Case of the Month
May 2004

47-year-old female — altered mental status/diabetic history

1846 hrs, after finishing a grueling workout, you and your partner have been dispatched to 6700 E. Slater for a 47-year-old female with an altered mental status and a history of diabetes. RP states that she had eaten some fruit a few minutes ago. You arrive and enter her home to find her sitting at the kitchen table. She is conscious yet confused in no apparent respiratory distress and is propping her head up with her hands. Her skin is pale, cool and sweaty. You determine that she has a bounding radial pulse at about 110, and she has no other obvious complaints or discomforts. Based upon these initial findings, altered mental status and skin signs, your initial assessment of this patient is…Sick!

You call for a medic unit and offer a patient status update to include your desire to perform blood glucometry. You place the patient on high flow oxygen by NRM @ 12Lpm, and confirm the patient’s vital signs: a blood pressure of 162/84, pulse (radial) @ 110 and bounding, respirations @ 24 with good tidal volume and bilateral breath sounds are heard ( pulse oximetry @ 96%) your patient is conscious yet confused, skin signs are pale, cool and moist. You continue with your physical assessment including a SAMPLE history and detailed physical exam as your partner prepares for blood glucometry.

S	—	Signs/symptoms — altered mentation/confusion, cool, moist skin
A	—	No known allergies
M	—	Lente, Ultra Lente, Allegra
P	—	Insulin dependant diabetes (IDD)
L	—	Early this am, eat an orange 10 minutes ago
E	—	Worked in the yard all day.

You perform blood glucometry and are surprised by a reading of 245…this causes some concern with you and your partner as this doesn’t seem to add up (decreased LOC, pale/cool/moist skin, hx of diabetes) you are now searching for other probables to this scenario…Medics give an update that they are 5-7 minutes out. Out of interest, your partner asks the husband if the patient handled the orange that she ate or did he place the pieces in her mouth. Curiously, the husband said that he handed the orange pieces to her and that she put them into her own mouth…with her right hand, the same hand that was used for the blood glucometry. Quickly, the other hand was cleaned with a wet towel and blood glucometry was repeated…the reading was 26!

Blood Glucometry
For this call, everything was done correctly at the BLS level in regards to assessment (Sick), treatment and the testing of the patient’s blood glucose level. The interesting fact in this case was the residual fructose that was still on the patient’s hand after handling the orange pieces. There was enough present to alter the reading. That said, the EMTs on this call did not let that alter their care for the patient, rather, once the appropriate treatment had been started they were able to process other reasons for the suspected false reading!

The lesson from this case: “Treat the patient first – figure the rest out later.”