The 57-year-old female presented with consciousness disturbance and fever for one day. Her physical examination revealed an altered mental status and hyperglycemia. Laboratory tests showed severe hyperglycemia, hyperosmolality, and acute kidney injury. She was diagnosed with type 2 diabetes mellitus with hyperglycemic hyperosmolar state and urinary tract infection. She received aggressive hydration, insulin infusion, electrolyte monitoring, antibiotic treatment, and blood and urine cultures. Her mental status and laboratory abnormalities improved with treatment.

1. 內科專科口試 107年度
姜冠宇 醫師

2. 題號 性別、年齡 主 述 診 斷 CASE有圖片，請
打勾(V)
是本人照顧，請打勾(V)
CASE 1. 41 y/o male; Dyspnea in 2 days (V) ( )
Acute myopericarditis
CASE 2. 44 y/o Male ; Suddenly onset abdominal pain (V) (V)
Acute pancreatitis with acute respiratory failure
CASE 3. 44 y/o male ; Progress shortness of breath for 1 week (V) (V)
1. Pulmonary tuberculosis with cavitation
2. Acute respiratory distress syndrome
CASE 4. 66 y/o female ; general weakness for 5 days (V) (V)
Hyponatremia
CASE 5. 56 y/o female ; Fever up to 40’C with chills for 1 day (V) ( )
Infective endocarditis of mitral valve, Staphylococcus aureus(MRSA)
CASE 6. The 57-year-old female ; consciousness disturbance and
fever for 1 day
(V) ( )
Type II diabetes mellitus with hyperglycemic hyperosmolar state

3. CASE 6. 病例摘要
主訴：
The 57-year-old female with consciousness disturbance and fever for 1 day
簡單病史：
Systemic disease: Sigmoid colon cancer s/p laparoscopic sigmoidectomy on 2015/4/6 and
hypertension、Allergy: no known drug or food allergy、Current medication: denied、
Residency: New Taipei City、Substance use: denied、Travel history: denied、
Occupation: accountant、Cluster history: denied、Contact history: Denied.
Consciousness deteriorated gradually for 1 day. Fever was also noted. Her family called
EMT for help. One touch sugar was checked by EMT and the result showed high. The
associated symptoms were progressive dyspnea, mild dysuria, and urinary frequency in
the recent days. Denied headache, chest discomfort, nausea, vomiting, abdominal pain
or bowel habit change.

4. CASE 6
The 57-year-old female with
consciousness disturbance and fever for
1 day
4

5. Personal profile
▶ Age: 57 years old
▶ Gender : female
▶ Marital status: married
▶ Occupation: accountant
▶ Cigarette smoking/Alcohol drinking/Betel nut chewing: all denied
▶ Allergy: no known food and drugs
5

6. Chief complaint
Consciousness disturbance and fever for 1 day.
6

7. Past history
⦿ Sigmoid colon cancer s/p laparoscopic sigmoidectomy on 2015/4/6.
⦿ Hypertension
7

8. Family history
8
Patient

9. Present illness ⦿ Consciousness deteriorated gradually for 1 day.
⦿ Fever was also noted.
● Call EMT
○ One touch sugar: high
⦿ Associated symptoms:
● Progressive dyspnea.
● Mild dysuria and urinary frequency.
⦿ Denied headache, chest discomfort, nausea,
vomiting, abdominal pain or bowel habit
change.
9

10. Physical
examination
⦿ Consciousness: E1V2M5
⦿ General appearance: acute illness
⦿ Height: 158cm, Body weight: 75kg (BMI:30.04)
⦿ Vital signs
● T/P/R: 38.3℃/141bpm/22cpm, BP: 126/85
mmHg
⦿ HEENT: grossly normal
● Isocoric pupils, light reflex:+/+
● Anicteric sclera, pink conjunctiva
⦿ Neck: supple
● No lymphadenopathy, no palpable goiter.
10

11. Physical
examination
⦿ Lung : bilateral clear breath sounds
⦿ Heart : regular heart beat, no obvious murmur
⦿ Abdomen: soft, ovoid, no scar
● Normoactive bowel sounds
● No tenderness; impalpable mass; no
rebounding pain; no costo-vertebral angle
knocking pain.
⦿ Extremities: no pitting edema, freely movable
⦿ Skin: dry skin turgor.
⦿ Peripheral pulse: intact and symmetric.
11

12. Laboratory
data (1)
12

13. Laboratory
data (2)
13

14. Laboratory
data (3)
14

15. CXR
15

16. Impression
16
⦿ Type II diabetes mellitus with hyperglycemic
hyperosmolar state.
⦿ Urinary tract infection
⦿ Acute kidney injury

17. Treatment
course
17
⦿ Aggressive hydration
⦿ Insulin infusion.
⦿ Keep electrolyte balance.
⦿ Collect blood culture and urine culture.
⦿ Empirical antibiotic of Cefazolin.

18. Follow up laboratory data
18