61 MALE, HYPOGLYCEMIA 2ry TO OHA, HFMEF, PRE RENAL AKI ON CKD, PERSISTENT AF WITH FVR, K/C/O.OSA, HTN, T2 DM


1. COMPLAINTS AND DURATION

61 y/MALE

H/O altered sensorium since ~5 AM (today)
Insidious; associated with profuse sweating & delayed response; gradually progressive.

H/O trauma to L foot d/t RTA 1 month ago for which treatment was taken @ outside hospital.

@ time of visit pt GRBS 79 mg/dL → sugar syrup given @ casualty 50 mL.
[? “2 p/s connected” — unclear marginal note]

2. HISTORY OF PRESENT ILLNESS

No H/O fever, cough, cold.
No H/O chest pain, palpitations, orthopnea, PND.
No H/O headache, dizziness, blurring of vision.

3. HISTORY OF PAST ILLNESS

No H/O pain abdomen, burning micturition, nausea, vomiting.

K/C/O T2DM + on T. [Glimi-M1 / Glimepiride1+Metformin500] PO BD since 1 month.
HTN + since 1 year.
OSA + ON home O₂ 

4 yrs back – A/F C VR 
Rx: Diltiazem 30 mg, Bisoprolol 5 mg PO OD 

  • T. Acebrophylline + Acetylcysteine 100/600 mg PO BD.
  • T. Apixaban 5 mg PO BD.
  • T. Dytor Plus 10/25 PO OD.

4. TREATMENT HISTORY
1 Diabetes - Yes, details: 1 year
2 Hypertension - Yes, details: 7 months
3 CAD - Yes, details: Global LV Hypokinesia :: 2 yrs
4 Asthma - No
5 Tuberculosis - No
6 Antibiotics - No
7 Hormones - No
8 Chemo / Radiation - No
9 Blood Transfusion - No
10 Surgeries - No
11 Other - Yes, details: OSA - Gr II

5. PERSONAL HISTORY
1 Marital Status: Married
2 Occupation: Farmer
3 Appetite: Normal
4 Diet: Vegetarian
5 Bowels: Regular
6 Micturition: Normal
7 Known Allergies: No
8 Habits / Addictions:
    a) Alcohol - Occasional
    b) Tobacco - Smoking - pack years: 5
    c) Drug use - No
    d) Betel nut - No
    e) Betel Leaf (Pan) - No

6. FAMILY HISTORY
1 Diabetes - No
2 Hypertension - No
3 Heart disease - No
4 Stroke - No
5 Cancers - No
6 Tuberculosis - No
7 Asthma - No
8 Any other hereditary disease -
9 Psychiatrist illness -
10 Sibling History -
11 Any other - Not significant.

PROVISIONAL DIAGNOSIS:

  •  Hypoglycemia 2° to OHA’s? Decreased food intake

  • Heart Failure → Midrange EF (EF = 42%)

  • ? Renal / Prerenal AKI on CKD

  • Non-healing ulcer over dorsum of (L) foot

  • K/C/O Atrial Fibrillation with FVR - 2 yrs. (Persistent)

  • K/C/O OSA - Grade II since 2 yrs.

  • K/C/O Type-II DM : 1 month

  • K/C/O Hypertension : 1 yr

  • ECG ON 19/07/2025 at 7 am

  • ECG ON 19/07/2025 at 7. 50am

  • INVESTIGATIONS:


DAY 1 ON EXAMINATION: 19/07/2025 
TEMP - 98.2 f
PULSE - 96/min irregular
HR - 114/ min
APEX PULSE DEFICIT - 18
BP - 130/80 mm of hg
RR - 20 / min
SPO2 - 70% on RA,90% @ 10 lt O2
CVS -S1,S2 PRESENT, NO MURMURS 
RS - BAE -PRESENT , NVBS 
PA - SOFT , NON TENDER 
CNS - NFND 
GRBS - 45 mg/dl 

TREATMENT ON 19/07/2025 
  1. Inj. 25% D 100 ml IV TID
  2. Inj. 5% D @ 20 ml/hr ↑ acc to GRBS
    (Target 140–180 mg/dl)
  3. Inj. THIAMINE 200 mg IV BD
  4. Inj. PIPTAZ 4.5 gm IV stat fb 2.25 gm IV QID
  5. Inj. LINEZOLID 600 mg IV BD
  6. Inj. PANTOP 40 mg IV OD
  7. Inj. ZOFER IV SOS
  8. IVF NS/RL @ 75 ml/hr
  9. Inj. OPTINEURON 1 amp in 100 ml N.S IV OD
  10. GRBS hourly monitoring
  11. Monitor vitals & I/O chart TDS
  12. T. BISOPROLOL 5 mg 1 OD
  13. T. DILZEM 30 mg 1 OD
  14. Inj. NATRUM 50 meq IV TID
  15. Inj. LASIX 10 mg IV BD + SOS 

DAY 2 ON EXAMINATION: 20/07/2025 
TEMP - 98.1 f
PULSE - 94/min irregular
HR - 112/ min
APEX PULSE DEFICIT - 18
BP - 130/80 mm of hg
RR - 24 / min
SPO2 - 91% @ RA
CVS -S1,S2 PRESENT, NO MURMURS 
RS - BAE -PRESENT , NVBS 
PA - SOFT , NON TENDER 
CNS - NFND 
GRBS - 224 mg/dl 

INVESTIGATIONS ON 20/07/2025 8 AM
TREATMENT ON 20/07/2025

Left Lower limb elevation

  1. INJ 25% Dextrose 50ml IV – ↑ / ↓ according to GRBS
  2. INJ PITAZ 2.25 gm IV/BD – i/v/o ulcer over dorsum of Lt foot
  3. INJ LINEZOLID 600 mg IV / BD – i/v/o ulcer
  4. INJ THIAMINE 200 mg IV / BD – i/v/o chronic alcoholic
  5. INJ PAN 40 mg IV / OD – i/v/o antibiotic-induced gastritis
  6. INJ LASIX 40 mg IV / BD, 8 AM – X – 9 PM – i/v/o Heart Failure
  7. TAB BISOPROLOL 5 mg 8 AM – X – X – i/v/o AF & FVR
  8. TAB DILTIAZEM 30 mg 8 AM – X – 8 PM – i/v/o HTN
  9. GRBS Hourly monitoring
  10. Strict I/O monitoring
  11. Monitor vitals & inform SOS
  12. TAB LINEZOLID 600 mg PO / BD
  13. TAB CHYMEROL FORTE PO BD.

DISCHARGE SUMMARY
Diagnosis
HYPOGLYCEMIASECONDARYTOORALHYPOGLYCEMICDRUGS(RESOLVED) HEART FAILURE WITH MIDRANGE EJECTION FRACTION (EF-42%)
PRERENALACUTEKIDNEYINJURY(RESOLVED)ONCHRONICKIDNEYDISEASE(STAGE3B) NON HEALING ULCER OVER DORSUM OF LEFT FOOT
K/C/OPERMANENTATRIALFIBRILLATIONWITHFVRSINCE2YEARS K/C/O OBSTRUCTIVE SLEEP APNEA SINCE 2 YRS
K/C/O OVERLAP SYNDROME
K/C/ODIABETESMELLITUSSINCE1MONTH K/C/O HYPERTENSION SINCE 1 YEAR
Case History and Clinical Findings
PATIENT CAME TO CASUALITY IN ALTERED SENSORIUM STATE SINCE MORNING INSIDIOUSONSET,ASSOCIZTEDWITHPROFUSESWATING,DELAYEDRESPONSEWHICH WAS GRADUALLY PROGRESSIVE .
H/OTRAUMATOLEFTFOOTDUETORTA1MONTHAGOFORWHICHTREATMENTISTAKEN AT OUTSIDE HOSPITAL
ATTHETIMEOFEVENTPTGRBSWAS7MG/DL--SUGARSYRUPWASGIVEN--AT PRESENTATION GRBS WAS 50MG/DL -INJ 25%DEXTROSE WAS CONNECTED H/O PALPITATIONS +,SOB GRADE 3 +
NOH/OFEVER,COUGH,COLD,VOMITINGS,LOOSESTOOLS NO H/O CHEST PAIN,PND
NOH/OPOLYURIA,POLYDYPSIA,BLURRINGOFVISION,PAINABDOMEN,BURNING MICTURITION,DECREASED URINE OUTPUT
PAST HISTORY :
K/C/OPERMANENTATRIALFIBRILLATIONWITHFVRSINCE2YEARS K/C/O OBSTRUCTIVE SLEEP APNEA SINCE 2 YRS
K/C/O OVERLAP SYNDROME
K/C/O HYPERTENSION SINCE 1 YEAR ON REGULAR MEDICATION K/C/ODIABETESMELLITUSSINCE1MONTHONTAB.GLIMIM1PO/BD
PERSONALHISTORY:MARRIED,MIXEDDIET,REGULARBLADDERMOVEMENTS,BOWELS- REGUAR, NO KNOWN ALLERGIES AND ALCOHOLIC +
FAMILY HISTORY - NOT SIGNIFICANT
GENERAL EXAMINATION: PEDAL EDEMA LEFT SIDE PITTING TYPE
NO PALLOR , ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY,MALNUTRITION VITALS:-TEMP:98.5F,BP:130/90MMHG,RR:18CPM,PR:108BPM,SPO2:70%ATRA-- 92%AT 5LIT O2, GRBS: 50 MG/DL---25%DEXTROSE ---130MG/DL
SYSTEMIC EXAMINATION
CVS,RS,PERABDOMEN-NORMAL CNS- GCS E4V5M6 ;NFND
COURSE IN THE HOSPITAL:
A 61 YEAR OLD MALE KNOWN DIABETIC,HYPERTENSION AND PERMANENT AF WITH FVR,OSACAMETOCASUALITYINALTEREDSENSORIUMSTATE,H/OTRAUMATOLTFOOT
,THOROUGH CLINICAL EXAMINATION WAS DONE WHICH SHOWED GRBS 50MG/DL
,INJ.25%DEXTROSE WAS CONNECTED FOLLOWING WHICH GRBS WAS 130MG/DL.ALL NECESSARY INVESTIGATIONS WERE SENT ,ABG SHOWED PH-7.20,PCO2-43,PO2-45.3,HCO3-
16.3 AND RFT SHOWED BLOOD UREA -42,CREATININE -2.1 AND PATIENT IS PROVISIONALLY DIAGNOSEDASHYPOGLYCEMIASECONDARYTOOHAS,HFWITHMIDRANGEEF,PRERENAL AKI IN CKD ,ULCER OVER DORSUM OF LT FOOT.PATIENT IS TREATED WITH DEXTROSE INFUSION,DIURETICS,ANTIBIOTICS,IVF,CCBS,BETA BLOCKERS. SERIAL ABG AND RFT SHOWED IMPROVEMENT .REGULAR DRESSINGS WERE DONE.
PATIENT IMPROVED CLINICALLY AND NOW IS BEING DISCHARGED WITH STABLE VITALS.
Investigation
ANTI HCV ANTIBODIES (Rapid Test)RAPID 19-07-2025 Non Reactive HEPATITIS-BSURFACEANTIGEN(HBSAg)RAPIDTEST19-07-2025Negative


HAEMOGLOBIN 12.2 gm/dl TOTAL COUNT 7,600 cells/cummNEUTROPHILS 91 %
LYMPHOCYTES04%EOSINOPHILS01%MONOCYTES04%BASOPHILS00%PCV35.1vol% M C V 95.1 fl M C H 33.1 pg M C H C 34.8 %RDW-CV 15.7 % RDW-SD 56.7 fl RBC COUNT 3.69
millions/cummPLATELETCOUNT2.51lakhs/cu.mmSMEARRBCNormocyticnormochromicLight MicroscopyWBC With in normal limits Light MicroscopyPLATELETS Adequate in number and distribution Light MicroscopyHEMOPARASITES No hemoparasites seen Light MicroscopyIMPRESSION Normocytic normochromic blood
COMPLETE URINE EXAMINATION (CUE) 19-07-2025 COLOUR Pale yellowAPPEARANCE ClearREACTIONAcidicSP.GRAVITY1.010ALBUMINNilSUGARNilBILESALTSNilBILEPIGMENTS NilPUS CELLS 2-4EPITHELIAL CELLS 1-2RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil
RFT 19-07-2025 UREA 42 mg/dlCREATININE 2.1 mg/dlURIC ACID 3.6 mmol/L CALCIUM 9.8
mg/dlPHOSPHOROUS 3.6 mg/dlSODIUM 136 mmol/LPOTASSIUM 4.6 mmol/L.CHLORIDE 101
mmol/L
Blood Lactate 18.0
FBS 80 mg/dl
TotalCholesterol116mg/dlTriglycerides95mg/dlHDLChoesterol32.6mg/dlLDLCholesterol74.8 mg/dl.VLDL * 11.0 mg/dl
LIVER FUNCTION TEST (LFT) 19-07-2025Total Bilurubin 0.52 mg/dlDirect Bilurubin 0.18 mg/dl SGOT(AST)13IU/LSGPT(ALT)10IU/LALKALINEPHOSPHATASE138IU/LTOTALPROTEINS5.8
gm/dlALBUMIN 3.52 gm/dl A/G RATIO 1.54
THYROID PROFILE 19-07-2025 T3 0.49 ng/mlT4 8.72 micro g/dl TSH 3.21 micro Iu/ml
RFT 19-07-2025UREA 37 mg/dl CREATININE 2.4 mg/dl URIC ACID 4.4 mmol/LCALCIUM 10.0
mg/dlPHOSPHOROUS 2.4 mg/dl SODIUM 134 mmol/L POTASSIUM 5.2 mmol/L. CHLORIDE 96
mmol/L
Arterial Blood Gas Analysis (ABG) 19-07-2025 PH 7.32PCO2 35.7PO2 66.1HCO3 17.9St.HCO3
18.6BEB -7.0BEecf -7.1TCO2 37.9O2 Sat 91.6O2 Count 93.5
RFT 20-07-2025UREA 43 mg/dl 50-17 mg/dlCREATININE 1.9 mg/dlURIC ACID 4.5
mmol/LCALCIUM 10.0 mg/dlPHOSPHOROUS 3.0 mg/dlSODIUM 141 mmol/L POTASSIUM 4.0
mmol/L.CHLORIDE 102 mmol/L
Arterial Blood Gas Analysis (ABG) 20-07-2025 PH 7.351PCO2 42.4PO2 60.9HCO3 22.9St.HCO3
22.6BEB-2.1BEecf-1.9TCO247.4O2Sat91.6O2Count14.4 APTT TEST 34 Sec
Prothrombin Time 17 Sec INR 1.25
2DECHOWASDONEON19/7/25:VPCSDURINGSTUDY GLOBAL HYPOKINESIA

RA,RVDILATED LA,LV DIALTED EF-46%
MILDTOMODERATEMR/TRWITHPAH MILD LV DYSFUNCTION
GRADE 2 DIASTOLIC DYSFUNCTION
IVC-1.5CMS MILD DILATED,COLLAPSING
USGABDOMENANDPELISWASDONE0N19/7/25 NO SONOLOGICAL ABNORMALITY

BLOOD ,URINE AND SWAB CULTURES SENT :REPORTS AWAITED
Treatment Given(Enter only Generic Name)
INJ.25%DEXTROSE@30ML/HRINCREASEDORDECREASEDACCORDINGTOGRBS IVF NS @50ML/HR
INJ.PIPTAZ 4.5GM IV/STAT INJ.PIPTAZ 2.25GM IV/QID -3DAYS INJ.LINEZOLID600MGIV/BD-3DAYS INJ.PAN 40MG IV/OD
INJ.LASIX 40MG IV/BD TAB.BISOPROLOL5MGPO/OD TAB.DILTIAZEM 30MG PO/BD
Advice at Discharge
TAB.AUGMENTIN 625MG PO/BD (1-0-1)X 5DAYS TAB.LINEZOLID 600MG PO/BD (1-0-1)X 5DAYS TAB.MET XL 50MG PO/OD (1-0-0) TO CONTINUE TAB.DILTIAZEM 30MG PO/TID (1-1-1) TO CONTINUE TAB.PAN40MGPO/OD(1-0-0)BEFOREFOODX5DAYS TAB.APIXABAN 5 MG PO/BD (1-0-1) TO CONTINUE TAB.DYTOR PLUS 10/25 PO/OD (1-0-0) TO CONTINUE TAB.CHYMEROL FORTE PO/TID (1-1-1) X 5DAYS TAB.THIAMINE 100MG PO/OD (0-1-0) X 10DAYS
PLANNINGTOSTARTANTIDIABETICTREATMENTAFTER3DAYS REGULAR DRESSING
Follow Up
REVIEW TO GM OPD AFTER 3 DAYS /SOS WITH CULTURE REPORTS
When to Obtain Urgent Care
INCASEOFANYEMERGENCYIMMEDIATELYCONTACTYOURCONSULTANTDOCTOROR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: 08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed andtheadviceregardingpreventiveaspectsofcare,whenandhowtoobtainurgentcarehavebeen explained to me in my own language
SIGNATUREOFPATIENT/ATTENDER SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY
DischargeDate Date:21/7/25 Ward:AMC
Unit:V.

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