A 62 yr old with hypoglycemia
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A 62 year old female ,sweeper by occupation was apparently asymptomatic 30 days back .After 3 days of wearing anklets,she developed ulcer on right ankle -lateral side.she came to our hospital on 19 th july for ulcer and she was advised regular dressings with magnesium sulfate crystals and glycerine.As they couldn't do the dressings nor bring her to the hospital they took her to local RMP for dressings where they checked her previous reports showing FBS-183mg/dl and was advised Tablet containing Glimepride and Metformin .on August 3rd she had first episode of sweating,giddiness ,her family members felt that it might be due to low sugar levels and gave her biscuits and some sugar and she was alright.on 16 th August she took her medication after food at almost 11Pm.
At 1:00 pm she developed 2nd episode of sweating,giddiness,she was unable to speak and was brought in altered sensorium to KIMS casualty.GRBS when measured in casualty was 34mg/dl for which 25 D was given as bolus.
Past History:known case of Hypertension since 3 years on Telmisartan 20 mg ,known case of diabetes since 3 months.No h/o jaundice,T.B,asthma,CKD,CHD
Family History: No H/o Hypertension,D.M in family
Drug History: Not allergic to any known drugs
Personal History: Diet : Mixed
Appetite: Normal
Sleep: Adequate
Bowel & Bladder: regular
No addictions
General examination:patient was in altered state with GCS- 13/15 ,moderately built and moderately nourished.
No pallor,no icterus,no cyanosis,nolympadenopathy,no pedal edema.
Vitals:
Afebrile
BP:150/100mmhg
PR:72 bpm
R.R: 12 Cpm
SPO2: 98%in R.A
GRBS:34mg/dl
Systemic examination:
CNS:pt is not oriented to place and time,
Memory is intact.
Slurred speech
Cranial nerve is intact.
Motor system :
Right. Left
Bulk : N. N
Tone:. N. N
Power:. 4/5. 4/5
Reflexes:
Biceps:+2. +2
Triceps: +2. +2
Supinator:. +2. +2
Knee:. +2. +2
Ankle:. +2. +2
Plantar: flexion flexion
Sensory system: Normal
No cerebellar signs
Cvs :s1 s2 present
Respiratory system:bilateral air entry present ,normal vesicular breath sounds heard,shape of chest normal
Per abdomen:soft,non tender,all quadrants are moving equally with respiration,no organomegaly,bowel sounds are heard Investigation:
Treatment
25D/ iv /sos
T.telma 20 mg po/od
Bp,GRBS monitoring 2 hrly
Inj.ceftriaxone iv/od
Regular ulcer dressing
Excellently documented. Sanya I think she was on Atenolol 50mg prior to this presentation. In fact, she told us that apart from sweating, she did not have palpitations, lightheadedness, tremors or headache during both those episodes. Although Atenolol is cardioselective, it does seem to have some role in causing Hypoglycemia unawareness.
ReplyDeleteFound some very interesting and significant risk of hypoglycemia with Atenolol or Metoprolol (cardioselective beta blockers).
DeleteMore here - https://cardiab.biomedcentral.com/articles/10.1186/s12933-019-0967-1/tables/2
https://pubmed.ncbi.nlm.nih.gov/6093522
ReplyDeleteAlso looked up on efficacy of Ceftriaxone for skin and soft tissue infections and found it has good penetration and cure rates. Although the patient sample size was small and this study was done just after India won the cricket world cup. The first one I mean !