Case vomiting in DM (type I)
20-02-2023 -by Elke Koestering – quality officer
On Sunday evening, a 62-year-old patient, known to have insulin-dependent diabetes, calls the HAP. She has just returned from Turkey and has been vomiting since the previous morning. In addition, she hardly eats or drinks and her glucose is around 20. She does urinate, has no diarrhea and is otherwise clear and alert. It calls for an antiemetic. In consultation with the directing physician, metoclopramide sup is prescribed and she is instructed to drink well when the stomach has calmed down a bit. In addition, it is indicated that she should contact again if she becomes sicker, drowsiness, confusion, lack of voiding, no urination, persistent vomiting or high blood sugars.
On Tuesday she calls her own GP because the vomiting persists, and her blood sugar remains around 20 despite frequent insulin injections. Upon assessment, she is dehydrated and hypotensive and is sent to the internist. There it is concluded that the vomiting is caused by a dysregulated type I diabetes. She has ketoacidosis and acute renal insufficiency. In addition, she also appears to have suffered a semi-recent submural infarction.
What can we learn from this? It is important to be alert to symptoms of vomiting in a diabetic (especially with a type I). Vomiting can be a sign that the body is acidifying due to high blood glucose levels. The vomiting is the result of high blood glucose levels and is not caused by, for example, a stomach virus.
Patients with type I diabetes, for whom the internist is almost always the main practitioner, are therefore always advised by the hospital to contact the diabetes nurse or the emergency room for advice and, if necessary, assessment in the hospital. In this case, the question is why this did not happen in this way. Was the patient not properly instructed or did she not think about it? Furthermore, it would have been good to build in a stricter check-up moment by either advising the patient to contact their own GP the next morning or asking the GP to contact the patient. Although the latter can be difficult if the doctor is on vacation, for example.
If a diabetic calls with vomiting, it is important to distinguish between type I and II.
Ask a type I diabetic after which appointment he/she has with the main practitioner about this and advise them to contact the main practitioner in case of complaints of vomiting or to transfer warmly to the main practitioner.
You also have to be alert with a patient with type II diabetes, who is usually being treated by the GP for this; They will usually report to us with complaints of vomiting and should therefore be assessed in an accessible manner. In addition, we share another observation. It has happened several times in recent months that patients of different ages (from child to elderly) who presented with persistent vomiting turned out to have diabetes de novo. Reason enough to measure glucose in the event of similar complaints or in other patients with a sick impression, even in patients without diabetes. Strict adherence to the ABCDE methodology will, of course, also lead to the control of the sugar.