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