Profuse sweating in a diabetic having past history of MI

57 Y / M, Sedentary lifestyle Chief Complaints Profuse sweating for 2 months. History Diabetic. Takes Glimeperide 3mg + Metformin 500 mg (before breakfast), Injection Insulin Glargin 8 Units (before lunch), Tab Glimeperide 1 mg + Metformin 1000 mg (before dinner). Sugar is under control. Past history of Myocardial infarction present (No documents available). No chest pain or palpitation , No pedal swelling, No jaundice, No lethargy or fatigability, No respiratory distress, No history of syncope. Non hypertensive, No anxiety disorder, no thyroid diseases or other known comorbidities. Vitals BP 126/80, Pulse 82, Respiratory rate 19/mint, Temperature normal. Physical Examination General: P⁰Cy⁰J⁰O⁰TempⁿCL⁰ CVS : NAD Chest : NAD Neck : No thyroid swelling Abdomen : NAD Reflexes : Normal Investigations FT4 and TSH : Normal FBS : 112 , PPBS : 127 ECG and Echo reports are attached. Management What is your diagnosis and how to manage this case ?

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Betablocker is not Diabetogenic, rather it MASKS the Hypoglycemic Symptoms. So, Hypoglycemic diagnosis is delayed. Anxiolytic, U can use Tablet Clonazepam 0.25mg initially TDS & after 7 days in BD doses. Increase it to 0.5mg at night, if adequate sleep is not ensured. Propranolol in low doses like 10mg BD are quite safe, to reduce sweating & tremors. But then also do Monitoring of Blood Sugar on daily basis, or as frequently as possible.

Dada, now he is telling that he's a COPD patient. Should I give Propranolol then ?
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H/o profuse sweating Dear dr Golam Murtuza specifically at what time he is sweating My concern is during night or early morning I suspect hypoglycaemia Hence guide him to test random sugar during episode also go deep in symptoms of hypoglycaemia Pt is long standing diabetic hence investigate for DKD Also consider obesity and overweight Look for any metabolic disorder

Edited Ecg and 2decho are normal studies
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SUGGESTIVE. OF... HYPERHIDROSIS SECONDARY. TO.... PEREPHERAL NEUROPATHY AND METFORMIN. INDUCED.. .. ..PEREPHERAL. NEUROPATHY.... IN. D. M.....IS. USUALLY ....SECONDARY. TO DEFICIENCIES. OF VIT. B. COMPLEX VIT. D AND SERUM. ELECTROLYTES' IMBALANCE..

His sugar is well controlled for DM. He may be going in for hypoglycemia or may be due to autonomic nuropathy due to DM. His echo is normal. Diastolic dysfunction grade 1 is normal for his age. Autonomic nuropathy is difficult to treat even if you control the blood sugar well.

Sir, he is a COPD patient and past alcoholic but doesn't drink now.
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Sweating is most common & natural phenomena during hypoglycemia & frontal sweating common during eating. Patient has past MI but this ECG is in WNL Cardiac symptoms are silent in long standing diabetes. So you should have to go for Angiography 100 % for any blockage

@Dr. Golam Mortuza Cognitive behavioral therapy (CBT) is the most widely-used therapy for anxiety disorder. Rule out Thyroid Problems Most probably Anxiety releated

Sir, no known thyroid diseases. FT4 and TSH are normal. Apparently no anxiety disorder is present.
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Suspected hypoglycemia, readjust the doses of antidiabetic drugs. Get RBS when the episode is there and treat accordingly.

Suspected hypoglycaemia, dose to be revised

Sir,I advised to reduce insulin dose .Sugar level is normal now.
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Differential Hypoglycemia Anxiety

Sir,no anxiety related risk factors,no other symptoms of anxiety disorder present. Sugar is well controlled . Still I advised to reduce Insulin dose by 2 units but no improvement noticed.
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Sinus rhythm LBBB with MI

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