90 year old M , with sustained hypoglycemia .

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan .

A 90 year old male resident  of choutappal , driver by occupation came to hospital with 

Cheif complaints  of sudden unresponsiveness since 6:00 pm ( 27/ 03 / 2023 ) , 

                                     Unability to speak since 6:00 pm (27/03/2023)

                                     Shortness of breath (grade 4) 

HOPI 

Patient was apparently  asymptomatic  10 yrs back ,   due to giddiness he was taken to hospital,  where he was  diagnosed with DIABETES MELLITUS TYPE 2 and HTN .Since then he is been taking medicines for it .

History of weakness of LEFT  side , UPPER LIMB and LOWER LIMB , 3 years ago , later was diagnosed CVA . 

   15 days back he developed cough with expectoration,  white in color,  and low grade fever which is on off .

He also developed shortness of breath even at rest for which  for which he went to local hospital  got treated with antibiotics for 6 days , and then got discharged. There was symptomatic improvement,  but since yesterday  (27/03/2023) , 6 pm with unresponsiveness.  

PAST HISTORY 

Known case of type 2 Dm , HTN since 10 years

Tablet GLIMIPERIDE 

Tablet  METFORMIN -XL 

FAMILY  HISTORY 

No significant history 

TREATMENT  HISTORY 

Medicines for DM and HTN 

PERSONAL HISTORY 

Married 

Normal appetite 

Diet - non-vegetarian 

Bowels - regular 

Bladder - normal 

No known allergies 

Addictions 

GENERAL EXAMINATION 

Pallor - no

Icterus - no

Cyanosis- no 

Clubbing - no 

Lymphadenopathy  - no 

Edema - no 

VITALS 

temperature- 98.6 F

Pulse rate- 74 bpm 

Respiratory rate- 18 cpm

BP - 120/70 mm of hg 

GRBS - 33mg%

SYSTEMIC  EXAMINATION  

Cvs: s1 s2 +, no murmurs

Cns: 

Stupurous at admission

Power R L

  UL 5/5 -

  LL 5/5 -

Glasgow scale: E2V1M5 at presentation

Investigations

Diagnosis

Oha induced hypoglycemia 

With congestive cardiac failure secondary to CAD

With old cva (3 years ago) left LL and UL

With T2DM (since 10 years) 

With HTH (since 10 years)

With hypokalemia

Treatment:

Inj 25% dextrose @30ml/hr

Stop oha/ insulin

Inj lasix 40g iv/bd

T.ecosprin av 75 10mg/po/ hs

T. Met xl 25 mg po/od

Syrup potklor 15ml in glass of water/ tid

T. Aldactone 25mg po/od