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Morning MeetingGeneral Medicine
Chi-Mei Medical Center
Reporter: PGY1 Chon-Seng Hong
2010-01-27
The patient
林 x 杏50-year-old femaleHistory No.: 20155864Admission: 2010-01-26Occupation: House wife
Chief Complaint
Conscious disturbance for several hours in the morning
Present illness
The 50-year-old female presented with about 15-year history of type 2 DM and 10-year-old history inoperable adrenal tumor.
Present illness
10 years ago, Headache LMD and high blood pressure
(SBP>200mmHg) was noted. Nephrology OPD malignant
hypertension Abdominal CT scan left adrenal tumor
( 2000-08-28Abdominal MRI comfirmed hyperplasia of
left adrenal gland
Present illness
Surgeon very high risk and low successful rate inoperable
Medications control and regular OPD f/uNo remarkable change as compared with
the previous MRI study in 2008, Jan
Present illness
In December 2009,Acute renal failure was noted after using
pain killers agent for lower back pain
Present illness
3 days before this admissionConscious change at the morning ER1 day before, She was well.No fever, chills, cough, diarrhea, or
traumatic history in recent days
Past history
1.Left adrenal tumor suspected adenoma, which related malignant hypertension about 10 years
2.Type 2 DM for more than 10 years with DM polyneuropathy.
3.Previous operation or major trauma: nil
Previous medications
Lipitor (40mg) F.C. Tab. 0.5 TB HS PO 7 4 TB Bokey (100mg) Cap. 品名注意 1 CP QD PO 7 7 CP Dulcolax (5mg)E.C.T(Bisacodyl) 2 TB HS PO 7 14 TB Euglucon (5mg)Tab.(Gliben) 注意 1 TB BID PO 7 14 TB Glucobay (50mg) Tab. 1 TB BID PO 7 14 TB Eltroxin (0.1mg) Tab. 1 TB QD PO 7 7 TB Aldactone(25mg)Tab.(Aldactin) 1 TB QD PO 7 7 TB Pentrexyl(500mg)Cap.(Ancillin) 2 CP Q12H PO 7 28 CP Loniten (10mg) Tab. 0.25 TB TID PO 7 6 TB Lasix (40mg) Tab. (Furide) 1 TB BID PO 7 14 TB
Personal history
1.Alcohol: Frequency alcohol drink with unknow amount about 30 years
2.Smoking: 1.5PPD about 20+ years 3.Drug abuse:no drug abuse
On physical examination at ER
GCS: E4 V1 M4 B.P.: 215/109mmHg T/P/R = 37.5 /132 /20
2.HEENT: Head: no deformity ENT: No oral ulcer, Lip:not cyanotic, Eyes: conjunctiva: not anemic, sclera:not icteric, mild discharge Eye lips edema 3.Neck: Jugular vein: supple, Lymph node: No cervical lymph node palpable Thyroid: No Goiter No carotid bruit 4.Chest: Chest wall: symmetrical expansion Breathing sound: clear 5.Heart: Regular heart beat without murmur Heart sound:S1,S2:normal, No S3 or S4 gallop
6.Abdomen: Soft, mild distent, No palpable mass 7.Extremities: pitting edema, grade 2, no clubbing finge
rs or toes 10.Skin & mucosa: No pigmentation, no petechia, no e
cchymosis 11.Peripheral pulses: Normal
Lab
Finger sugar : 34 mg/dLSerum glucose: 35mg/dL Gitose 20ml x 4 ampConscious recovery fully without any neur
ological sign
Diagnosis
Hypoglycemia, recoveryType 2 DM
Discussion
Hypoglycemia
Glucose is an obligate metabolic fuel for the brain
The brain cannot synthesize glucose or store more than a few minutes'
roughly 70–110 mg/dL endogenous glucose production hepatic glycogenolysis, and hepatic (and renal)
gluconeogenesis
Harrison 17th
Hypoglycemia
Neuroglycopenic symptoms behavioral changes, confusion, fatigue, seizure,
loss of consciousness, death Neurogenic (or autonomic) symptoms C
NS-mediated sympathoadrenal discharge Adrenergic symptoms
palpitations, tremor, and anxiety cholinergic symptoms
sweating, hunger, and paresthesias
Harrison 17th
Harrison 17th
Hypoglycemia
Whipple's triad 1) symptoms consistent with hypoglycemia 2) a low plasma glucose concentration
measured with a precise method (not a glucose monitor)
3) relief of those symptoms after the plasma glucose level is raised
Harrison 17th
Harrison 17th
Harrison 17th
Harrison 17th
Treatment
Oral Readily absorbable carbohydrates (glucose) Milk, candy bars, fruit, cheese
IV 50% dextrose 20-50ml, bolus D5W infusion keep glucose>100
IM/SC Glucagon 1mg Side effect: vomiting
Education Medication, diet, and exercise regimens
The Washington manual 32th
Confirmation of Hypoglycemia in the 'Dead-in-Bed' Syndrome as Captured by a Retrospective Continuous Gl
ucose Monitoring System.
23 year old man with a history of type 1 diabetes treated with an insulin pump
< 30 mg/dL around the time of his death This report should raise the awareness of physicians to the potential
ly lethal effects of hypoglycemia and provide justification of efforts di
rected at avoiding nocturnal hypoglycemia
Endocr Pract. 2009 Oct 15:1-13
Thank You