63 YEAR OLD MALE WITH HYPOGLYCEMIA

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22-02-2022

                                                                                   

CASE:

A 63 year old male came to the hospital with the complaints of discomfort, excessive sweating, dizziness 

HISTORY OF PRESENTING ILLNESS:

The patient was apparently asymptomatic one day ago when he developed discomfort and excessive sweating early in the morning he then lost consciousness. He was then brought to the hospital by the attender. He was brought in an ambulance and on the way to the hospital he was given glucose as his sugars were low. He gained consciousness after administering glucose.

He had no h/o of fever, cough, cold, seizures etc.

PAST HISTORY:

The patient is a known diabetic since 18 years. 

In 2019, the patient experienced a skin prick on his great toe of left leg in the farm, which eventually developed into an ulcer. After the prick the patient didn’t address the wound for a week after which he went to a local doctor who advised him a TT injection. The wound was left open as he was diabetic. The wound started gradually growing in size and involved the medial aspect of the foot and the first few toes.

After the ulcer involved most of his leg he was taken to a hospital where he underwent an amputation of his first two toes. After the amputation the infection persisted and he underwent further investigations. A doppler was done.

He had fever and cough during this period. He underwent a percutaneous coronary intervention on his left lower limb following which the foot was debrided and vacuum assisted closure was done.

Four days after the discharge after the amputation the patient experienced a similar episode to yesterday. He experienced discomfort, excessive sweating and his skin felt cold.

He was ventilated and was in the hospital for 15 days.

He was discharged and the wound dressing was continued at home.

In 2020, the patient had another episode of similar complaints and had seizures , he was given sugar water after he regained consciousness and he was not taken to the hospital.

In 2021, September the patient had complaints of anasarca for 4 days which was sudden in onset and progressive, decreased urine output which ceased completely in 4 days, he did not pass faeces for 4 days, he had abdominal distention for 4 days and it was also progressive. He also had shortness of breath (grade 3), he had vomiting after meals. The patient was taken to the hospital where he underwent dialysis and this was followed by 20 sessions of dialysis in 2 months ( twice a week).

The patient is now receiving dialysis twice a week .

FAMILY HISTORY:

There are no similar complaints in the family. His mother was diagnosed with cancer when he was young.

PERSONAL HISTORY:

Diet : mixed diet

Appetite : has three meals a day and his appetite increases and decreases occasionally

Sleep: initially he slept 4-5 hours a day and after dialysis he sleeps 2-3 hrs a day 

Bowel: regular

Addictions: consumed alcohol occasionally and stoped 3 years ago 

Allergies: none

He was previously a farmer and has stopped working since the amputation

He stays at home and goes out occasionally 

GENERAL EXAMINATION :

The patient was conscious, coherent and co - operative. 

He is well oriented to time, place and person.

Pallor was present

No icterus

No clubbing

No cyanosis

No generalized lymphadenopathy   

Skin is dry and rough

GRBS ON DAY 1: 138  (Morning 11 am)

VITALS:

Temp - afebrile 

BP - 140/90 mmhg 

PR - 92 bpm 

RR - 18 cpm 

SpO2 - 99% at RA 

SYSTEMIC EXAMINATION:

CVS: S1 and S2 are heard

         No thrills and murmurs

RESPIRATORY SYSTEM: 

INSPECTION:

Chest wall is bilaterally symmetrical and elliptical in shape

 No chest wall and spine abnormalities 

No dilated veins, sinuses

Scars present on the base on the right neck

PERCUSSION:

Areas: all areas are bilaterally resonant

Supra clavicular

Infra clavicular

Mammary

Axillary

Infraxillary

Supra-scapular

Scapular

Infra-scapular

PALPATION:

No local rise of temperature, no tenderness

Trachea is centrally placed

No tactile fremitus

No vocal fremitus

AUSCULTATION:

Normal vesicular breath sounds are heard

BAE present

No dyspnea

ABDOMEN:

INSPECTION:

Shape of abdomen: scaphoid

Scar present above the umbilicus

PERCUSSION:

 no fluid thrill or dullness

PALPATION:

No tenderness, no palpable mass, no free fluid, liver and spleen are not palpable 

AUSCULTATION:

Normal bowel sounds heard

CENTRAL NERVOUS SYSTEM: 

Speech: normal

No neck stiffness

Cranial nerves -N

Gait: walks with a walking stand since the amputation 

Sensory system- normal

Motor system: tone: normal

Power: normal

Reflexes: normal