Patient presents the emergency room with a 2-day history of increasing confusion not eating much or drinking much.  She was confused when she came in not doing well.  Blood sugar in the ambulance was 46 upon entering the emergency room it was 14. Initially upon entering the emergency room we are unable to do a review of systems secondary to her mentation.  Once we got the IV finally started start some fluids her mentation did come around.  Initially she was complaining quite a bit of back pain confusion weakness.  Apparently has been going on for couple of days.  Talking with her husband on the phone and the only medication she taken is some tramadol and ibuprofen. Initial physical exam sure to be quite confused somewhat resistant to our cares.  She had to be reminded again and again to hold still.  3 attempts were made at starting IVs all unable to get there.  She was supposed to get D50 secondary to her low blood sugar but we are unable to do that she did drink a container of orange juice which did perk her up a little bit.  Anesthesia was called in to get her IV started.  In the meantime the lab drew very little blood but again enough to see that she was in acute renal failure her blood sugar was back up to 38.  Her hemoglobin was at 8.8.  Multiple examinations were done while she was in the emergency room the final exam is the one that will be documented here.  Initially HEENT is fine other dry mucous membranes her heart was regular lungs were clear abdominal exam was benign no complaints of pain to palpation.  Later on that changed and she was having some back pain. Patient is confused she has had low blood sugars her blood pressure continues to drop she is in acute renal failure as far as we know for sure renal failure.  She is anemic.  We have very little history on her as she is unable to give us much history and there is nothing in the hospital.  I need to admit the patient get a hydrate her to get her blood pressure up order to monitor her blood sugars I will recheck her kidney function and hemoglobin in the morning.  In the meantime we will get the monitor her oxygen saturations her blood pressure pulse and her blood sugars as they continue to drop.  I still have some lab pending we will follow up that closely. Patient is extremely confused this morning.  During the night we are trying to hydrate her with a creatinine of 5.2 there was no change this morning.  She started to fluid overload so we stopped the IVs try to give her Lasix again basically no urine output.  As far as we know she has not taken anything at home other than Toradol and ibuprofen.  My fear she took too much but were unsure still why her blood sugars are bottoming out and why she is so confused.  This morning we will do a CT of her head and do a CT of her abdomen and I will follow up with these.  Will need more lab work and wait till after the CAT scans to see if there is something else we need to order.  Plans are to try to transfer her to a nephrologist depending on her findings.  We need the CAT scans first. Patient's renal failure is no better.  She has huge calculus in the ureters which is obstructing the patient's urine flow she is getting no fluid output she is in dire straits at this time. In the emergency room patient sensation would clear then should be confused again.  Blood work was okay other than her blood sugars continue to stay low.  We initially gave her D50 a couple times.  It was difficult due to the fact that it took for 5 attempts at starting IVs to get 1 that would work.  When I did start working we started hydrating the patient significantly due to her low blood sugars her blood pressure and such.  Has a picture started to clear she started to become more confused.  She would have moments of normal sensorium and then she would be quite confused again.  Again her blood sugars were staying low so we did start her on D5.  After she had a couple liters and it was noted that she was having difficulty breathing and her urine output had been next to nothing.  We did float a Foley initially so we could monitor this.  We did eventually have to stop the IVs but her blood sugars continued to stay low so we started her on D10 at 250 eventually moving it down to 125.  Her vital signs remained somewhat stable.  She had some problems with oxygenation early on but we did give her oxygen which did bring it up into the normal range.  Eventually confused as to why her blood sugar stayed low I did a CT of her head which was essentially normal and a CT of her abdomen which showed enormous renal calculi which was causing obstruction which is why she was getting no urine output.  We had noted that her creatinine was 5.2 the next day it had not improved probably from obstruction.  At this point time her mentation was not clearing she was staying confused the whole time somewhat combative or at least restless.  We have given her Ativan some Haldol to keep her from tearing out her IVs and the nurses and such.  We then attempted to transfer the patient where she can get a higher level of care and we can take care of the renal stones.  We had excepting physician but his Institute had no availability.  We then called approximately 50 hospitals in the 6 state area and had no facility that would take our patient.  We continue to monitor her maintaining her blood sugars her blood pressure then bottomed out and Levophed had to be started.  It is currently running at 34 mics but had been much higher to maintain blood pressure.  Again very little urine output it was noted that the urine she did have out was full of bacteria whites and reds.  We started her on Rocephin.  We did get an opening at the hospital 40 miles away with an accepting physician who states that he can go when and stent her kidneys.  We are currently working on that transfer and as soon as we get acceptance patient will be discharged and transferred to another hospital.  Patient is in and will remain in very guarded condition.