CHIEF COMPLAINT: Syncope.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male who has had syncope 7 times recently. He got up to go to the bathroom and then found that his legs were shaking, and his wife thought he was having a seizure.
EMS was summoned. His blood sugar was too low to read, given amp of D50, and brought him here. Family states his blood sugar was low this morning at 40. They gave him some juice.
PAST MEDICAL HISTORY: Hypertension, hypercholesterolemia, colon cancer with colostomy, bowel obstructions and diabetes mellitus.
SOCIAL HISTORY: Nonsmoker and nondrinker.
MEDICINES: Tricor, Lortab, Celexa, Coumadin, Flomax, Amaryl, glyburide, Nexium, Flomax, Avapro, Compazine and metoprolol.
ALLERGIES: None.
REVIEW OF SYSTEMS: As in HPI. He has no headache. No chest pain. No shortness of breath. No abdominal pain. No fever. No vomiting. No dysuria. All the systems were reviewed and negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 98/50, heart rate 88, respirations 18, temperature 36.2, and O2 saturation is 94% on room air.
GENERAL: This is an awake and alert male in no acute distress.
HEENT: Pupils are equal, round and reactive to light. No scleral icterus or pallor. Nares without drainage. Oropharynx is dry. No erythema.
HEART: Regular rhythm. No murmurs.
LUNGS: Clear to auscultation bilaterally with no rales or wheezes.
ABDOMEN: Soft, nontender and nondistended. Normoactive bowel sounds. He has a colostomy bag with stool.
EXTREMITIES: Warm.
SKIN: Without rash. Pulses are 2+ x4. No calf tenderness or edema.
NEUROLOGIC: Cranial nerves II through XII intact bilaterally. Muscle strength 5/5. Sensory intact to light touch x4. DTRs are 1+ and symmetric.
EMERGENCY DEPARTMENT COURSE: The patient had an IV established by EMS. He was given a 500 mL normal saline bolus here bringing his blood pressure up into the 120s. He had an electrocardiogram showing normal sinus rhythm with T-wave inversions in V2 and V3, which appeared to be new from previous EKG. No ST segment changes.
LABORATORY DATA: Comprehensive metabolic panel; sodium 134, BUN 36, creatinine 1.6 and glucose 64. Initial i-STAT showed a pH of 7.25, bicarbonate 18, potassium 5.2, and BUN 36. CBC: White count 6.6, hemoglobin 12.2, platelets 246, differential 87%, and neutrophils without bands. PT 15.8 with an INR of 1.2, CK and total MB normal with a troponin less than 0.02.
We repeated a blood sugar on him shortly after arrival and it was again low at 42. He was given an amp of D50 and 1 L of D5 normal saline bolus under my supervision. Given his recurrent hypoglycemia on oral agents and worsening renal function versus dehydration, we felt he should be admitted as the risks for recurrence of hypoglycemia is high within the next 24 hours.
We spoke with Dr. John Doe, on-call for the hospitalist service, and his primary care physician. He is aware of the patient’s EKG changes from previously as well. The patient is not having any chest pain, and his cardiac enzymes were negative.
DIAGNOSES:
1. Recurrent hypoglycemia.
2. Falls.
3. Dehydration and renal insufficiency.
4. EKG changes.
CONDITION ON ADMISSION: Stable.
Care was transferred to Dr. John Doe. At the time of admission, we did repeat blood glucose on this patient and it was 128 after an hour.
