A 65yr old M with Hypoglycemia,Hypotension

 A 65 yr old male patient, resident of miryalguda came with chief complaints of 

Hypoglycemia.


Pt came with  Hypoglycemia with Grbs 30mg/dl.


Pt came to the surgery department with c/o multiple ulcers over lt leg since 6 months.

Pt was apparently asymptomatic 6 months back then he developed 4 small ulcers of size 1x 1 cm initially, which was gradually increasing to attain present size.H/o fever which was on and off. Then he suddenly developed Hypoglycemic symptoms and became unconscious  and transferred to medicine department.No H/o trauma 

H/o Fracture at left elbow joint which was ill treated - Non union of Fracture 30 yrs back.

Pt is a K/C/O of DM and is on regular medication - T. Glimestarmil PO/OD

Had H/o pulmonary cox 2 yrs ago.

N/K/C/O HTN,Asthma,Epilepsy. 


Married

He worked as a Sarpanch in his village.

Have Normal appetite with mixed diet and regular bowel and bladder movements. 


No significant family history 


General examination 

Pt is c/c/c . 

No pallor,Icterus, Clubbing,Cyanosis, Lymphadenopathy, oedema.

Temp : Afebrile

Pulse Rate : 82 bpm

Bp : 110/80mmhg

RR : 18 cpm

Spo2 : 97% On RA

Grbs : 101 mg/dl 


Systemic examination 


RS : 

decreased  air entry on left side,NVBS + ,No crepts. 


CVS : 

s1 s2 + ,No murmurs 


CNS : NFD 


ABDOMINAL EXAMINATION  


Inspection : 

Abdomen flat

Moves with respiration

no abdominal distension

umbilicus is central and  inverted 

no engorged veins

no scars,sinuses,

hernial ornifices are clear 


Palpation

All inspectory findings are confirmed

No tenderness

Percussion

No significant findings 

Auscultation 

Bowel sounds heard

No bruits 


Local examination - ulcer over lt lower limb 


Inspection: 


An ovoid ulcer of size 8x 6cm over lower 1/3 of lateral aspect of left leg with well defined margins with sloping edges with pale granulation tissue with slough with floor as underlying muscle.

An oval ulcer of 2x1cm over lt ankle region on lateral aspect with well defined margins 

with sloping edges with pale granulation tissue with scab with floor as underlying muscle.

A vertically oval ulcer of size 4x 2cm over lateral aspect of lt ankle region with well defined margins with sloping edges with pale granulation tissue with floor as underlying muscle.

An ovoid ulcer of size 4x3 cm over medial aspect of lt ankle region with well defined margins with sloping edges with pale granulation tissue with floor as underlying muscle with minimal slough.

Surrounding skin is pigmented. 


Palpation: 


Tenderness + 

All inspectory findings are confirmed, base of all ulcers are formed by underlying bone.


Clinical images




Investigations 




4/9/23



3/9/23




2/9/23









1/9/23
















Diagnosis : Recurrent Hypoglycemia (resolved) 2° to Sepsis / OHA with Septic shock (resolved) with renal Acute kidney injury 2° to ulcer over lt leg with type 2 DM with true hyponatremia (resolved) with severe anemia ,rt upper lobe and middle lobe pneumonia with lt pleural effusion with consolidation.



T/t : 

IV fluids NS @50ml/hr 

Inj. Meropenem 500mg/IV/BD 

Inj. Pan 40mg /IV /OD

Inj. PCM 650 mg /IV/SOS 

T chymerol Forte/PO/BD

T Vit C /PO/OD

Syp Ascoril LS 10ml /PO/TID 

Oint Thrombophobe for L/A

Dressing over lt lower limb

Grbs 4th hrly monitoring

Pr,Rr,spo2 1hrly monitoring 

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