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 Consciousness

Patient

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 wasnt problem in defecation.

blackish stool was denied.

History of

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 -/-

+/+
+/+
-/-/-

 Complete
Parameter

Blood Count
Result

Unit

Reference range

WBC

10,8

103/L

4,1 11,0

-Ne

3.7

103/L

2,5 7,5

-Ly

1,40

103/L

1,0 4,0

-Mo

1,30

103/L

0,1 1,2

-Eo

0,50

103/L

0,0 0,5

-Ba

0,00

103/L

0,0 0,1

RBC

4,32

106/L

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/L

150 440

 Blood

Chemistry Panel

Result

Unit

Remarks

Reference
Range

SGOT

30

U/L

11,00 33,00

SGPT

32

U/L

11,00 50,00

BUN

20,18

mg/dL

10,00 23,00

1,18

mg/dL

0,50 1,20

Parameter

Creatinin

K
Na

3.64

Mmol/L

3.50 - 5.10

136 - 145
140

Mmol/L

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 dpm
Bolus 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

Severe

Capable of
self-treating

May 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

Neuroglycop
enic

Neuroglycopen
ic


1.

Preparations
Oral: Equivalents of 15
grams glucose (1
carbohydrate)
1. Three glucose tablets (or
2.
3.
4.
5.
6.

15 grams of glucose gel)

Fruit juice 1/2 cup (4
ounces)
Regular soda 3/4 cup (6
ounces)
Milk 1 cup (8 ounces)
Honey or corn syrup 3
teaspoons
Crackers (6 saltine
crackers)

2.

Glucagon Intramuscular
or Subcutaneous
1. Precautions
1.
2.
3.

Transient effects only

Ineffective when Liver
Glycogen depleted
Vomiting and aspiration
risk
1. Roll patient onto their
side when used

2. Dose
1.
2.

Teens and adult: 1 mg

Children: 0.5 mg (0.5 ml)
or 15 mcg/kg

3.

Administer
Intravenous Dextrose
1.
2.

3.
4.

Bolus: 10-20 ml of
D50W IV
Maintenance: D10W IV
at 100 cc/hour until
stable
Keep plasma glucose
over 100 mg/dl
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):

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

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

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