An unconscious diabetic patient

Accepted 10 March 1998 A 49-year-old man was transferred to our hospital by ambulance on 25th December 1995, for unconsciousness, hypotension, and hypothermia. The patient was unemployed and living alone. He had been well until a year earlier, when polyuria, polydipsia and weight loss (15 kg/4 months) developed. He had experienced a sore throat and a cough productive of yellowish sputum 4 days earlier, but had not consulted any doctors. His mother had suffered from non-insulin-dependent diabetes mellitus (NIDDM). On his admission, physical examination showed him to be in deep coma and his rectal temperature was 29.2°C. His body mass index was 20, blood pressure was 54/26 mmHg, heart rate was 62 beats/min, and respiratory rate was 24 breaths/min. His pupils were dilated and right reflex was sluggish, but his deep tendon reflexes were normal. Laboratory data revealed that his plasma glucose (48.3 mmol/l), acetoacetate (4540 ,umol/l, normal 18-83) ,umol/l), and 3-hydroxybutyrate (10500,mol/l, normal 0-106 gmol/l) were markedly elevated. His urine was positive for ketone bodies. Arterial blood gas analysis showed severe metabolic acidosis (pH 6.783, pO2 133.7 mmHg, pCO, 10.9 mmHg, HCO3 3.4 mEq/l). His plasma potassium and phosphate levels were raised to 6.2 mmol/l and 2.9 mmol/l, respectively. There were no abnormal findings in his chest X-ray. His electrocardiogram (ECG) is shown in the figure.