澳大利亞John Murtagh 全科病案研究(三十四)——對(duì)糖尿病患者的連續(xù)診治過程(1)

John Murtagh (著)，楊 輝(譯)

作(譯)者單位:3165 澳大利亞維多利亞州，澳大利亞Monash大學(xué)

譯者按:慢性疾病患者的病程可以持續(xù)十幾年甚至幾十年，患病過程中的臨床表現(xiàn)、心理健康和社會(huì)健康情況也會(huì)隨著時(shí)間的推移而改變。全科醫(yī)生是能夠全程和連續(xù)地觀察和診治慢性疾病的衛(wèi)生專業(yè)人員，根據(jù)病程發(fā)展采取各種不同的措施，幫助病人管理好慢性病。Murtagh 教授以2 型糖尿病管理為例，跟我們討論了一個(gè)跨越10 多年的2 型糖尿病患者的病案，本期是該病案討論的第一部分。從這個(gè)案例中，我們可以學(xué)習(xí)和思考怎樣以全科醫(yī)學(xué)的理論視角和實(shí)踐方法，來進(jìn)行社區(qū)糖尿病管理。

1 病史

13 年前，金42 歲，到全科醫(yī)學(xué)診所來體檢。他是一位警察，以前身體一直很健康，不過近幾個(gè)月來感到很勞累，很容易疲倦。特別是鍛煉身體后，常感到疲憊不堪。最近他晉升為警督，工作更加繁忙了，而且要花更多的時(shí)間處理公務(wù)，疲勞感也就更為嚴(yán)重。他說感到自己力不從心，而且體重也增加了不少。他倒是沒有什么其他的癥狀，特別是沒有泌尿系統(tǒng)的癥狀。

金抽煙，每天10 支，以前有過輕度高血壓病史，不過沒有吃藥，而是通過減少食鹽和減少飲酒的方法來控制血壓。

我給金做體檢，他看上去還是很健康的，只是體重超重，BMI 為33 kg/m2，腰圍106 cm。脈搏72 次/min，規(guī)律。血壓145/90 mm Hg (1 mm Hg =0.133 kPa)。其他體檢結(jié)果屬正常。尿檢結(jié)果:尿糖(+)，未發(fā)現(xiàn)尿蛋白。隨機(jī)血糖(指血)8.5 mmol/L。

2 問題

(1)你采用什么方法診斷金的病?如果需要的話，需要做哪些進(jìn)一步檢查?(2)如果你做了初步診斷，病人的哪些方面與“標(biāo)準(zhǔn)的診斷”不一樣?

3 答案

問題1:你可以考慮金可能患的是2 型糖尿病。這個(gè)病人給你的第一印象是肥胖，而且他的工作性質(zhì)是那種久坐不動(dòng)的工作。糖尿病是一個(gè)世界范圍的嚴(yán)重問題，患病率很高，而且呈現(xiàn)快速增加的趨勢(shì)。然而現(xiàn)在僅憑他的隨機(jī)血糖8.5 mmol/L 是不能下糖尿病診斷的。你需要做一個(gè)很重要的檢查，就是空腹血糖(FBG)。其他應(yīng)該做的檢查包括空腹血脂檢查、腎功能檢查。你還應(yīng)該根據(jù)FBG 的檢查結(jié)果，進(jìn)一步做葡萄糖耐量試驗(yàn)。

資料框:世界衛(wèi)生組織糖尿病診斷指南

-空腹血糖≥7 mmol/L

-餐后隨機(jī)血糖或攝入75 g 葡萄糖2 小時(shí)后血糖≥11.1 mmol/L

-如空腹血糖5.5 ～6.9 mmol/L，需要進(jìn)一步做口服葡萄糖試驗(yàn)

問題2:2 型糖尿病的一個(gè)特點(diǎn)，是很多病人并不表現(xiàn)出臨床癥狀。在金的案例中，病人的隨機(jī)尿糖試驗(yàn)發(fā)現(xiàn)少量葡萄糖，這可以提示可能患糖尿病，但這種尿糖試驗(yàn)的可信度較低，很多2 型糖尿病患者的隨機(jī)尿糖試驗(yàn)可以是陰性。因此在沒有做血糖檢查前，僅僅憑尿糖試驗(yàn)很難篩查出糖尿病。

4 對(duì)金的進(jìn)一步臨床檢查

FBG:6.7 mmol/L，餐后2 h 葡萄糖耐量試驗(yàn):12.8 mmol/L，空腹血脂:總膽固醇5.7 mmol/L，高密度脂蛋白膽固醇(HDL-C)1.0 mmol/L，低密度脂蛋白膽固醇(LDL -C)3.2 mmol/L，三酰甘油(TC)1.8 mmol/L，表皮生長因子受體(eGFR)100 ml/min。

5 進(jìn)一步的問題

(3)你對(duì)金的病情評(píng)價(jià)結(jié)果是什么?(4)請(qǐng)列出你的治療計(jì)劃要點(diǎn)。

6 對(duì)進(jìn)一步問題的答案

問題3:金患的是2 型糖尿病。餐后2 h 葡萄糖耐量實(shí)驗(yàn)結(jié)果為12.8 mmol/L，這是診斷2 型糖尿病的關(guān)鍵依據(jù)。金的糖尿病并非剛剛開始，而是像很多“隱形”病人一樣，經(jīng)過了一段沒有癥狀的糖尿病階段，但現(xiàn)在他已經(jīng)開始表現(xiàn)出嚴(yán)重的癥狀，比如疲勞、全身乏力，隨著他的生活方式變化，這些癥狀表現(xiàn)的越來越明顯。文獻(xiàn)報(bào)道，人群中大約有一半這類病人沒有被診斷出糖尿?。?］。

問題4:近期的糖尿病管理計(jì)劃。

-進(jìn)一步檢查:一定要注意到金這種糖尿病病人的并發(fā)癥，因?yàn)楹芏嗖∪嗽谠\斷之初就已經(jīng)開始有并發(fā)癥［1］。進(jìn)一步的檢查可以包括心血管的生命體征檢查、皮膚疾病檢查、足部神經(jīng)學(xué)檢查以及視網(wǎng)膜檢查。另外還可以考慮尿微量白蛋白檢查。在開始治療2 ～3 個(gè)月時(shí)，最好要做糖化血紅蛋白(HbA1C)檢查。

-血壓問題:金的血壓高于糖尿病管理的控制水平(＜130/80 mmHg)。如果通過改變生活方式還不能很好地控制血壓，最好讓他開始服用降壓藥，如血管緊張素轉(zhuǎn)化酶抑制劑(ACEI)。

-吸煙問題:應(yīng)該給金提供關(guān)于戒煙的健康教育信息，并通過動(dòng)機(jī)談話技術(shù)，幫助他戒煙。

-血糖控制:應(yīng)該給病人提供飲食指導(dǎo)，并指導(dǎo)病人至少在8 周內(nèi)增加身體活動(dòng)，在此之后，要指導(dǎo)病人監(jiān)測(cè)血糖和體重。

-血脂控制:金的低密度脂蛋白膽固醇高于理想值(＜2.5)，如果飲食控制和身體鍛煉等措施還不能奏效，就應(yīng)該考慮采用調(diào)脂治療。

-口服降糖藥:如果通過改變生活方式不能明顯地改善血糖水平，應(yīng)該讓病人服用降糖藥。不過從長期保健的角度看，還是應(yīng)該著重于通過飲食和身體鍛煉來降低血糖。

1 Dunstan DW，Zmmet PZ，Welborn TA，et al. the rising prevalence of diabetes and impaired glucose tolerance:the Australian Diabetes ［J］.Obesity and Lifestyle study. Diabetes Care，2002，25:829 -834.

譯者注:動(dòng)機(jī)談話技術(shù):請(qǐng)參見《中國全科醫(yī)學(xué)》雜志近期刊登的快樂生活俱樂部——社區(qū)慢性病管理模式的研究報(bào)告。

History

Kim，aged 42 years，presents for a check up. He has enjoyed good health but in recent months feels tired and becomes easily fatigued especially after physical activity. This situation has arisen since he has been promoted to a senior police administrator and spends considerable time in the office. He feels unfit and has put on weight. He has no other symptoms particularly no urinary symptoms. He smokes 10 cigarettes per day and has a history of mild hypertension but attempts to manage it through elimination of salt and alcohol.

On examination he looks well but overweight. He body mass index is 33 kg/m2，waist circumference 106 cm，pulse 72 and regular，blood pressure 145/90 mmHg. The rest of the examination is normal. Urinalysis 1 + glucose but no protein. A random blood glucose (finger pick sample)is 8.5 mmol/L.

Questions

1 What would be your diagnostic approach to Kim and what investigations (if any)would you order?

2 What are the unusual aspects about the provisional diagnosis?

Feedback

1 You would have to consider the diagnosis of type 2 diabetes mellitus in a person who is obese and has a sedentary lifestyle. Diabetes is a massive worldwide problem and increasing at an alarming rate. Kim's random blood glucose of 8.5 mmol/L is not diagnostic of diabetes. Your key investigation would be a fasting blood glucose(FBG). Other appropriate investigations would be fasting lipid studies，kidney function (eGFR)and a glucose tolerance test (depending on the fasting blood glucose).

Box 1

WHO guidelines for diagnosis of diabetes

Fasting blood glucose ≥7 mmol/L

Random blood glucose (post prandial)or 2 hours after 75g glucose load ≥11.1 so need to perform an oral glucose test

If fasting blood glucose is 5.5 -6.9 mmol/L，diabetes is uncertain

2 A feature of type 2 diabetes is that most people with it are asymptomatic. In Kim there was a small amount of glucose in a random urine dipstick test and this pointed to the diagnosis of diabetes but the dipstick test is unreliable and many patients with type 2 diabetes test negative for urinary glucose. This made the screening for diabetes very difficult for those practising before blood glucose estimation became available.

Further clinical details for Kim

The results of investigation:FBG 6.7 mmol/L

Glucose tolerance test -2 hour post glucose level 12.8 mmol/L

Lipids (fasting):total cholesterol 5.7 mmol/L，HDL - C 1.0 mmol/L，LDL - C 3.2 mmol/L，triglyceride 1.8 mmol/L，eGFR 100ml/min

Questions

3 What is your assessment of Kim's medical condition?

4 Outline your immediate plan of management

Feedback

3 Kim has type 2 diabetes. His blood glucose level 2 hours postglucose load was 12.8 mmol/L，which is diagnostic of type 2 diabetes. Like so many people he has remained asymptomatic for a long time but he started to develop vague symptoms of tiredness and malaise in line with his changed lifestyle. It is estimated that up to one half of people with diabetes have not yet been diagnosed［1］.

4 Immediate plan of management

-Examination:It is important to examine Kim for complications of diabetes since these patients can develop complications by the time of diagnosis［1］. This should include cardiovascular vital signs，the skin，neurological of the feet and retinal examination. Also perform a 'spot' urine examination for microalbumin. A HbA1C estimation is best left to about 2 to 3 months after treatment is initiated.

-Blood pressure:Kim's BP is above the target for people with diabetes (＜130/80 mmHg)so if it is not controlled after a reasonable trial of lifestyle modification it would be appropriate to start medication with an angiotensin converting enzyme inhibitor(ACEI).

-Smoking:Kim should be offered information and motivational counselling about quitting smoking.

-Glucose level:a trial of dietary advice and increased physical activity for 8 weeks with monitoring of glucose control and weight during and after this time.

-Cholesterol:Kim's LDL-C is elevated above the ideal target (＜2.5)so he could be considered for stain therapy if this level is not improved after a trial of diet and physical activity.

-Oral hypoglycaemic agent:if lifestyle measures do not improve his blood glucose levels consideration should be given to the introduction of medication but it is best to consider the long term and promote control with diet and physical activity.

Reference

1 Dunstan DW，Zmmet PZ，Welborn TA，et al. the rising prevalence of diabetes and impaired glucose tolerance:the Australian Diabetes，Obesity and Lifestyle study. Diabetes Care，2002，25:829 -834.