Name : NML

Sex : Female

Age : 49 years old

Marital Status : Married

Religion : Hindu

Address : Br, kawan Kel Serangan

Date of admission : 18 June 2014

Chief complaint: Decrease of ConsciousnessPatient came with chief complaint of decrease of consciousness since the afternoon BATH.

The decrease of consciousness happened when the patient was sleeping. She was found unconscious in her bedroom.

Her family said that the patient took DM medicine early in the morning after breakfast . Family said she just eat 2 spoon of chicken porridge.

Her family said that the patient also complaint weakness in whole body and also complain cold sweat 1 hour before BATH.

There was no other complaint like cough, breathlessness, nausea and vomiting.

.

Urination was said to be normal. There wasn’t problem in defecation. History of

blackish stool was denied.

Past History :History of same complaints denied. She has DM since 1 year ago. She did consume DM medicines

regularly.

Family History :None of her family members have the same complaints as patient.

Medication History :Patient took glibenclamide 5 mg early in the morning BATH.

Sosial History :Patient is married and she is a housewife.Smoking habit and alcohol consumption were denied by the patient.

General Appearance : severely ill

Level of Consciousness : E2V2M5

Blood Pressure : 130/80 mmHg

Respiratory Rate : 20x/mnt

Pulse Rate : 80 x/mnt

Axillary Temperature : 360 C

BW : 80 kg

BH : 165 cm

BMI : 29,4 kg/m2

Eye : Anemic -/-, Icteric -/-, Pupil Reflex +/+ isochor ENT : lip cyanosis (-) Neck : JVP PR ± 0 cm H20 Thorax : Cor :Inspection : Ictus Cordis Unseen

Palpation : Ictus Cordis unpalpable Percussion : Right Border – Parasternal Line D

Left Border – MCL S Auscultation : S1S2 Single, Reguler, Murmur (-)

Lung : Inspection : Simetric Palpation : vocal fremitus N/N. Percussion : Sonor / Sonor Auscultation : Vesicular +/+, Rhonchi-/- , Wheezing -/-

+/++/+

-/--/-

Parameter Result Unit Reference range

WBC 10,8 103/μL 4,1 – 11,0

-Ne 3.7 103/μL 2,5 – 7,5

-Ly 1,40 103/μL 1,0 – 4,0

-Mo 1,30 103/μL 0,1 – 1,2

-Eo 0,50 103/μL 0,0 – 0,5

-Ba 0,00 103/μL 0,0 – 0,1

RBC 4,32 106/μL 4,00 – 5,20

HGB 14,30 g/dL 12,00 – 16,00

HCT 41.7 % 41,0 – 53,0

MCV 93,70 fL 80,0 – 100,0

MCH 33,10 pg 26,0 – 34,0

MCHC 35,30 g/dL 31,0 – 36,0

PLT 243,00 103/μL 150 – 440

Complete Blood Count

Blood Chemistry Panel

Parameter Result Unit RemarksReference

Range

SGOT 30 U/L N 11,00 – 33,00

SGPT 32 U/L N 11,00 – 50,00

BUN 20,18 mg/dL N 10,00 – 23,00

Creatinin 1,18 mg/dL N 0,50 – 1,20

K 3.64 Mmol/LN

3.50 - 5.10

Na 140 Mmol/L N136 - 145

Sinus Rhytm Axis normal HR 75x/ minute P normal PR Interval normal QRS: normal ST change (-) T wave normal

Conclusion: normal sinus rhytm

Obs. Decrease of consciousness ec suspect hypoglycaemia (Glibenclamide induced)

DM type II

Hospitalized IVFD Dextrose 10% - 20 dpmBolus Dextrose 40% 30-50 cc @ 15

minutes until blood glucose ≥ 70 gr/dl

Stop glibenclamid ( temporary) .

Fasting Blood Glucose + 2 hours PP

MONITORING Vital Signs Complains BS @ 1 hour

Definition: The level of glucose falls in the blood so that the cells in the periphery, and eventually the brain cells, do not get adequate glucose impaired function

Blood glucose level below 4mmol/L (72mg/dL)

Wide variation of symptom

Blood glucose level is about 4.2mmol/L (75.6mg/dl) the secretion of endogenous insulin is suppressed

At about 3.7mmol/L (66.7mg/dl) the secretion of glucagon is increased – releasing stored glucose. This is followed by increases in epinephrine, cortisol and growth hormone. All these hormones are in effect trying to raise blood glucose.

At about 3.1mmol/L (55.8mg/dl) autonomic (adrenergic) symptoms appear: Tremors in 32%-78% of people Palpitations in 8%-62% Sweating in 47%-84% Anxiety in 10%-44% Ravenous hunger in 39%-49% Nausea in 5%-20% Tingling especially around lips in 10%-39%.

At about 2.5mmol/L (45mg/dL), the brain no longer receives enough glucose and temporary cognitive impairment occurs.

This shortage of glucose (glycopenia) in the brain is called neuroglycopenia. Prolonged neuroglycopenia can result in permanent damage to the brain.

People experience: Difficulty concentrating (31%-75%) Confusion (13%-53%) Weakness (28%-71%) Drowsiness (16%-33%) Vision changes (24%-60%) Headache (24%-36%) Tiredness (38%-46%).

Mild Moderate SevereCapable of

self-treatingMay require prompting

Not capable of self-treatment

Tremors, palpitation, sweating, hunger, fatigue

Headache, mood

changes, low attentiveness

Conscious or unconscious,

seizures, transient paralysis, cognitive

impairment, death

Adrenergic Neuroglycopenic

Neuroglycopenic

Preparations1. Oral: Equivalents of 15

grams glucose (1 carbohydrate)1. Three glucose tablets (or

15 grams of glucose gel)2. Fruit juice 1/2 cup (4

ounces)3. Regular soda 3/4 cup (6

ounces)4. Milk 1 cup (8 ounces)5. Honey or corn syrup 3

teaspoons6. Crackers (6 saltine

crackers)

2. Glucagon Intramuscular or Subcutaneous

1. Precautions1. Transient effects only2. Ineffective when Liver

Glycogen depleted3. Vomiting and aspiration

risk1. Roll patient onto their

side when used

2. Dose1. Teens and adult: 1 mg2. Children: 0.5 mg (0.5 ml)

or 15 mcg/kg

3. Administer Intravenous Dextrose

1. Bolus: 10-20 ml of D50W IV

2. Maintenance: D10W IV at 100 cc/hour until stable

3. Keep plasma glucose over 100 mg/dl

4. May require 10 grams/hour IV

Protocol: Glucose monitoring

1. Monitor Blood Glucose every 15 minutes until >100 mg/dl

2. Redose glucose replacement per above every 15 min prn

Mild Hypoglycemia (BG 60-70 mg/dl):

Give 15 carb grams Glucose oral gel 40%

15 grams orally or Glucose 3 tablets

orally or Juice 4 ounces orally

Moderate Hypoglycemia (BG 45-59): Give 20 carb grams

Glucose oral gel 40% 20 grams orally or

Glucose 4 tablets orally or Juice 6 ounces orally or Dextrose 50% 25 ml IV

Severe Hypoglycemia (BG <45): Give 30 carb grams

Glucose oral gel 40% 30 grams orally or

Glucose 6 tablets orally or

Juice 8 ounces orally or

Dextrose 50% 25 ml IV

Unconscious with severe Hypoglycemia (BG<45)

Dextrose 50% 25 ml IV or

Glucagon 1 mg SQ or IM (0.5 mg for child)

Vomiting and aspiration risk Roll patient onto their side when used