties，accompanied by headache，dizziness，photophobia，nausea，and vomiting.Several similar episodes occurred over the next months and the symptoms usually resolved spontaneously within a few minutes to hours.However，the patient reported a gradual progression with each episode.Then she was admitted to a local hospital where head computed tomography(CT)revealed no abnormalities.Magnetic resonance imaging(MRI)found a punctate subcortical lesion in the left parietal white matter.She was given warfarin followed by aspirin therapy.After that the patient was free of symptoms through two months’ follow-up.On the day of admission，she was found confused and sent to the emergency room where she was found paralytic in the right lower limb and the head CT didn’t show significant abnormities.Besides，the patient was diagnosed as diabetes over 10 years ago.And she had hypertension,myocardial infarction,congestive heart failure,and intermittent atrial fibrillation.Other medical problems included depression，and duodenal ulcer.She denied family histories of diabetes.Her mother died of lung and renal disease，and her father died of myocardial infarction at the age of 59.Nothing special with other family members.
实习医师甲：病人，女性，58岁。因反复乏力、头痛、言语困难3年，神志模糊、右侧肢体乏力1d入院。从入院前3年起，病人突发言语困难，伴头痛、头晕、畏光、恶心、呕吐。此后数月内，类似症状反复发作，且在数分钟至数小时内自行缓解，但每次发作症状逐渐加重。遂入住当地医院，头颅计算机体层扫描（CT）示无异常，磁共振成像（MRI）显示左侧皮下白质有小点状病灶。予以华法林继之以阿司匹林治疗，随访2月内病人未再有发作。入院当日，病人因神志模糊被送至急诊室。当时查右下肢瘫痪，头颅CT未见明显异常。该病人有糖尿病史10余年。此外，有高血压、心肌梗死、心力衰竭、阵发性房颤、抑郁症以及十二指肠溃疡病史。否认糖尿病家族史。其母死于肺肾疾病，其父59岁时死于心肌梗死。其他家族成员无特殊疾病。
Chief Physician:Well，Dr.Shi has given us a quite overall history.When the patient was admitted?
Intern A:One week ago.
Chief Physician:What lab tests were ordered after admission?
Intern A:On admission，the patient received a fasting blood glucose which showed 197mg/dl and the glycated hemoglobin was 8.5%.fasting plasma insulin level was 20mU/L and the C peptide level was less than 0.1pmol/L.Other blood tests reveled creatinine level 210μmol/L，blood urea nitrogen(BUN)2.6mmol/L，and uric acid 490μmol/L.
实习医师甲：病人入院后，查空腹血糖为197mg/dl，糖化血红蛋白8.5%。空腹血胰岛素水平20mU/L，C肽水平小于0.1pmol/L。另外，其他血液检查肌酐水平210μmol/L，血尿素氮（BUN）2.6mmol/L，尿酸490μmol/L。
Resident:What’s more，the urinary albumin excretion rate was 644μg/min.And she went over a head MRI the next morning of admission which revealed extensive，T2-hyperintense signal abnormalities mostly in the cerebrum.On diffusion-weighted imaging，several lesions of infarction were visible in the left coronal radiate and the corpus callosum.
住院医师：此外，尿蛋白排泄率检查结果为644μg/min。病人于入院次晨行头颅MRI检查，提示大脑广泛的T2高信号，弥散加权像显示左像放射冠和胼胝体多发梗死灶。
Chief Physician:Dr.Shi，what significance do you think of those results?
Intern A:Well,the elevated fasting glucose and glycated hemoglobin levels showed poor glucose control.Although the insulin level was in normal range，the low C peptide suggested significant insulin insufficiency.Judging from creatinine，BUN，and urinary albumin excretion rate，she had renal dysfunction.And as what MRI reported，there were infarction lesions in the brain.
实习医师甲：空腹血糖和糖化血红蛋白水平升高说明血糖控制不佳。尽管病人胰岛素水平在正常范围内，但是C肽水平低下提示存在明显的胰岛素缺乏。根据肌酐、尿素氮和尿白蛋白排泄率判断，病人有肾功能不全。根据MRI报告，脑部有梗死病灶。
Chief Physician:Good,those results are very helpful for diagnosis and treatment and we’ll discuss them later.What about her current situation.
Intern A:Now her vital signs are relatively stable，but the patient is still in confusion most of the time except for a few words with relatives.She takes in very little food.The blood pressure and the ancillary temperature measured this morning are 130 mmHg/85 mmHg(17.3 kPa/11.3 kPa)and 37.5℃ respectively,and the heart rate is 88 beats per minute.The past 24-hour urine volume is 1200 ml.
Chief Physician:All right.Now we’ve learned quite a lot of the history，it’s high time for us to see the patient.
Chief Resident:OK.Let’s go to Ward Three.
In the Ward
Chief Resident：Hello，Mrs.Zhang.This is our Chief Physician（主任医师），Professor Wang，who comes here specially for you.
Patient:(Opening her eyelids a bit but no reply.)
Patient’ s husband:Hello，Professor
Chief Physician:Hello，sir.You are her relative，aren’t you?
Patient’ s husband:Yes，she’s my wife.You may ask me if you want.
Chief Physician:OK.Is she always sleeping?
Patient’ s husband:Er…most of the time，yes.But at night she’s more excited and sometimes awake for a while with a few words.
Chief Physician:About how much does she eat every day?
Patient’ s husband:Almost none except a little fluid when she’s awake.
Chief Physician:Does she talk with you when awake?
Patient’ s husband:Er…yes，but just a few words we can’t understand and no dialogues at all.
Chief Physician:What medication for diabetes did she receive?And how about her blood sugar?
Patient’ s husband:At the beginning，she was given oral drugs but five years ago the treatment transferred into insulin injection.Firstly her blood sugar could be controlled fairly well，but during recent years，it often fluctuated greatly.
Chief Physician:And any other drugs?
Patient’ s husband：Oh，quite a lot，drugs for heart and nerve diseases，hypertension，and depression.Besides，the doctor added some kidney drugs two years ago when she was diagnosed as nephropathy.（很多，有心内科和神经科药物，以及抗高血压和抗抑郁药。另外，2年前，医生诊断她有肾病后又给她开了一些肾脏科药物。）
Chief Physician：So much indeed.While it’s just a characteristic of diabetic patients，for diabetes often causes systematic complications.Did you find any changes of your wife in recent years？（确实非常多。因为糖尿病会引起全身多系统的并发症，所以这也是糖尿病病人的一个特点。最近这几年你觉得你的妻子有什么变化吗？）
Patient’ s husband：Yes，I’ve found her more and more stupid.And sometimes she spoke with no logic or consecution，always complaining about insomnia，blur vision，and weakness.Additionally，during this year，she often pissed without awareness.（我觉得她越来越迟钝了，有时候讲话前言不搭后语，总是抱怨晚上睡不着，看东西很模糊，经常觉得腿脚无力。近1年来经常发生尿失禁。）
Chief Physician:Did she mention any pain in feet or hands?
Patient’ s husband:No.But she often complained about numbness.(https://www.daowen.com)
Chief Physician:You sent her to the emergency room one week ago，didn’t you?
Patient’ s husband:Yes，it was in the evening when I found her confused.
Chief Physician:Did she come into sudden confusion?
Patient’ s husband:Er… Honestly I can’t tell the details of onset，for I failed to notice it at the beginning.Instead，I thought she was sitting there，sleeping.It was not until I couldn’t wake her up that I called the ambulance.
Chief Physician:Was she aware of stools and urine?
Patient’ s husband:No.
Chief Physician:Well，thank you，Mr Zhang.Now could we give her an examination?
Patient’ s husband:Of course.
Chief Physician：Dr.Xi，please give her a physical examination，majoring in specialized exam（以专科检查为主）.
Intern B:OK.
(Intern B is examining the patient.)
Intern B:The patient is in confusion and breathes smoothly at a rate of 16 per minute.Pulse rate is 80 per minute.Blood pressure is 120/80mmHg.No jaundice in skin or mucosa.There’s no enlargement of superficial lymph nodes or engorged jugular veins.Bilateral corneal reflexes exist.The breath sounds thick with no rales.The point of maximum impulse(PMI)is at the fifth costal interspace，left midclavian line(MCL)and no thrills are palpated.The heart rate is 100 bpm and is absolutely irregular.There’s a 2/6 murmur at the apex.The abdomen feels soft with no masses.There’s no hepatomegaly or splenomegaly.Gurgling sound occurs 3 times during one minute’s auscultation.Her muscles atrophy generally and the muscle power of the right lower limb is zero with elevated muscular tension.The biceps and triceps reflexes can be induced and the right Babinski sign is positive.
实习医师乙：该病人神志模糊，呼吸频率18次/min，节律规则。脉搏80次/min，血压120/80mmHg。皮肤、黏膜无黄染，未扪及浅表淋巴结肿大，颈静脉未见怒张。双侧角膜反射存在，两肺呼吸音粗，未闻及啰音。心尖冲动（PMI）位于左锁骨中线（MCL）、第5肋间、未触及震颤。心率100次/min，心律绝对不齐，心尖部闻及2/6心脏杂音。腹软，未扪及包块，肝脾无大。听诊肠鸣音3次/min。肌肉大面积萎缩，右下肢肌力0级、肌张力过高。肱二头肌、肱三头肌反射存在，右侧Babinski征阳性。
Chief Physician:Good job.Dr.Xi has done and overall examination.Dr.Zhu，what do you think should be added?
(Resident is examining the patient.)
Resident:The patient is generally emaciated.No compulsory body positions.Bilateral pupils equal in size about 1.5 mm in diameter.Direct and indirect light reflexes exist.The neck moves softly and there’s edema in bilateral legs.The pulse of bilateral arteria dorsalis pedes(ADP)haven’t been touched.The patient can react to pain stimulation.The right knee reflex accentuates and right patella and ankle clonus is positive.In addition to Babinski sign，Oppenheim and Chaddock signs at the right side can be induced，while negative at the left.And Kernig and Brudzinski signs are negative.
住院医师：该病人体型消瘦，无强迫体位。双侧瞳孔等大，直径约1.5mm，直接与间接对光反射存在。颈软。双下肢水肿。双侧足背动脉（ADP）搏动未触及。病人对疼痛刺激有反应。右侧膝反射亢进，右侧髌阵挛和踝阵挛阳性。除Babinski征外，右侧Oppenheim征、Chaddock征阳性，左侧未引出。Kernig征、Brudzinski征阴性。
Chief Physician：Good.As diabetes often involves multiple systems，we should do an overall examination.In view of the patient’s conscious disturbance，we should also do a general set of neurological examination.Dr.Shi，what conscious disturbance consists of？（由于糖尿病可累及全身多系统，因此需做全身检查。由于该病人有意识障碍，因此神经系统检查应全面、完整。史医生，意识障碍有哪些？）
Intern A：They are somnolence，stupor，coma，confusion，delirium，and coma vigil.（包括嗜睡、昏睡、昏迷、意识模糊、谵妄和睁眼昏迷。）
Chief Physician:Then according to the findings of physical examination,what do you think of the patient’s disturbance?
Intern A:Somnolence，I suppose.
Chief Physician：Well.It’s true that the patient is in pathologic sleep and awake once a while.But it seems quite difficult to arouse her except strong stimulus and actually she can’t make herself understood although she does speak.So I think the patient should be diagnosed as stupor.Dr.Shi，I noticed that in history presentation，you used confusion in main complaints.While I think it would be more accurate to say stupor.（好。该病人确实处于病理性睡眠状态，偶尔可醒来。但是唤醒病人非常困难，需要用较强的刺激。而且尽管该病人确实能够说话，但实际上她说的话别人听不懂。因此，我认为该病人应诊断为昏睡。史医生，我注意到刚才在病史汇报的过程中，你在主诉中用了意识模糊，然而我认为用昏睡应该更为确切。）
Intern A:I see，Professor.
Chief Physician:Dr.Xi，what is the significance of accentuated knee reflex and positive clonus?
Intern B:They mean accentuated tendon reflexes，I remember.
Chief Physician:Right.And what about accentuated tendon reflexes?
Intern A:Oh，I’m not sure.
Chief Physician：Accentuated tendon reflexes along with pathological signs such as Babinski sign usually reflect impaired pyramidal tract.And according to the patient’s history，physical examination，and the result of head MRI，cerebrovascular disease should be considered as the cause of conscious disturbance.Dr.Shi，do you know why Dr.Zhu mentioned pulse of ADP when making supplements？（结合Babinski征等病理征阳性，腱反射亢进通常说明锥体束受损。结合该病人病史、体检和头颅MAR检查结果，考虑意识障碍为脑血管病变引起。史医生，刚才朱医生在补充时为什么要提到ADP搏动？）
Intern A:Is it to judge the microcirculation?
Chief Physician:Right.ince chronic diabetic complications mainly involve systematic vessels，it’s quite important to judge patients’ microcirculation.And the patient’s ADP pulse couldn’t be touched，suggesting that the patient might have arterial ischemia even obstruction in the lower limbs.（由于糖尿病慢性并发症以累及全身血管为主，因此判断病人微循环状态非常重要。该病人ADP搏动未触及，很可能存在下肢动脉缺血，甚至阻塞。）All right，let’s go back to the office for further discussion.Thank you for cooperation，Mr.Zhang，bye.
Patient’s Husband:That’s OK，bye，Professor.
In the Doctor’s Office
Chief Physician:Now，Dr.Shi，please summarize the patient’s gist for diagnosis.
Intern A:OK.Firstly，the patient is a senior female with long-period diabetes，hypertension，and coronary heart disease(CHD).Then she complained mainly about 3 years’ recurrent fatigue，headache，and word-finding difficulties，as well as 1-day stupor and right-sided weakness.And physical examination findings include paralysis and elevated muscle tension in the right lower limb，as well as positive pathological signs in the right side.Besides，head MRI has revealed multiple infarction in the left coronal radiate and the corpus callosum.Hereby the patient’s primary diagnosis is diabetes and cerebral infarction.
实习医师甲：首先，该病人为老年女性，有长期糖尿病、高血压及冠心病（CHD）史。主诉为反复乏力、头痛、言语困难3年，昏睡、右侧肢体乏力1d。查体发现，该病人右下肢偏瘫伴肌张力过高，右侧病理征阳性。头颅MRI显示左侧放射冠和胼胝体多发梗死灶。故该病人初步诊断为糖尿病合并脑梗死。
Chief Physician:Good.While given her history and other results of lab tests，diabetic nephropathy，hypertension，and depression should be added.In fact,according to the history provided by the relative,the patient also have symptoms of diabetic neuropathy and retinopathy,especially the latter which is the most common microvascular complication of diabetes and always accompanies advanced diabetic nephropathy.Dr.Shi，what do you think should be differentiated with cerebral infarction?
主任医师：很好。结合病史和其他实验室检查结果，该病人的诊断结果还需加上糖尿病肾病、高血压和抑郁症。实际上，根据家属提供的病史，病人同时有糖尿病神经病变和视网膜病变的症状。尤其是后者，因为视网膜病变是糖尿病最为常见的微血管并发症，经常同时发生在后期糖尿病肾病的病人中。史医生，除了脑梗死，我们还需与哪些疾病鉴别？
Intern A:I think we should exclude other cerebral vascular disease firstly.The patient has hypertension and manifested as conscious disturbance and paralysis,so cerebral hemorrhage and subarachnoid hemorrhage could be considered.But according to the patient’s MRI result，we can make differentiation.
Chief Physician:Well.Anything else?
Intern B:And central nerve system(CNS)infection.But the patient had no fever or antecedent infections,and meningeal irritation signs are negative,so along with MRI result，it can’t be excluded.
Chief Physician:Good.Besides，Binswanger’s disease，that is，subcortical leukoencephalopathy should be considered.It is a progressive subcortical white matter disease associated with progressive cognitive and motor decline.Patients are usually in the fourth to seventh decades at diagnosis，and more than 80% have a history of hypertension.Most patients have small discrete infarction or large areas of incomplete sclerosis and demyelination，with thickened and hyalinization of arterioles.Dr.Guan,is it possible for lacunar infarction?
主任医师：很好。另外，我们还需要与Binswanger病，即皮质下白质脑病相鉴别。这是一种进行性的皮质下白质疾病，与进行性认知及动力的下降联系在一起。病人常在40~70岁时被诊断出来，超过80%的病人有高血压病史。大多数病人有非连续性小梗死灶或大面积的不完全硬化和脱髓鞘，伴有小动脉增厚和透明样病变。管医生，该病人考虑空洞性梗死吗？
Attending Physician:It might be，but I’m not quite in favor of it.Lacunar infarction is occlusion of penetrating arteries in white matter.Lesions seen on MRI are usually intermittent and less than 15mm in diameter.The occlusion may be caused by multiple processes,such as hypertension,diabetes,advanced age，ischemic heart disease，and cigarette smoking.It is possible for this case，for diabetes and hypertension are significant risk factors.However，the patient’s large，confluent lesions in the corpus callosum were atypical.
主治医师：有可能，但是我认为可能性不大。空洞性梗死为脑白质深部的动脉闭塞。MRI上病灶通常为间隙性，且直径小于15mm。闭塞可由多种病变引起，最常见的是高血压、糖尿病、老化、缺血性心脏病、吸烟。高血压和糖尿病是尤其危险的因素，因此该病人应考虑此可能。但是，该病人胼胝体病灶较大且为连续性的病灶，因此不是很典型。
Chief Physician:I agree with you，but we can’t make exact differentiation unless we have pathological proof.Generally speaking，this 58-year-old woman with vascular risk factors and stroke-like symptoms had progressive cerebrovascular disease.According to the history，she had several episodes of transient ischemia attack(TIA).Having ruled out hemorrhage，CNS infection，and Binswanger’s disease，we were left with the diagnosis of small-vessel ischemic disease of the brain with multiple infarction，along with type-2 diabetes.What’s more，the complete diagnosis should include diabetic nephropathy，CHD，hypertension，depression，and duodenal ulcer.As the patient’s overall glucose control is fairly poor,and several severe vascular complications have developed,it’s quite possible that she had diabetic cerebrovascular disease which is a frequent vascular complication of diabetes and characterized by multiple encephalomalacia,with small infarction lesions commonly in pons，thalamus，and basal ganglia.Thus，diabetes is the most likely cause of this patient’s cerebrovascular disease.
主任医师：我同意你的看法，但是除非有病理学依据，否则很难做出明确鉴别。该女病人58岁，有血管病变和中风样症状，有进行性的脑血管病变。根据病史，病人有多次缺血性卒中（TIA）病史。排除出血、CNS感染和Binswanger病等，诊断为小血管缺血引起的脑部多发性梗死和2型糖尿病。另外，完整的诊断还应包括糖尿病肾病、CHD、高血压、抑郁症和十二指肠溃疡。由于该病人总体血糖控制不佳，且同时合并有多种严重的血管并发症，那么也很可能存在糖尿病脑血管病变。该病为常见的糖尿病血管并发症，以多发的脑软化为特征，一般在脑桥、丘脑和基底神经节可以看见小梗死灶。因此，这个病人的脑血管病变很可能是由于糖尿病引起的。
Intern A：Professor，may I ask you a question?Why she was diagnosed as type 2 diabetes?
Chief Physician:Well.Actually the classification of diabetes is very complex，for diabetes itself is a complicated disease associated with quite a lot of factors.Currently，the international-recognized standard for classification was established by WHO in 1999，that is，type 1，type 2，gestational，and special diabetes.Type 1 patients often begin in youths，especially adolescents，while type 2 usually occurs in senior patients.But the fundamental difference between type 1 and type 2 is whether insulin insufficiency is absolute or relative rather than age of onset.Although the patient’s onset was a bit earlier，she seemed quite sensitive to oral drugs which usually fail to improve type 1 diabetes，suggesting she probably had relative insulin insufficiency which can be alleviated by oral drugs.Additionally，spontaneous ketoacidosis happens much more frequently in type 1 than in type 2.Given the patient’s history，clinical manifestation，and treatment course，I consider type 2 diabetes.Of course，in fact it’s quite difficult to distinguish type 1 and type 2 diabetes，especially in patients with years of history.So tests of some autoimmune antibodies such as glutamic acid decarboxylase antibody(GADA),insular cellular antibody(ICA),insulin autoantibody(IAA),ect.are needed sometimes.However，even in type 2 diabetes with relative insulin insufficiency，the final result is destruction ofβcells，so many type 2 patients have to rely on insulin injection several years after onset.And what we have to do is to reduce and delay that destruction and vascular complications，as well as to increase patient’s living quality，no matter what the type is.
主任医师：由于糖尿病本身是一种涉及多种因素的复杂疾病，因此糖尿病的分型亦相当复杂。目前，国际上公认的分型标准是由WHO于1999年制定的，即1型、2型、妊娠糖尿病和特殊类型糖尿病。1型糖尿病常发病于青年，尤其是青少年，而2型糖尿病通常发病于老年。然而1型和2型本质的区别并不在于发病年龄，而在于胰岛素的缺乏是绝对性的还是相对性的。尽管该病人起病年龄较早，但是对口服药敏感，而1型病人口服药效果多欠佳。这说明该病人很有可能存在相对性的胰岛素缺乏，因而应用口服药后可改善。此外，1型糖尿病自发性酮症酸中毒的发生率明显高于2型。因此，鉴于该病人的病史、临床表现、治疗经过，我认为应诊断为2型糖尿病。当然，其实1型和2型糖尿病还是非常难以鉴别的，尤其是有多年病史的病人。所以，有时候我们需要借助于一些自身抗体的检查，如谷氨酸脱羧酶抗体（GADA）、胰岛素细胞抗体（IAA）等。但是，即使是胰岛素相对缺乏的2型糖尿病，最终的结果还是β细胞破坏，因此很多2型糖尿病人在发病数年后需依赖胰岛素注射。所以，不管糖尿病如何分型，我们治疗的重点是减少和延缓β细胞的破坏和血管并发症的发生，从而提高病人的生存质量。
Chief Physician:What about the current treatment，Dr.Zhu?
Resident:After admission，the patient was given insulin，anti-coagulation，and supporting treatment.
Chief Physician:All right.As the patient hardly eats anything，we should pay attention to energy supply to prevent acute diabetic complications.Dr.Shi，what are acute complications of diabetes?
Intern A：Ketoacidosis，hyperosmolar coma，and lactic acidosis.（酮症酸中毒、高渗性昏迷和乳酸型酸中毒。）
Chief Physician:Good.Dr.Xi,could you tell us the difference among them?
Intern B:Ketoacidosis is often induced by infections,stress,and other factors，characterized by hyperglycemia，hyperketonemia，and metabolic acidosis.While hyperosmolar coma often occurs in old and weak patients，and glucose levels usually go extremely high with dramatically elevated plasma osmotic pressure.And lactic acidosis happens to senior patients using biguanides，especially Phenethylbiguanide and generally having renal or liver dysfunction.However，it’s now quite infrequent with disuse of that drug.
实习医师乙：酮症酸中毒多由感染、应激等因素诱发，以高血糖、高血酮、代谢性酸中毒为主要表现；高渗性昏迷多见于身体虚弱的老年人，血糖异常升高，伴血浆渗透压明显上升；乳酸型酸中毒通常发生与应用双胍类药物，尤其是苯乙双胍的老年人，病人多合并肝、肾功能不全，然而随着苯乙双胍的停用，该病现已非常罕见。
Chief Physician:Great.Stroke is a dramatic stress factor for diabetic patients，so we should be concerned about ketoacidosis.Moreover，given the patient’s overall situation and little food intake，danger of hyperosmolar coma couldn’t be ignored.So we should give her adequate fluid and energy to prevent further catabolism of glycogen，protein，and fat.At the same time we should pay more attention to electrolytes,provide appropriate glucose to avoid elevated osmotic pressure caused by hypernatremia coming from too much saline injection，and use nasal feeding if necessary.What’s more，we should continue monitoring vital signs as well as water，electrolytes，and aci-base balance，heeding the patient’s urine volume and cardiac function，and using central venous pressure(CVP)monitoring if necessary to regulate fluid supply.Also，we couldn’t neglect the danger of pulmonary infection.Of course，we should prevent dual infection which often occurs in patient with stroke.Withal，we couldn’t forget to prevent stress ulcer which is far more than an ailment and often causes death.Now what about the patient’s glucose level?
主任医师：很好。卒中病人为糖尿病病人的一个主要应激因素，因此我们需留意酮症酸中毒。该病人一般情况欠佳，进食、进水极少，还须警惕高渗性昏迷。我们应给予充足的液体和能量以防止糖原、蛋白质和脂肪的进一步分解。同时，注意维持电解质平衡，适当补充葡萄糖溶液以防因补充大量生理盐水引起高钠血症，从而导致渗透压升高。必要时可给予鼻饲。另外，我们应及时监控生命体征和水、电解质、酸碱平衡情况，留意该病人的尿量和心功能情况，必要时可监测中心静脉压（CVP）以调整补液量。除此之外，还需注意肺部感染的风险。当然，在抗感染过程中需注意卒中病人经常出现的二重感染。另外，还应注意预防应激性溃疡，这绝不是小问题，而是经常导致死亡的原因。现在病人的血糖如何？
Resident：Digital glucose（手指血糖）is now monitored three times a day，and it’s maintained at 10-15 mmol/L.
Chief Physician:And how insulin is used?
Resident：Regular insulin（短效胰岛素），hypodermic injection at 6 am，11 am，5 pm respectively.
Chief Physician:That’s OK.As hyperglycemia will aggravate imbalance of internal environment and increase the risk of infection，insulin injection is necessary for glucose control.However，the patient has renal impairment and little feeding activities，so we should exceptionally heed hypoglycemia.Furthermore,as the patient is in conscious disturbance,sometimes severe hypoglycemia might be neglected，which would have lethal effect on the patient.Therefore，regular insulin which has short half period and quick excretion is more appropriate.To sum up，the patient has severe cerebrovascular disease and multi-systematic dysfunction caused by long-period diabetes,so the prognosis is far to be optimistic.As for the treatment，we should pay extraordinary attention to maintaining balance of the internal environment,preventing infections and other complications.That’s all.Thank you all.
Chief Resident:Thank you，Professor.
主任医师：可以。由于高血糖会加重内环境紊乱，增加感染风险，因此需要注射胰岛素来控制血糖。然而，病人进食极少且合并肾功能不全，我们需特别留意出现低血糖。而且，该病人神志不清，有时严重低血糖难以被发现，这对病人的情况来说可能是致命的。因此，宜应用半衰期短、排泄快的短效胰岛素。总之，该病人由于长期糖尿病引起全身多器官功能不全，合并脑血管意外，预后不容乐观。治疗上应特别注意维持机体内环境平衡、预防感染和其他并发症。好了，今天的查房就到这里了，谢谢大家。