This is an irrational treatment first of all. No T2DM patient aged around 45 yrs, has an erratic eating habit, a hectic roaming field work, can be put on SU like Glibenclamide to start with and Voglibose TID. This is not called treatment at all because there is no Metformin in the prescription. As per the Recommendations of ADA/EASD consensus for the treatment of T2DM, any patient suffering from T2DM should be put on Metformin as first line of choice unless otherwise contraindicated. The next drug can be anything like SU like Glimepiride OR Gliclazide in Indian Scenario. OR AGI like Voglibose in Indian Scenario. OR DPP4 Inhibitors OR Basal Insulin OR TZD like Pioglitazone in Indian Scenario. OR SGLT2 Inhibitors OR GLP1 Analogues. In the given case scenario the poor patient went in to Hypoglycemia. Still he is in Stage 1 only. What's important now is 1) Correction of Hypoglycemia as ADA has warned very strictly against the hazardous effects of even single episode of Hypoglycemia could lead to CAD CVA Dysarthria Aphasia Seizures Coma Death if not treated properly. So this gentleman should take care of Hypoglycemia first by taking 20 g of Glucose dissolved in Water and repeat if necessary. As a protocol, any hypoglycemia caused by SU especially Glibenclamide should be hospitalized and kept under observation for at least 72 hours because out of all Hypoglycemia episodes the most dangerous and serious is that's caused by Glibenclamide. Now a days no one is using Glibenclamide except in the Government Hospital set up. This molecule must be discouraged to the possible extent. Not only Hypoglycemia, but interfering with Ischemic preconditioning of the heart is one of the major disadvantages. In many International conferences I have witnessed speakers saying SU Vanished. In a country like India though we can not avoid SU, we still have better molecules like Glimepiride or Gliclazide. 2) The prescription should be changed with immediate effect like ask him over phone, after stabilisation of Hypoglycemia to report before the treating Physician immediately. Take off all. Start Metformin 500 mg SR. Up titrate to maximum dose of 1,000 mg BD. Next best add on would be DPP4 Inhibitors like Linaglipin 5 mg. In case not to the target slowly introduce AGI Voglibose. So in the given case both are important Correction of Hypoglycemia immediately Change the molecules with immediate effect. Thanks for presenting a good case and regards.
This post of mine is going to create a record of some sort, the longest ever written ! Today , I am going to be the first to use the Disagree button ! This post is dedicated to Our esteemed Influencer Dr Krishna Mohan. ! What is an irrational treatment ? Where is it written that a T2DM patient aged 45 yrs , who has an erratic eating pattern and hectic working style cannot be put on SU drug like Glibenclamide ( quote: DrKM ). It seems our respected doctor is not aware of lives of our majority Indian patients. All need a cost effective approach. Most of them don't have the luxury of tiffin breaks and lunch intervals. Most have an erratic eating disorder and a busy day all the time, for instance, auto drivers, lorry drivers, maintenance workers etc.. Even doctors have an erratic eating pattern ! I have number of incidents to quote if you wish, where in they themselves had to take Treatment for Hypoglycaemia. Did I say that Glibenclamide was the drug, I started with, in this patient ? Did you read the clinical history properly ? But Dr KM is bit too keen to prove me wrong. I don't know the reason ! DrKM means to say that whoever has been prescribing Glibenclamide in the past and who continue to do so are not in line! DrKM wants to play the role of a teacher, Nothing wrong with that, But there is a way to contradict ! DrKM says " This is not called Treatment " . What does he mean by that ? Is it death sentence ? DrKM talks about Recommendations, as if he was on the panel of ADA/EASD. Let me remind DrKM that the recommendations are meant to be mere Guidelines to consider for treatment. The recommendations are never meant to be the Law ! This has been written over and over again at the outset of the chapter, that finally physician's clinical judgement is more important, Next important is the patient's preferences which has a very vital role to play in devising the management regimen . ADA/EASD have never attempted to impose their views on doctors worldwide. Why I chose Glibenclamide for my patient ? I do know that Metformin Is the first drug to be considered in the pharmacotherapy of a T2Diabetic. Unfortunately my patient has shown repeated episodes of UGI upset , with as little as 500mg. So I decided to take him off the drug ! DrKM asks us to choose only SU of his liking, Glimepiride and Gliclazide in Indian patients. I ask Do we the clinical research data to consolidate your point. Sadly He cannot find it. ! He feels that there is no role of Glibenclamide and Glipizide ( even though he didn't mention it ), Meglitinides ( Repaglinide and Nateglinide ) in T2DM. We already know that Glibenclamide is the most potent of all SUs and most economical too. DrKM seems very empathetic when he comments " this poor patient went into hypoglycaemia " ! What does he mean by that ? Poor socio-economic status. ? or because you pity him that he is my patient ? DrKM further rambles, " he is in Stage 1 " . This is indeed hilarious ! I am yet to come across Stages of hypoglycaemia in Stages except for Mild, Moderate and Severe. I wonder what is Stage 1 ? More is coming ! He comments" ADA has warned very strictly against the hazardous effects of even one single episode of hypoglycaemia could lead to CAD , CVA, dysarthria, aphasia, seizures, coma and death. " . I challenge him on this forum to bring out any passage/ excerpt/recommendations issued by ADA that proclaims this above said subject applicable for Hypoglycaemia for all ages ! And then let me ask everyone, how many of us has seen a patient with hypoglycaemia landing in CVA and ACS. ? DrKM further advises " as a protocol,a hypoglycaemia caused by a SU especially Glibenclamide should be hospitalized and kept for at least 72 hrs " This is a misinterpretation ! This patient has been taking Glibenclamide 5 mg daily for the last 6 months with uneventful period.. How can this drug at this modest dosage cause prolonged hypoglycaemia ? Neither this drug was taken in higher doses ( more than 20 mg /day ) , nor did he take inadvertently nor is it a suicidal attempt ( first dose effect ) DrKM seems to bent upon one leg when he says that Glibenclamide is no longer prescribed by private practice doctors and only used in government hospital setups. This means to say that government of India and government medical officers are ignorant to be still using this molecule ! I am yet to hear from any endocrinologist that Glibenclamide is bad and must be discouraged at all levels. And I am also yet to come across any government directive that Glibenclamide is being considered to be banned or to be issued with a black box warning ( as for Pioglitazone ). He views that Glibenclamide interfere with ischemic preconditioning of heart . This is yet again misunderstood. Why would any body keep Glibenclamide in a diabetic with ACS or Heart failure ? I like to remind you that even ADA/EASD have no plans to ban Glibenclamide. They infact use it by the name of Glyburide on par with Glimepiride usage ! Let me tell DrKM , this interesting news that Glibenclamide has been used and is still being used in clinical trials in South Africa in women with GDM and Progestational Diabetes. The results available are favourable and match with that of Insulin therapy. Glibenclamide has the added benefit that it doesn't cross the placenta, where as other SUs do. ! What does DrKM mean when he says" SU vanished."? SUs have the best A1c reducing potential, next to Insulin In cases where Glimepiride and Gliclazide have failed, ther Glibenclamide has proved effective. DrKM seems very interested to change the treatment for this patient who had only one single episode of hypoglycaemia without investigating the cause of hypoglycaemia. I wonder at DrKMs audacity to suggest costlier molecules like linagliptin ! Before commenting , DrKM should have read the clinical history once more. This patient had a near perfect A1c and Glucose levels under target goals but our learned DrKM is very eager to suggest treatment changes as an easy option,instead of identifying the cause of hypoglycaemia. We, at Curofy should be learning and respecting each other, not try to intimidate, just because there is a scoring system and you are way up the ladder ! This sounds like a feudal system. It is time to modify the system. Back to the case, We always attempt to control the blood sugars effectively as nearer to the target goals, this may tilt the patient towards hypoglycaemic zones at times.Let us not forget that when you are performing Gymnastics, you are bound to get hurt, in the same way ,in the persuit of tight glycemic control, hypoglycaemia is bound to come up. I spoke to my patient at length in my clinic and I enquired into his affairs. He admitted that he has taken DAONIL 5mg as usual before breakfast but had taken little than usual breakfast and in addition he also missed his 11 AM snack . THAT explained why he had the hypoglycaemia. ! So I took this excellent opportunity in educating him about the importance of regular intake of meals both in right quantity and quality, and also the importance of small snacks at 11 AM and 4 - 5 PM, thereby avoiding the risk of even Subclinical hypoglycaemia . I am highly disappointed that our esteemed Influencer DrKM could not come up with the rationale of treating of this patient's hypoglycaemia. Let me explain : Glibenclamide acts by stimulating Insulin secretion. Voglibose acts by slowing the intestinal CHO digestion / absorption , by inhibiting the intestinal Alpha glucosidase. By inhibiting this enzyme, CHO in the form of polysaccharide / starch breakdown is slowed down and the absorption of CHO in glucose form is delayed. so if we ask him to take regular food which is a mixture of CHO, proteins and fats, heis not going to improve immediately because Voglibose is acting against the CHO breakdown, proteins donot breakdown so early and easily and also stimulate Insulin secretion to a little extent. Fats impair the CHO absorption. Hence The availability of glucose to the body is almost too little at that moment. Therefore we should ask the patient to take plain Glucose 15 - 20 gms in powder or in liquid form immediately, This will resolve his hypoglycaemia because Voglibose won't interfere with glucose absorption but may do with table sugar. Even chocolates don't do any good because they are composed mainly of proteins, fat and little glucose in sugar form. Thanks for patient Reading . Now I think I am in the record books as the longest post ever. !
Dear Dr Lele, let me clarify your doubts, one by one 1.No matter how many times I correct or edit myself in my profile settings, it still showing that I am undergraduate, Then How can I derive any mileage by calling myself an undergraduate, instead of senior doctor with 30 yrs of experience. 2. Why do you say it is criticism, I was stating facts, of what he wrote, .I hold difference of opinion and I contradicted quoting him . There should be nothing wrong with that.. His very post started with unnecessary criticism ( pl read his post again,and he didn't even bother to address or even acknowledge me by my name ) 3.whatever clarifications,one needs from the question , He or she should ask from me, instead of jumping to conclusions and showing that I was incompetent. And I posted my explanation and DrKM was miles away from question . I asked in the post what is remedy for his hypoglycaemia in that clinical setting, but instead he went loggerheads in lambasting my treatment that it is irrational and which is why that " poor " patient landed in hypoglycaemia. There should be a minimum courtesy. ! 4. I always respect my seniors and juniors And I expect the same etiquette from them. DrKM never showed that in the post except for adding that it was a good case after attempting to dissect me ! 5. you are Right when you say that I am best judge to Treat my patient, but. a senior member like DrKM should Remember this . Finally What do I gain from humiliating anybody, Everybody gets what do deserve. " The boomerang effect ". I was talking about subject and contradicting him .where he went wrong. That seems to be a problem when people have a dogmatic approach. We should evolve , correct ourselves and move forward.
hypoglycaemia is more dangerous than hyperglycemia. so immediate attention n treatment required if BSL of 62 mg is confirmed, then ask him to consume 15 gm glucose in 100 ml water or 100 ml concentrated fruit juice repeat BSL after 10 min. relax if normal. else repeat the above step of 15 gm glucose in 100 ml water or a concentrated fruit juice. repeat BSL. relax if normal. if still low, ask the patient to consume the next/ subsequent major meal. it may b noted that I mentioned glucose n not sucrose, coz voglibose will not allow the sucrose to b immediately broken down n hence will not increase BSL immediately, as is reqd in ds case. continuous SMBG is to b reinforced, as to find out which other times is he going into hypoglycemia. re enforcement of regularity in timings, quantity n quality of meals, along with a disciplined exercise lifestyle cannot b over ruled. voglibose can b withheld for some time. may or may not b introduced, depending on the SMBG reading
Please read the clinical history, particularly the medication part. The last passage should be read again to grasp my Question Hint : I am not just asking a remedy for his hypoglycaemic condition but also the rationale of such approach ! Remember , this is his first Hyperglycemic episode. Keep guessing and Please do write. I will post my answer tomorrow !
Such pts can always keep candy or chocolate in there pockets ,as many times if noone in the home pt finds difficult to make a drink with trembling hands & giddiness So can consume a candy with immediate effect. His glycemic control is fantastic Dr u can reduce the dose of Voglibose to .2 mg ,before food. Many pts get diarrhoea due to voglibose thus reducing sugar
Ask him to take a glass of sweetened sugar or glucose drink or chocolate or sweets, whatever is handy. Also advise bread or chapatis. Check blood sugar after an hour and then monitor for 24 hours as daonil has a long half life. Such patients should be managed by metformin only. Avoid sulphoureas.
HYPOGLYCEMIA, ,GLUCON -D POWDER 15 GM DISSOLVED IN WATER AND DRINK, ,TAKE BISCUITS, ,CHOCOLATE, ,CAN Y'S, ,CHECK BSL IF INCREASED THEN KKK, ,STOP ALL PRESCRIPTION BCOZ DAONIL HAS A LONG HALF LIFE, ,PUT HIM ON TB GLCIPHAGE 500 MG SR OD BBF, ,VOGLIBOSE TWICE AND REGULAR AND TIMELY FOOD HABITS, ,
Your patient's BL sugar is well controlled.now on hypoglycemic. he should take chocolates,candies,biscuits.keep these with him..acc to me he can be put on Metformin only.He will have better control.Moreover we should avoid advise in phone.
also try n avoid a fat based sweet for treating hypoglycemia. fat does not allow the BSL to b raised quickly / in other words, fat blunts the hyperglycemic response of sugars. so for treatment of hypoglycemia, only pure sugars to b given
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You can find here key changes in ADA guidelines. They are published in Diabetes Care once yearly in the month of January. GENERAL CHANGES The field of diabetes care is rapidly changing as new research, technology, and treatments that can improve the health and well-being of people with diabetes continue to emerge. With annual updates since 1989, the ADA has long been a leader in producing guidelines that capture the most current state of the field. To that end, the “Standards of Medical Care in Diabetes” now includes a dedicated section on Diabetes Technology, which contains preexisting material that was previously in other sections that has been consolidated, as well as new recommendations. SECTION 1. IMPROVING CARE AND PROMOTING HEALTH IN POPULATIONS Additional information was included on the financial costs of diabetes to individuals and society. Because telemedicine is a growing field that may increase access to care for patients with diabetes, discussion was added on its use to facilitate remote delivery of health-related services and clinical information. SECTION 2. CLASSIFICATION AND DIAGNOSIS OF DIABETES Based on new data, the criteria for the diagnosis of diabetes was changed to include two abnormal test results from the same sample (i.e., fasting plasma glucose and A1C from same sample). The section was reorganized to improve flow and reduce redundancy. Additional conditions were identified that may affect A1C test accuracy including the postpartum period. SECTION 3. PREVENTION OR DELAY OF TYPE 2 DIABETES This section was moved and is now located before the Lifestyle Management section to better reflect the progression of type 2 diabetes. The nutrition section was updated to highlight the importance of weight loss for those at high risk for developing type 2 diabetes who have overweight or obesity. Because smoking may increase the risk of type 2 diabetes, a section on tobacco use and cessation was added. SECTION 4. COMPREHENSIVE MEDICAL EVALUATION AND ASSESSMENT OF COMORBIDITIES On the basis of a new consensus report on diabetes and language, new text was added to guide health care professionals’ use of language to communicate about diabetes with people with diabetes and professional audiences in an informative, empowering, and educational style. A new figure from the ADA-European Association for the Study of Diabetes (EASD) consensus report about the diabetes care decision cycle was added to emphasize the need for ongoing assessment and shared decision making to achieve the goals of health care and avoid clinical inertia. A new recommendation was added to explicitly call out the importance of the diabetes care team and to list the professionals that make up the team. A recommendation was added to include the 10-year atherosclerotic cardiovascular disease (ASCVD) risk as part of overall risk assessment. The fatty liver disease section was revised to include updated text and a new recommendation regarding when to test for liver disease. SECTION 5. LIFESTYLE MANAGEMENT Evidence continues to suggest that there is NOT an ideal percentage of calories from carbohydrate, protein, and fat for all people with diabetes. Therefore, more discussion was added about the importance of macronutrient distribution based on an individualized assessment of current eating patterns, preferences, and metabolic goals. Additional considerations were added to the eating patterns, macronutrient distribution, and meal planning sections to better identify candidates for meal plans, specifically for low-carbohydrate eating patterns and people who are pregnant or lactating, who have or are at risk for disordered eating, who have renal disease, and who are taking sodium–glucose cotransporter 2 inhibitors. There is NOT a one-size-fits-all eating pattern for individuals with diabetes, and meal planning should be individualized. A recommendation was modified to encourage people with diabetes to decrease consumption of both sugar sweetened and nonnutritive-sweetened beverages and use other alternatives, with an emphasis on water intake. The sodium consumption recommendation was modified to eliminate the further restriction that was potentially indicated for those with both diabetes and hypertension. Additional discussion was added to the physical activity section to include the benefit of a variety of leisure-time physical activities and flexibility and balance exercises. The discussion about e-cigarettes was expanded to include more on public perception and how their use to aide smoking cessation was not more effective than “usual care.” SECTION 6. GLYCEMIC TARGETS This section now begins with a discussion of A1C tests to highlight the centrality of A1C testing in glycemic management. To emphasize that the risks and benefits of glycemic targets can change as diabetes progresses and patients age, a recommendation was added to reevaluate glycemic targets over time. The section was modified to align with the living Standards updates made in April 2018 regarding the consensus definition of hypoglycemia. SECTION 7. DIABETES TECHNOLOGY This new section includes new recommendations, the self-monitoring of blood glucose section formerly included in Section 6 “Glycemic Targets,” and a discussion of insulin delivery devices, blood glucose meters, continuous glucose monitors (real-time and intermittently scanned, and automated insulin delivery devices. The recommendation to use self-monitoring of blood glucose in people who are not using insulin was changed to acknowledge that routine glucose monitoring is of limited additional clinical benefit in this population. SECTION 8. OBESITY MANAGEMENT FOR THE TREATMENT OF TYPE 2 DIABETES A recommendation was modified to acknowledge the benefits of tracking weight, activity, etc., in the context of achieving and maintaining a healthy weight. A brief section was added on medical devices for weight loss, which are not currently recommended due to limited data in people with diabetes. The recommendations for metabolic surgery were modified to align with recent guidelines, citing the importance of considering comorbidities beyond diabetes when contemplating the appropriateness of metabolic surgery for a given patient. SECTION 9. PHARMACOLOGIC APPROACHES TO GLYCEMIC TREATMENT The section on the pharmacologic treatment of type 2 diabetes was significantly changed to align, as per the living Standards update in October 2018, with the ADA-EASD consensus report on this topic. This includes consideration of key patient factors: (a) important comorbidities such as ASCVD, CKD, and HF, (b) hypoglycemia risk, (c) effects on body weight, (d) side effects, (e) costs, and (f) patient preferences. To align with the ADA-EASD consensus report, the approach to injectable medication therapy was revised. A recommendation that, for most patients who need the greater efficacy of an injectable medication, a GLP-1 agonist should be the first choice, ahead of insulin. A new section was added on insulin injection technique, emphasizing the importance of technique for appropriate insulin dosing and the avoidance of complications (lipodystrophy, etc.). The section on non-insulin pharmacologic treatments for DM1 was abbreviated, as these are not generally recommended. SECTION 10. CARDIOVASCULAR DISEASE AND RISK MANAGEMENT For the first time, this section is endorsed by the American College of Cardiology. Additional text was added to acknowledge heart failure as an important type of cardiovascular disease in people with diabetes for consideration when determining optimal diabetes care. The blood pressure recommendations were modified to emphasize the importance of individualization of targets based on cardiovascular risk. A discussion of the appropriate use of the ASCVD risk calculator was included, and recommendations were modified to include assessment of 10-year ASCVD risk as part of overall risk assessment and in determining optimal treatment approaches. The recommendation and text regarding the use of aspirin in primary prevention was updated with new data. For alignment with the ADA-EASD consensus report, two recommendations were added for the use of medications that have proven cardiovascular benefit in people with ASCVD, with and without heart failure. SECTION 11. MICROVASCULAR COMPLICATIONS AND FOOT CARE To align with the ADA-EASD consensus report, a recommendation was added for people with type 2 diabetes and chronic kidney disease to consider agents with proven benefit with regard to renal outcomes. The recommendation on the use of telemedicine in retinal screening was modified to acknowledge the utility of this approach, so long as appropriate referrals are made for a comprehensive eye examination. Gabapentin was added to the list of agents to be considered for the treatment of neuropathic pain in people with diabetes based on data on efficacy and the potential for cost savings. The gastroparesis section includes a discussion of a few additional treatment modalities. The recommendation for patients with diabetes to have their feet inspected at every visit was modified to only include those at high risk for ulceration. Annual examinations remain recommended for everyone. SECTION 12. OLDER ADULTS A new section and recommendation on lifestyle management was added to address the unique nutritional and physical activity needs and considerations for older adults. Within the pharmacologic therapy discussion, de-intensification of insulin regimes was introduced to help simplify insulin regimen to match individual’s self-management abilities. SECTION 13. CHILDREN AND ADOLESCENTS Introductory language was added to the beginning of this section reminding the reader that the epidemiology, pathophysiology, developmental considerations, and response to therapy in pediatric-onset diabetes are different from adult diabetes, and that there are also differences in recommended care for children and adolescents with type 1 as opposed to type 2 diabetes. A recommendation was added to emphasize the need for disordered eating screening in youth with type 1 diabetes beginning at 10–12 years of age. Based on new evidence, a recommendation was added discouraging e-cigarette use in youth. The discussion of type 2 diabetes in children and adolescents was significantly expanded, with new recommendations in a number of areas, including screening and diagnosis, lifestyle management, pharmacologic management, and transition of care to adult providers. New sections and/or recommendations for type 2 diabetes in children and adolescents were added for glycemic targets, metabolic surgery, nephropathy, neuropathy, retinopathy, nonalcoholic fatty liver disease, obstructive sleep apnea, polycystic ovary syndrome, cardiovascular disease, dyslipidemia, cardiac function testing, and psychosocial factors. SECTION 14. MANAGEMENT OF DIABETES IN PREGNANCY Women with preexisting diabetes are now recommended to have their care managed in a multidisciplinary clinic to improve diabetes and pregnancy outcomes. Greater emphasis has been placed on the use of insulin as the preferred medication for treating hyperglycemia in gestational diabetes mellitus as it does not cross the placenta to a measurable extent and how metformin and glyburide should not be used as first-line agents as both cross the placenta to the fetus. SECTION 15. DIABETES CARE IN THE HOSPITAL Because of their ability to improve hospital readmission rates and cost of care, a new recommendation was added calling for providers to consider consulting with a specialized diabetes or glucose management team where possible when caring for hospitalized patients with diabetes. SECTION 16. DIABETES ADVOCACY The “Insulin Access and Affordability Working Group: Conclusions and Recommendations” ADA statement was added to this section. Published in 2018, this statement compiled public information and convened a series of meetings with stakeholders throughout the insulin supply chain to learn how each entity affects the cost of insulin for the consumer, an important topic for the ADA and people living with diabetes.Dr. Peerzada Ovais Ahmad6 Likes7 Answers
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11.09.201 A case of repeated hypoglycaemic episodes in a case of liver damage. Hypoglycaemia is the cause or effect of liver damage? This case is about T2DM of about one year duration in 82 years old man. He is normotensive. His sugar was moderately high. Initially he was on 1000 mg of Metformin. Considering his high sugar it was increased to 1500 mg and 2 mg of Glimiperide was added. About a week ago he developed jaundice. Liver enzymes and other biochemical values were very high. Serological test for HBsAG was positive. Lab report is enclosed herewith. He was brought to me for second opinion about 5 days back. In view of his age and liver damage Metformin was withdrawn and Glimeperide was reduced to 0.5 mg a day (1/4th of the previous dose). In addition he was put on B-complex, dietary advice was also given. He was advised to come for follow up after a week. Today morning his son calls me on phone at about 7.30 to inform me that his father has become suddenly semi-conscious and they don't know what to do. Patient was sweating a lot too. Hypoglycaemia was suspected, therefore the son was asked to forcefully give his father about 3-4 spoonful of sugar and report the developments after about 15 minutes. Accordingly he called me to say that his father has started blinking and recovering. I too was happy. But this didn't last long, he had one more such episode after about an hour, one more round of sugar, made him recover. He was advised to visit me for a thorough checkup. He looked like any other normal person waiting for his turn in the clinic. He had his breakfast about an hour ago, his capillary blood sugar was astonishingly as low as 32 mg/dl. Doubting about a possible defect in my Glucometer itself I checked my own blood sugar for verification. It was as it should be, meaning thereby that the device was normal. He was given sumptuous sugar and a repeat test was done after 20 minutes. He was advised to stop Glimmiperide till further instructions. The value was a mere 80 mg/dl. At night after his dinner his sugar was again checked, it was again a mere 74 mg/dl. In view of repeated episodes he was hospitalised. Points to ponder: Evidently it was a case of hypoglycaemia on all the four occasions. But why should he go into hypoglycaemia inspite of Metformin withdrawal and reducing Glimiperide to 0.5 from 2.0 mg OD. The case will be further discussed after 2-3 days. If you have anything to add or ask, kindly do so, I will try to answer. There will be someone who can highlight on this case, if I fail to comply.Dr. Shreeram Herlekar7 Likes19 Answers
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A case of sudden onset of desaturation ,tachycardia chest discomfort sweating, diarrhea associated with h/o fever on n off past 15 days. widal positive O/e- BP-190/130 mmhg, HR-132 min,Spo2-84%,TLC counts - 19500,PCV-27,RBS - 46mg/dl Interpret CXR with ECG with proper treatment plan???Dr. Prashant Ved5 Likes16 Answers
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71 year old 150 kilo male presents to EMS with 1.5 hour sudden onset of heavy chest pressure and shortness of breath. Patient found in above rhythm. Rate 188 with a bp of 60/30. Patient's skin slightly moist but warm. Hx of afib, htn, and diabetes. What do you call the rhythm and how would you treat it and why? I'll disclose after some discussion how we managed it.Dr. Manish Malhotra1 Like13 Answers
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M66. c/o Diarrhoea 12days. Vomiting 2times Mucus stool. Dry cough 8days. kco T2DM 30yrs. HTN 5yrs.Dr. Syam Sundar Patro0 Like10 Answers