oral sulfonylureas and 30's yr old chest pains

[unchartedem]

I'm having 2 problems since I started practicing. I haven't been sure what to do with the stable one episode of hypoglycemia patients who are on sulfonylureas( should I admit them regardless?) I know an overdose is a no brainer but the literature hasn't been too clear about someone taking their normal daily dose and has a random episode of hypoglycemia.(excluding sepsis, renal/hepatic failure etc...).

Also I get really irritated when I pick up a chart of a 30 something yr old and CC is chest pain, because I'm always indecisive. I've been trained to basically always do cardiac workups on these people if it's not obvious PE or muscle, but I've been doing the opposite and if they have no fam hx, no coke, normal ekg, no risk factors, I do a CXR and then discharge. Is this reasonable?

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[kat82]

I don't think you can safely discharge a patient who had an episode of hypoglycemia who is known to be on a long acting agent (oral or insulin). If they were otherwise healthy I would put them in the obs unit (or admit if none available) and discuss with their PMD/endocrinologist

Chest pain: For me, at a bare minimum every adult patient gets an EKG/CXR. After that, its patient specific and you have to go with the patients story and individual characteristics. A 30y/o with bogus chest pain can have an MI or it can just be bogus. Just document why you think/don't think its ACS, PE, dissection, GERD, etc. If there's one thing I've learned there is huge practice variation in how people manage chest pain, so you'll see different attendings doing different things. There is no right answer and you'll develop ideas about what your style will be when you graduate.

 

[BADMD]

I'm having 2 problems since I started practicing. I haven't been sure what to do with the stable one episode of hypoglycemia patients who are on sulfonylureas( should I admit them regardless?) I know an overdose is a no brainer but the literature hasn't been too clear about someone taking their normal daily dose and has a random episode of hypoglycemia.(excluding sepsis, renal/hepatic failure etc...).

My rule of thumb: If you can explain why they got hypoglycemic, you can discharge them. If you can't, observe them.

 

[Daiphon]

I don't think you can safely discharge a patient who had an episode of hypoglycemia who is known to be on a long acting agent (oral or insulin). If they were otherwise healthy I would put them in the obs unit (or admit if none available) and discuss with their PMD/endocrinologist

If on a hypoglycemic agent such as insulin or a sulfonylurea, I usually give them food +/- d50 first (honestly most ems systems will hit them with a stick of dextrose before they hit my door).

If they drop again, 23h obs. If there's impaired clearance (AKI), IVF + 23h obs.

If they're maintaining euglycemia after a few hours & accucheks, and no other problems, then ALC (a la casa) w/ close follow up.

Cheers!
-d


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[Arcan57]

If on a hypoglycemic agent such as insulin or a sulfonylurea, I usually give them food +/- d50 first (honestly most ems systems will hit them with a stick of dextrose before they hit my door).

If they drop again, 23h obs. If there's impaired clearance (AKI), IVF + 23h obs.

If they're maintaining euglycemia after a few hours & accucheks, and no other problems, then ALC (a la casa) w/ close follow up.

Cheers!
-d


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Seconded. Also, I don't send unexplained hypoglycemia home.

 

[Daiphon]

Also, I don't send unexplained hypoglycemia home.

Ditto.

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