PaJR case report of 27M Diabetes on insulin 15 years, hypoglycemic seizures, retinopathy Telangana

 DEPARTMENT OF GENERAL-MEDICINE

DISCHARGE SUMMARY ***
Pay Type : Paying
Age/Gender : 27 Years/Male
Address : 
Discharge Type: Relieved
Admission Date: 10/06/2024 09:46 AM

Diagnosis
HYPOGLYCEMIC SEIZURES 

TYPE 1 DM SINCE 15 YRS

SEIZURE DISORDER 15 YRS AGO
ANEMIA [IDA-NUTRITIONAL]
HYPOTHYROIDISM SINCE 2 YRS

Case History and Clinical Findings

C/O SEIZURES 1 EPISODE ONE HOUR AGO

HOPI : PATIENT WAS APPARENTLY ASYMPTOMATIC 1 HR AGO THEN HE DEVELOPED
SEIZURES 1 EPISODE OF VOMITING ,NON PROJECTILE ,NON BILIOUS FOOD AS CONTENT

NO H/O FEVER/COLD/COUGH
NO H/O POST ICTAL CONFUSION N
NO H/O GIDDINESS
NO H/O ABDOMINAL PAIN
NO H/O CHEST PAIN CHEST TIGHTNESS
NO H/O SOB,ORTHOPNEA ,PND
NO H/O BOWEL AND BLADDER ABNORMALITIES
NO H/O BLEEDING MANIFESTATIONS
PAST HISTORY

K/C/O DM ON MIXTARD 20 IU 15 years 
K/C/O SEIZURES 10 YRS BACK
K/C/O Hypothyroidism ON THYRONORM 100 MG
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PERSONAL HISTORY :
DIET - MIXED
APPETITE - NORMAL
SLEEP - ADEQUATE
BOWEL& BLADDER MOVEMENTS - REGULAR
ADDICTIONS - NIL

GENERAL PHYSICAL EXAMINATION :
PATIENT IS CONSCIOUS , COHERENT &COOPERATIVE , WELL ORIENTED TO TIME AND
PLACE .
NO PALLOR/ ICTERUS / CYANOSIS / CLUBBING / LYMPHADENOPATHY / OEDEMA.

VITALS :
BP ; 110/80MM HG
PR : 90 BPM
RR : 22 CPM
TEMP ; 98F
SPO2 : 98 @ RA
GEBS- 205 MG/ DL

SYSTEMIC EXAMINATION :
CNS : NFND
REFLEXES :
B T S K A
R +2 +2 + 1 +2 +
L +2 +2 +1 +2 +
CVS :
S1, S2 HEARD , NO MURMURS
RS :
BAE + , NVBS
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P/A :
SOFT , NON TENDER

COURSE IN THE HOSPITAL : 

A 27 YR OLD MALE PATIENT CAME WITH C/O INVOLUNTARY
MOVEMENTS AND CONFUSION WITH GRBS OF 23 MG/DL AND WAS DIAGNOSED AS
HYPOGLYCEMIC SEIZURES .PATIENT IS A K/C/O DM I AND SEIZURE DISORDER SINCE 15
YRS FOR SEIZURES HE USED ANTIEPILEPTICS FOR 3 YES AND STOPPED MEDICATION FOR
DM I HE WASON MIXTARD 20U-X-20U BD FOR GLYCEMIC CONTROL HE WAS PUT ON HAI TID
OPTHALMOLOGY OPINION WAS TAKEN AND PATIENT HAS DIABETIC RETINOPATHIC
CHANGES [ MILD NPDR] PATIENT HAS HYPOTHYROIDISM SINCE 3 YRS WAS ON 100 MCG
CHANGES TO 75 MCG BUT PATIENT HAD FLUCTUATING SUGARS AND . ENDOCRINE
OPINION WAS TAKEN IN VIEW OF ?BRITTLE DIABETES ?HYPOPITUTARISM AND SIR HAS
ADVICED INJ.LANTUS 8U AT NIGHT WITH 4U HAI TID BUT PATIENT HAS HYPOGLYCEMIA AT
NIGHT.

SO PT IS BEING Discharged UNDER OCTREOTIDE 100 MG STAT AND LOW DOSE
STEROID TO MAINTAIN EUGLYCEMIA

PATIENT IS BEING Discharged UNDER
HEMODYNAMICALLY STABLE CONDITION

Investigation

Name Value Range
Name Value Range

COMPLETE URINE EXAMINATION (CUE) 10-06-2024 10:38:AM

COLOUR Pale
yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN +SUGAR TraceBILE
SALTS NilBILE PIGMENTS NilPUS CELLS 3-4EPITHELIAL CELLS 2-3RED BLOOD CELLS
NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil
HBsAg-RAPID 10-06-2024 10:38:AM NegativePOST LUNCH BLOOD SUGAR 10-06-2024 10:40:AM
101 mg/dl 140-0 mg/dl
BLOOD UREA 10-06-2024 10:40:AM 25 mg/dl 42-12 mg/dlSERUM CREATININE 10-06-2024
10:40:AM 1.4 mg/dl 1.3-0.9 mg/dl
SERUM ELECTROLYTES (Na, K, C l) 10-06-2024 10:40:AMSODIUM 141 mmol/L 145-136
mmol/LPOTASSIUM 3.5 mmol/L 5.1-3.5 mmol/LCHLORIDE 104 mmol/L 98-107 mmol/LLIVER
FUNCTION TEST (LFT) 10-06-2024 10:40:AMTotal Bilurubin 0.44 mg/dl 1-0 mg/dlDirect Bilurubin
0.14 mg/dl 0.2-0.0 mg/dlSGOT(AST) 30 IU/L 35-0 IU/LSGPT(ALT) 33 IU/L 45-0 IU/LALKALINE
PHOSPHATASE 180 IU/L 128-53 IU/LTOTAL PROTEINS 6.4 gm/dl 8.3-6.4 gm/dlALBUMIN 3.8
gm/dl 5.2-3.5 gm/dlA/G RATIO 1.48
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T3, T4, TSH 11-06-2024 05:50:AMT3 0.85 ng/ml 1.87-0.87 ng/mlT4 6.67 micro g/dl 12.23-6.32 micro
g/dlTSH 0.37 micro Iu/ml 5.36-0.34 micro Iu/mlPERIPHERAL SMEAR 11-06-2024 03:50:PM RBC :
Microcytic hypoochromic WBC : With in normal limits PLATELET : Adequate
STOOL FOR OCCULT BLOOD 11-06-2024 03:50:PM Negative (-ve)ABG 12-06-2024 07:40:AMPH
7.342PCO2 33.8PO2 73.3HCO3 17.8St.HCO3 18.9BEB -6.6BEecf -6.8TCO2 37.2O2 Sat 94.3O2
Count 14.1
SERUM CREATININE 12-06-2024 10:41:PM 1.6 mg/dl 1.3-0.9 mg/dlSERUM ELECTROLYTES (Na,
K, C l) 12-06-2024 10:41:PMSODIUM 136 mmol/L 145-136 mmol/LPOTASSIUM 3.8 mmol/L 5.1-3.5
mmol/LCHLORIDE 102 mmol/L 98-107 mmol/L
PHOSPHOROUS 3.0 mg/dl 4.5-2.5 mg/dl
FBS : 287 MG/DL
PLBS : 101 MG/DL
HBA1C 8.2%

Treatment Given(Enter only Generic Name)
INJ.LEVITIRECETAM 1GM IV/OD
INJ. GLARGINE SC/OD 8 UNITS 8 PM
INJ.HAI SC/TID ACCORDING TO GRBS
INJ.OCTREOTIDE 100 MG IV/ STAT
TAB.THYRONORM 100 MICRO GRAMS PO/OD
Advice at Discharge
INJ.GLARGINE S/C OD [8 UNITS ]
TAB.LEVITIRACETAM 500 MG PO/OD
TAB. THYRONORM 75 MCG PO/OD 1-0-0 8 AM
INJ.HAI S/C TID [6-6-6]
TAB .DEFOCORT 6 MG 0-1-0 2PM
Follow Up

REVIEW TO GENERAL MEDICINE OPD AFTER 2 WEEKS ON MONDAYS.

When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR
ATTEND EMERGENCY DEPARTMENT.
Preventive Care
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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: hospital phone helpline For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed
and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been
explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER
SIGNATURE OF PG/INTERNEE
SIGNATURE OF ADMINISTRATOR
SIGNATURE OF FACULTY
Discharge Date
Date:15/6/24
Ward:AMC
Unit: I