Patient with no known h/o DM and HTN, c/o dizzness, fbs is 2.3mmol/l . suggest investigation and tx

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 In view of his age and liver damage Metformin was withdrawn and Glimeperide was reduced to 0.5 mg a day (1/4th of the previous dose).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.

5 yr old child brought for 2 episodes of altered sensorium Each episode associated with skipped meal in night and followed by altered sensorium in early morning around 5 am .there is documented hypoglycaemia each episode .Child improved immediately after glucose administration .Routine investigations like CBP CRP are normal.Serum Insulin is low and serum cortisol is normal.Diagnosis and further any work up ?

What is Whipple's TRIAD ? PROCEDURE ? DISEASE ? Historically, Whipple's criteria(or triad) were once used to justify surgical exploration for an insulinoma for intractable hypoglycaemia. 1. Symptoms of hypoglycemia especially after fasting or heavy exercise. 2. A low plasma glucose measured at the time of the symptoms 3. Relief of symptoms when the glucose is raised to normal. Often this triad is also interpreted for hypoglycaemia due to any cause. One would expect that Whipple disease, Whipple triad and Whipple procedure would all have been named after one person as they are all sort of clustered around the same region. But there are two Whipples. One for the disease and one for the triad and procedure.  The Last two are named after Allen Whipple (1881-1963), American surgeon who had pioneered pancreatic surgery(Whipple's procedure). He proposed that pancreatic surgery for an insulinoma to be performed only when Whipple's criteria were met. Whipple's disease is a rare, systemic infectious disease caused by the bacterium Tropheryma whipplei. First described by George Hoyt Whipplein 1907 and commonly considered GIT disorder, Whipple's disease primarily causes malabsorption but may affect any part of the body including the heart, brain, joints, skin, lungs and the eyes.Weight loss, diarrhea, joint pain, and arthritis are common presenting symptoms, 87 % being male. When recognized and treated, can usually be cured with long-term antibiotic therapy; if the disease is left untreated, it is ultimately fatal. Whipple procedure, or Kausch-Whipple procedure, is a major surgical operation involving the removal of the head of the pancreas, the duodenum including the duodenal papilla or ampulla of Vater, the proximal jejunum, gallbladder and often the distal stomach. This operation is performed to treat cancerous tumours of the head of the pancreas, malignant tumors involving the common bile duct, duodenal papilla or ampulla of Vater, or duodenum near the pancreas, some precancerous lesions, insulinomas, some cases of pancreatitis with or without a definitive cause, and rarely severe trauma.

A 55 year old male presented with intermittent drowsiness since last two months he had no past history of smoking or alcohol intake his vital parameters were fine and so was rest of clinical examination except his blood sugar was 71. He had one episode of spontaneous hypoglycaemia after admission corrected by giving Iv dextrose his serum insulin was 132( normal is up to 22) his c peptide was elevated. Cect abdomen was normal triple phase ct is there showing a enhancing mass in tail of pancreas

65-year old man present with a recent history of weight loss, early satiety, mild flank pain and this rash on his legs. A Ct scan revealed a mass in the head of the pancreas. Which neuroendocrine tumor is associated with this rash? A.Insulinoma B.Glucagonma C.VIP secreting tumor D.Somatostatinoma