A 68 year old female came to hospital with altered sensorium (since 20 mins) on time of admission GRBS was 33 mg /dl .
After infusion of one 25 D , patient became normal within 15 minutes.
She had similar episode in the night. She had complaints of
1.) Decreased urine output since 10 days
2.) Vomitings and loose stools since 4 days
Patient was apparently asymptomatic 10 days back. Then she had decreased frequency of urine at night ( from 10 episodes to 2 episodes ) . Not associated with any fever, burning micturation.
4 days back patient had 5 episodes of vomitings and loose stools .
Vomitings - non projectile, containing food particles, mom foul smelling.
Loose stools - watery in consistency, not associated with any bloody discharge , not associated with pain abdomen.
History of past illness :-
K/c /o DM 2 since 2 years using Glimiperide 2 mg + Metformin 500 mg 1.5 tab OD
K/c/o HTN since 2.5 years using Amlodipine 5mg Hydrochlorthiazide 12.5 mg
Patient is on Deriphyllin retard 150 mg and Betamethasone 0.5 mg since 2 months ( SOS)
Patient is on Spironolactone 25 mg and Furesemide 100 mg since 2 years.
EXAMINATION
patient is conscious , coherent.
BP - 140/90 mmHg ; PR - ;RR-
CVS- S1 S2 heard . No thrills. No murmurs
RS - trachea central in position . No dyspnea , no wheeze, vesicular breath sounds.
P/A - scaphoid in shape. No tenderness, no palpable mass. Normal hernial orifices. No free fluid and bruits.
CNS - conscious with normal speech. No signs of meningeal irritation. No motor, sensory and cranial nerve deficits.
PROVISIONAL DIAGNOSIS
Recurrent hypoglycemia ( OHA induced , sulfonylureas) with pre renal AKI with k/c/o HTN with anemia of chronic disease ( 2° to ? CKD ).
TREATMENT on 16-02-2021
1.) GRBS hourly.
2.) IVF DNS @ 25 ml / hour.
3.) I/ O charting
4.) Strict BP / PR monitoring.
5.) With hold OHA till further orders
6.) Intial dose 0.5 - 1 g /kg / bolus ( dextrose )
7.) Inj. Na HCO3 50 m Eq in 100 ml NS IV stat
8.) T. Orofer XT BD
9.) T. Nodosis 500 mg PO BD
10.) T. Amlong 5 mg OD
SOAP update on 17-02-2021
S- multiple episodes of profuse sweating and giddiness.
At 5:30 am or was unresponsive with frothing with profuse sweating with GRBS 24 mg /dl . Gave 4 units of 25 % dextrose. Regained consciousness , GRBS -284 mg /dl
O- pt is c/c/c
Afebrile, BP- 140/90 mmHg ; PR - 87/ min
CVS - S1 S2 heard , RS - BAE present
P/A - soft, non tender; CNS - HMF, NFD
A- recurrent hypoglycemia ( OHA induced sulfonylureas)
2° to pre renal AKI ( resolving)
? diabetic nephropathy with known case of HTN with anemia of chronic disease with cholelithiasis.
P-
1.)GRBS hourly
2.) IVF -25% Dextrose in 50 ml NS @50 ml per hour
3.) T. Orofer XT BD
4.) T. Amlong 5 mg OD
5.) BP/ PR charting hourly
6.) I/O charting
7.) T. SHELCAL CT 500 mg OD
8.) T. Furesemide 40 mg PO BD
9.) Inj. NaHCO3 50 new in 50 ml NS over 30 mins.
Anion gap (k) = 12.9
SOAP update on 18-02-2021
S - no fresh complaints. Pedal edema present . Stools passed . No fever spikes.
O- pt is c/c/c
Afebrile, BP- 150/90 mmHg ; PR - 88/ min
CVS - S1 S2 heard , RS - BAE present ,NVBS
P/A - soft, non tender; CNS - HMF, NFD
A- recurrent hypoglycemia ( OHA induced sulfonylureas) ( resolving) .
2° to pre renal AKI ( resolving)
With diabetic nephropathy with known case of HTN with anemia of chronic disease with cholelithiasis.
P-
1.) Allow regular diet
2.) GRBS 4th hourly and inform less than 100 mg/dl or more than 200 mg /dl
3.) T. Amlong 5 mg PO OD
4.) T. Orofer XT BD
5.) T. SHELCAL CT OD
6.) T. Furesemide 40 mg PO OD
7.) T. Nodosis 550 mg PO OD
8.) Strict I/O charting
9.) BP/PR/ temp hourly
10.) IVF NS 2 pints @30 ml/ hr
11.) Inj. Iron sucrose in 100 ml NS IV OD over 10 min
SOAP update of 19-02-2021
S- no fresh complaints
O- pt is conscious, coherent, cooperative
Afebrile, PR- 96bpm
BP- 140/80mmhg
CVS- S1S2 heard ,
RS- BAE+ NVBS
P/A- soft non tender
CNS- no focal deficits
A- RECURRENT HYPOGLYCEMIA ( OHA induced ( sulfonylureas) ]
Secondary to PRE-RENAL AKI ( resolving)
With DIABETIC NEPHROPATHY
With k/c/o HTN with ANAEMIA OF CHRONIC DISEASE with CHOLELITHIASIS
With subclinical hypothyroidism
P-
Rx
1. Allow regular diet
2. GRBS 6th hourly
3. T.AMLONG 5mg/PO/OD
4. T.OROFER XT /BD
5. T.SHELCAL CT/ OD
6. T.FUROSEMIDE 40mg/PO/BD
7. T.NODOSIS 550mg/PO/BD
8. T.THYRONORM 25mcg/PO/OD
9. Ointment thrombophobe for L/A
10. T. CINOD 10mg/OD
11. Cap. Bio D3 -3/week
