70M with altered sensorium sec to hypoglycemia with DM

DOA : 4/2/2023
DischargeDate 
Date: 7/02/2023 
Ward:medicine 
Unit:GM-6

Diagnosis
ALTERED SENSORIUM SECONDARY TO HYPOGLYCEMIA (RESOLVED),
?OHAINDUCEDHYPOGLYCEMIA, HFmEF (EF :50%),
RIGHTGREATTOEGANGRENEWITHAKIONCKD ANEMIA UNDER EVALUATION ?IDA HYPERKALEMIA (RESOLVED)
DM SINCE : 20 YEARS
Case History and Clinical Findings
PATIENT WAS BROUGHT TO THE CASUALITY IN AN UNCONSCIOUS STATE .PATIENT WAS APPARENTLY NORMAL UNTIL 9PM YESTERDAY NIGHT , THEN HE SUDDENLY WENT INTO THE STATE OF UNCONSCIOUSNESS AFTER EATING FOOD , NOT ASSOCIATED WITH VOMITING , SEIZURES,CHEST PIAN , PALPITATIONS , INVOLUNTARY MICTURITION , FROATHINGFROMMOUTH.NOH/OFALL,TRAUMATOHEAD,GIDDINESS,FEVER,BURNING MICTURITION.
PASTHISTORY:K/C/ODMSINCE20YEARSANDONT.GLIMIM1 NO H/O HTN/EPILEPSY/TB/CVD/CAD
H/OTRAUMATORIGHTLOWERLIMBFORWHICHTIMELYINTERVENTIONWASDONEATA LOCAL HOSPITAL , BUT STILL GANGRENOUS GREAT TOE +

PERSONAL HISTORY :
APPETITE-NORMAL DIET - MIXED
BOWELANDBLADDER-REGULAR SLEEP - ADEQUATE

GENERAL EXAMINATION :
PT IS C/C/C
NOPALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHEDENOPATHY,PEDALEDEMA VITALS ON ADMISSION:
TEMP-98.5 PR-90 BPM
BP-160/90MMHG RR-16 CPM
SPO2-100%ATRA GRBS - 33 MG/DL

SYSTEMIC EXAMINATION:
PER ABDOMEN:
INSPECTION:UMBILICUSISCENTRALANDINVERTED,ALLQUADRANTSMOVINGEQUALLY WITH RESPIRATION,NO SCARS,SINUSES,ENGORGED VEINS,PULSATIONS.
PALPATION:SOFT,NONTENDER.NOORGANOMEGALY. ASCULTATION: BOWEL SOUNDS - HEARD 
2)RESPIRATORY SYSTEM:
INSPECTION:SHAPEOFTHECHESTISELLIPTICAL,B/LSYMMETRICAL.BOTHSIDESMOVING EQUALLY WITH RESPIRATION..NO SCARS,SINUSES,ENGORGED VEINS,PULSATIONS. PALPATION:NO LOCAL RISE OF TEMPERATURE AND TENDERNESS ,TRACHEA IS CENTRAL
IN POSITION.EXPANSION OF CHEST IS SYMMETRICAL .VOCAL FREMITUS IS NORMAL
PERCUSSION: RESONANT B/L
ASCULTATION: BAE + , NVBS HEARD, LEFT IMA CREPTS +
CVS:
INSPECTION:B/LSYMMETRICAL,BOTHSIDESMOVINGEQUALLYWITHRESPIRATION,NO SCARS,SINUSES,ENGORGED VEINS,PULSATIONS.
PALPATION: APEX BEAT FELT IN LEFT 5TH ICS.NO THRILLS AND PARASTERNAL HEAVES.
ASCULTATION: S1S2 +,NO MURMURS
CNS:
PATIENT WAS C/C/C.
HIGHERMENTALFUNCTIONS-INTACT GCS - E4V5M6
B/L PUPILS - NORMAL SIZE AND REACTIVE TO LIGHT
NOSIGNSOFMENINGEALIRRITATION,CRANIALNERVES-INTACT,SENSORYSYSTEM- NORMAL,
MOTOR SYSTEM: TONE- NORMAL, POWER- 5/5 IN ALL LIMBS
REFLEXES : BICEPS - 1+ , TRICEPS-1+ , SUPINATOR - ,KNEE - 1+ , ANKLE - 1+


REFERRALS TAKEN:
OPTHALMOLOGY:I/V/ORAISEDICT-FUNDUSEXAMINATIONREVEALEDCATARACTOUS LENS- ADVISED B/L CATARACT SURGERY
SURGERY:I/V/ORIGHTGREATTOEGANGRENE-SUGGESTEDRAYAMPUTATIONUNDER SA OR ANKLE BLOCK.
BRIEF COURSE IN HOSPITAL:
PATIENT WAS BROUGHT TO CASUALITY WITH ABOVE MENTIONED COMPLAINTS AND NECESSARRY INVESTIGATIONS WERE SENT AND AS PATIENT WAS UNCONSCIOUS UPON EVALUATION HIS GRBS WAS 33 MG/DL FOR WHICH 25D WAS GIVEN , POST WHICH HE REGAINED CONSCIOUSNESS. INSPITE OF 25 D INFUSION PATIENT HAD REPEATED EPISODES OF HYPOGLYCEMIA FOR WHICH HE WAS TREATED SYMPTOMATICALLY. AFTER PATIENT WAS STABILISED SURGERY RFERRAL WAS TAKENI/V/O RIGHT GREAT TOE GANGRENE- SUGGESTED RAY AMPUTATION UNDER SA OR ANKLE BLOCK . SO DOPPLER OF RIGHT LOWER LIMB WAS DONE ,WHICH SHOWED: NO FLOW SEEN IN DISTAL PTA.POPLITEAL,PROXIMAL PTA, ATA DPA SHOWS BIPHASIC WAVEFORM LIKELY PVD,NO DVT,MODERATEATHEROSCLERTICCHANGESNOTEDINEXAMINEDARTERIES.FOLLOWING THIS,NOWTHEPATIENTISBEINGREFERREDTOKHLFORREVASCULARIZATIONSURGERY OF RIGHT LOWER LIMB .

Investigation
HEMOGRAM:
4/02/23
HB:7.3 MG/DL
TLC: 12000 CELLS/CUMM
PLAT: 2.9 LAKH/CUMM


7/02/23
HB:6.3mg/dl PCV : 34.4%
TLC:6900CELLS/CUMM PLT : 3.2 LAKH/CUMM
USG ABDOMEN:
RIGHTGRADE3RPDCHANGES LEFT GRADE 2 RPD CHANGES
B/LSIMPLERENALCORTICALCYST GRADE 1 PROSTOMEGALY
DOPPLER OF RIGHT LOWER LIMB:
NO FLOW SEEN IN DISTAL PTA.
POPLITEAL,PROXIMALPTA,ATADPASHOWSBIPHASICWAVEFORMLIKELYPVD NO DVT
MODERATE ATHEROSCLERTIC CHANGES NOTED IN EXAMINED ARTERIES.
2DECHO:NORWMA,MILDLVH+ MODERATE TR+ WITH PAH
MILDAR+/MR+,MILDGLOBALHYPOKINESIA,NOAS/MS SCLEROTIC AV,
EF=50%
FAIR LV SYSTOLIC FUNCTION, DIASTOLIC DYSFUNCTION +, NO PE.
URINE C/S: NO GROWTH DETECTED
Treatment Given(Enter only Generic Name)
VF 1NS @ 75 ML/HR
INJ CEFTRIAXONE 1 GM IV BD - D3 ON 7/2/23
INJ LASIX 40 MG IV BD
T ECOSPIRIN GOLD 75/75/20 PO HS
T RAMIPRIL 2.5 MG PO OD
T CARVIDIOL 3.125 MG PO OD
T OROFER XT PO OD
PLENTY OF ORAL FLUIDS
INJ HAI S/C ACC TO GRBS


Advice at Discharge
1.T TAXIM 200 MG PO BD
T LASIX 40 MG PO BD 8AM 4PM
T ECOSPIRIN GOLD 75/75/20 PO HS
T RAMIPRIL 2.5 MG PO OD
T CARVIDIOL 3.125 MG PO OD
T OROFER XT PO OD
7.INJ HUMAN ACTRAPID INSULIN 6U---6U 6U


REFERREDTOHIGHERCENTERI/V/OREQUIREMENTOFVASCULARSURGEONFOR REVASCULARISATION OF RIGHT LOWER LIMB.

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