Records From My Trip to the ER on October 1, 2025

The following is a transcript from my medical files from October 1, 2025 in the ER. Names have been edited out or redacted. Formatting is altered as well, but not the content other than the names.

PHYSICIAN ASSESSMENT:

· History: 58-year-old male

Presenting to the emergency department with primary concerns of general weakness. The patient is feeling dizzy, diaphoretic, and generally weak starting today. States the last time that he ate was yesterday. Has been having some nausea, but no vomiting. Denies any fevers or chills. No chest pain or shortness for breath. Denies any abdominal pain. No recent changes to bowel or bladder function. Has been taking his medications as prescribed. No history of diabetes. It is not on any insulin or other diabetic medications. EMS found a patient with a glucose of 2.1. Was given 250 cc of D5W. Normal saline bolus also started

Past medical history:  Hypertension, chronic back pain, fibromyalgia, arthritis, heart failure. The patient is on Entresto. Has Schizoaffective disorder.

Atrial fibrillation

Medications:

Furosemide

Risperidone

Rabeprazole

Bupropion

Rivaroxaban

Entresto

Atenolol

Spironolactone

Vitamin-B 1

· Physical: Well.  No acute distress. GCS 15

Temperature 36.7°, heart rate 150, respiratory rate 22, O2 saturation 93% on room air, blood pressure 122/78. Cardiac: S1-S2 normal. No audible murmur. There is bilateral edema noted. Respiratory: Air entry is equal bilaterally. No crackles or wheeze present.

Abdomen:  Soft, nontender

· Impression/Plan: Hypoglycemia

The patient again went hypoglycemic. 50 cc of D50W were given. Will continue to monitor blood sugar

Blood work ordered

· Reassessment: Blood work reviewed:

Troponin 20. Electrolytes are unremarkable. Lactate 6.7. Remainder of blood work is largely unremarkable. CRP is negative. BNP pending

The patient's glucose once again dropped to 3.0. The patient was given juice and a sandwich.

Repeat blood sugar 5.2. The patient remains tachycardic, given Ringer's lactate 1 L IV x1

BNP is returned at 172. Repeat glucose 3.3. The patient remains hungry. Will feed more. The patient still remains quite tachycardic.  I am hesitant to give fluids, as it may push him into fluid overload. Will wait for BNP result

Repeat blood sugar now 5.3. The patient remains tachycardic in atrial fibrillation, given Metoprolol 5 mg IV x1, Metoprolol 25 mg p.o. x1

MOST RESPONSIBLE DIAGNOSIS:

· Diagnosis: Hypoglycemia, uncontrolled AFib

HANDOVER:

· Handover *********

· To Do : Please monitor the patient overnight. If heart rate settles and the patient remains normal glycemic, and can likely be discharged home. If not, we will require internal medicine consultation.

Did well overnight with improvement in labs and symptoms. Able to tolerate PO. Ambulating per self. Discharged home.

FIRST ORDER MODIFIER: VITAL SIGNS

Triage Vital Signs:

· Temperature C 36.7 C

· Temperature Site oral

· Heart Rate 150 bpm

· Respiratory Rate 22 breaths/min

· Oxygen Saturation 93 %

· Oxygen Delivery room air

· BP Systolic 122 mm Hg

· BP Diastolic 78 mm Hg

· BP Site upper arm right

SUBJECTIVE:

· Comments BIBEMS with confusion, dizzy, diaphoretic, nauseated Glucose 2.1. Was given 250mls of D5 1L NS being given no abdominal pain. No chest pain. Patient admits to not eating today, denies UTI symptoms, lower leg edema PMHx- HTN, Chronic back pain, fibromyalgia, arthritis of the knees,  heart failure on Entresto, Schizoaffective disorder.

ALLERGIES SUMMARY: erythromycin: 11-Mar-2018 17:36, Swelling (Major)