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Clinical Assessment & Management Review

80-Year-Old Indian Female | Pune | August 2026

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PROBLEM SUMMARY

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SECTION 1: INTERPRETING THE INVESTIGATIONS

Blood Parameters

• At creatinine 4.35 mg/dL, age 80: eGFR approximately 9-11 mL/min/1.73m² → CKD Stage G5 (near-ESRD)
• At creatinine 6.34 mg/dL: eGFR approximately 5-7 mL/min/1.73m²

Urine Report Analysis

Key Clinical Conclusion from Urine: This patient has active complicated UTI/pyelonephritis with renal involvement (WBC casts). This is a significant contributor to both the acute-on-chronic renal deterioration AND the congestive heart failure exacerbation (infection as a precipitant of AHF). Antibiotics are urgently needed - and choice must be renal dose adjusted.

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SECTION 2: ANALYSIS OF CURRENT MEDICATIONS

Actrapid (Regular Insulin) 40 IU - 0-3-3 (Total 6 IU daily?)

• "0-3-3" likely means 0 units morning, 3 units afternoon, 3 units evening = 6 IU/day total (unlikely for 40 IU prescription)
• OR it means 40 IU total split with the ratio 0:3:3 proportionally
• More likely interpretation: 40 IU/day with distribution 0 (morning) - some afternoon - some evening

• Insulin clearance is reduced in renal failure - kidneys normally degrade 25-40% of insulin
• At creatinine 4.35 (eGFR ~10), hypoglycemia risk is significantly elevated
• Fasting BSL 131.7 is acceptable - but the dose (40 IU) needs careful monitoring
• No oral antidiabetics noted - appropriate for CKD Stage 5 (most OHAs are contraindicated)
• Recommendation: Monitor BSL closely, consider dose reduction if hypoglycemic episodes occur. Target HbA1c ~7.5-8% in this elderly frail patient (looser targets per geriatric diabetes guidelines).

Cilnidipine 5 mg + Bisoprolol 5 mg (Combination tablet) + Cilnidipine 10 mg separate

• Cilnidipine: N-type and L-type calcium channel blocker. Unique advantage over amlodipine in diabetic nephropathy - N-type blockade reduces proteinuria and is renoprotective. Safe to continue. Well-tolerated in CKD. No major dose adjustment needed.
• Bisoprolol 5 mg: Beta-1 selective blocker. Used here for both HTN and heart failure. Safe in CKD - primarily hepatic metabolism. Appropriate for HF with reduced EF. Check: Is EF known? Bisoprolol is beneficial in HFrEF (EF <40%) but less evidence in HFpEF.
• Caution: Bisoprolol + diuresis may cause bradycardia in this frail elderly patient - monitor HR.

Sodium Bicarbonate 500 mg

• Appropriate. Chronic metabolic acidosis is near-universal in CKD Stage 5.
• Target serum bicarbonate: 22-24 mEq/L
• Alkali therapy (NaHCO3) has been shown to slow CKD progression and preserve muscle mass.
• Caution: Each 500 mg tab = ~6 mEq sodium. In a patient with fluid overload and HF, sodium load matters. Monitor.

Oxethazaine + Aluminium Hydroxide + Magnesium Hydroxide (Antacid)

• Used as antacid/mucosal protectant.
• Concern: Aluminium-containing antacids in CKD can cause aluminium accumulation (neurotoxicity, bone disease). Magnesium accumulation can also occur.
• Recommendation: Use with caution. If GI protection is needed for peptic symptoms, pantoprazole alone (already prescribed) is preferred. Consider discontinuing the aluminium-containing antacid or using it sparingly.

Levocarnitine (L-Carnitine) 330 mg

• Appropriate and evidence-based for CKD/dialysis patients.
• CKD causes carnitine deficiency (lost in dialysis, reduced synthesis).
• Benefits: may improve anemia response to EPO, reduce muscle weakness, improve cardiac function.
• Safe to continue.

Pantoprazole 40 mg

• Proton pump inhibitor - gastroprotection.
• Appropriate given the multiple medications.
• Safe in CKD. No dose adjustment needed.
• Mild concern: Long-term PPI use has been associated with hypomagnesemia and CKD progression in some observational studies - but at this stage of disease, gastroprotection benefit outweighs risk.

Torsemide 10 mg

• Loop diuretic for fluid overload/HF.
• Torsemide is preferred over furosemide in CKD due to more predictable oral bioavailability (~80% vs furosemide's variable 10-80%).
• Braunwald's Heart Disease notes: "Torsemide and furosemide are equally effective; torsemide has higher oral bioavailability."
• Current dose of 10 mg appears LOW for a patient with severe fluid overload and creatinine 4.35. Higher doses (20-40 mg or more) are typically needed in CKD due to reduced tubular secretion of diuretics.
• Recommendation: Consider uptitrating torsemide to 20-40 mg/day if fluid overload persists, monitoring serum creatinine and electrolytes (K+, Na+) closely.

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SECTION 3: CRITICAL GAPS IN MANAGEMENT

1. ACTIVE UTI / PYELONEPHRITIS - UNTREATED

• Urine shows pus cells 60-80/HPF + WBC casts + bacteria = complicated UTI with upper tract involvement
• Neutrophilia 79% confirms systemic response
• This infection is likely a precipitant of the acute HF exacerbation (infection → increased metabolic demand → cardiac decompensation)
• Urgent urine culture and sensitivity is needed before starting antibiotics
• Empiric antibiotic choices for complicated UTI/pyelonephritis in elderly with CKD (eGFR ~10):
  • IV Ceftriaxone 1g once daily (dose adjustment for severe CKD: 1g q24h acceptable, not renally cleared significantly)
  • Oral Nitrofurantoin - CONTRAINDICATED in eGFR <45 (inadequate urinary concentration, peripheral neuropathy risk)
  • Fluoroquinolones (ciprofloxacin): Use with caution - dose reduction needed; risk of tendinopathy in elderly; QTc monitoring
  • Avoid aminoglycosides (nephrotoxic)
  • Avoid Trimethoprim/co-trimoxazole in severe CKD (raises creatinine by blocking tubular secretion, hyperkalemia)
• Duration: 10-14 days for complicated UTI/pyelonephritis

2. ANEMIA - PARTIALLY ADDRESSED

• Hb 7.1 g/dL in CKD - this is anemia of CKD (AoCKD)
• Assessment needed:
  • Iron studies (serum ferritin, transferrin saturation) - iron deficiency may be concurrent
  • If ferritin <100 or TSAT <20%, IV iron is first-line before EPO
  • If iron replete: Erythropoiesis-Stimulating Agent (ESA) - e.g., Darbepoetin or Epoetin alfa
  • Target Hb: 10-11.5 g/dL (not normal - higher targets increase CV events per TREAT trial)
• Levocarnitine (already prescribed) may augment ESA response.
• Blood transfusion if Hb drops further or patient is symptomatic (avoid unless necessary - sensitization risk if future transplant considered, though unlikely at 80 years)

3. HYPERKALEMIA RISK

• Not mentioned but very high risk in this patient:
  • CKD Stage 5 + metabolic acidosis → K+ shift out of cells
  • No renin-angiotensin blockade (ACE-i/ARB) currently - appropriate at this stage of CKD (eGFR <15, high K+ risk)
  • Check serum electrolytes urgently - especially K+

4. NO ACE INHIBITOR / ARB

• Absent from prescription - this may be deliberate and correct at CKD Stage 5 (eGFR ~10)
• ACE-i/ARB are nephroprotective in earlier CKD (Stage 1-4) but at Stage 5 carry high risk of:
  • Worsening renal function (reduced GFR further)
  • Hyperkalemia
• Current management without RAAS blockade is acceptable at this stage.

5. FLUID OVERLOAD MANAGEMENT

• Torsemide 10 mg may need uptitration
• Fluid restriction: 800-1000 mL/day total fluid intake should be advised
• Salt restriction: <2g sodium/day
• Daily weight monitoring - target 0.5-1 kg/day fluid loss until euvolemia
• Monitor for diuretic resistance (common in CKD - reduced tubular secretion of loop diuretics)
• If diuretic-resistant: add metolazone 2.5-5 mg (30 min before torsemide) for synergistic effect

6. DIALYSIS CONSIDERATION

• eGFR ~10 mL/min with:
  • Fluid overload refractory to diuretics
  • Uremia symptoms (loss of appetite - uremic anorexia)
  • Metabolic acidosis
• Indications for urgent dialysis are borderline-present:
  • Loss of appetite + nausea = uremic symptoms
  • Fluid overload with HF
  • Creatinine 4.35 (though improving)
• Urgent nephrology consultation for dialysis planning (peritoneal dialysis or hemodialysis)
• Given patient is 80 years, goals of care discussion with family is essential

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SECTION 4: WEIGHT & NUTRITIONAL STATUS

• Uremic anorexia at eGFR <15 is a significant quality-of-life issue and a uremic symptom indicating dialysis need
• Protein intake: In CKD Stage 5 not on dialysis: 0.6-0.8 g/kg/day (low protein diet to reduce uremic solute generation). Once on dialysis: increase to 1.2 g/kg/day
• L-Carnitine (already prescribed) may help appetite and muscle function
• Consider nutritional supplementation with renal-specific formula (low K+, low phosphate)
• Phosphate binders if phosphorus elevated (calcium carbonate with meals or sevelamer - check phosphorus level)

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SECTION 5: MONITORING PLAN

Urgent (within 24-48 hours):

• Urine culture & sensitivity (C/S) → guide antibiotic choice
• Serum electrolytes (Na+, K+, Cl-, HCO3-)
• Serum phosphorus, calcium, parathyroid hormone (PTH)
• Iron studies (ferritin, TIBC, TSAT)
• ECG (rate, rhythm, hypertensive changes, LVH)
• Echocardiogram (assess EF - critical to classify HF type and guide Bisoprolol use)

Regular monitoring:

• Daily weight and urine output
• Serum creatinine and urea every 3-5 days during acute phase
• BSL monitoring (fasting + 2hr PP) - hypoglycemia risk with 40 IU insulin in CKD
• Blood pressure (target <130/80 mmHg in diabetic nephropathy per KDIGO 2021)

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SECTION 6: RED FLAGS REQUIRING URGENT ESCALATION

1. Oliguria/anuria - may indicate need for emergency dialysis
2. K+ >6.0 mEq/L - risk of fatal arrhythmia
3. Worsening breathlessness/desaturation - AHF decompensation
4. Altered sensorium - uremic encephalopathy
5. Fever with rigors - bacteremia/urosepsis requiring IV antibiotics + hospitalization
6. Hypoglycemia - at 40 IU insulin with poor oral intake

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SECTION 7: SUMMARY RECOMMENDATIONS

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A NOTE ON PROGNOSIS

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Disclaimer: This analysis is for clinical decision support only. Final management decisions must be made by the treating physician with full access to the patient's history, examination findings, and complete investigations.

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Updated Clinical Interpretation + Detailed Diet Plan

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FIRST: UPDATED CLINICAL REVIEW OF NEW RESULTS

Urine C/S - No Growth (Twice: Aug 2024 & Jan 2026)

CRITICAL RECOMMENDATION: Send urine for AFB (Acid Fast Bacilli) smear and CBNAAT/GeneXpert urgently. Genitourinary TB is easily missed and is a treatable cause of progressive renal failure. This patient has had sterile pyuria for at least 2 years with declining renal function - GUTB must be ruled out.

Serum K+ = 5.98 mmol/L - HYPERKALEMIA

• This is Grade 1-2 Hyperkalemia (normal 3.5-5.0)
• Risk of life-threatening arrhythmia - especially with HR 100-110 bpm
• Diet must strictly restrict potassium immediately
• Medications to avoid/review: Any K+-sparing agents, ACE-i/ARB, NSAIDs (none currently noted - good)
• No salt substitutes (they contain KCl)
• ECG urgently to look for peaked T waves, widened QRS
• Consider: Oral sodium polystyrene sulfonate (Kayexalate) or patiromer if K+ continues to rise

Serum Calcium = 9.77 mg/dL, Phosphorus = 5.27 mg/dL

• Phosphorus: Elevated (normal 2.5-4.5 mg/dL) → Hyperphosphatemia
• Calcium: Normal (8.5-10.5 mg/dL)
• Ca × P product = 9.77 × 5.27 = 51.5 (normal <55, risk threshold >55 - borderline)
• PTH not done - but with CKD Stage 5 + hyperphosphatemia + normal calcium, likely secondary hyperparathyroidism
• Diet must strictly restrict phosphorus

Iron = 1.12 mmol/L (Serum Iron)

• Normal serum iron = 10-30 µmol/L (or 0.56-1.68 mmol/L)
• 1.12 mmol/L = 112 µmol/L - this is actually borderline HIGH (or possibly the unit is mg/dL: 1.12 mg/dL = 20 µg/dL which would be LOW)
• Most likely this is reported in µg/mL or mg/L - needs TIBC and ferritin for full interpretation
• Without ferritin + TSAT, iron status cannot be fully assessed - request these

ECG: HR 100-110, Regular Rhythm

• Tachycardia - possible causes: anemia (Hb 7.1), fluid overload, pain/discomfort, infection, hyperkalemia
• With K+ 5.98 - ECG must be checked for hyperkalemic changes
• Bisoprolol 5 mg should be helping with rate - if still at 100-110 despite bisoprolol, check compliance and adequacy of dose

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DETAILED RENAL-DIABETIC-CARDIAC DIET PLAN

Patient Parameters for Diet Calculation

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NUTRIENT TARGETS (Evidence-Based for CKD Stage 5, Pre-Dialysis)

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FOODS: ALLOWED vs RESTRICTED

STRICTLY AVOID (High Potassium)

• Banana, coconut water, guava, chikoo (sapota), dates, dry fruits (raisins, figs, almonds, cashews)
• Potatoes (especially boiled/baked), sweet potato, raw tomato, colocasia (arbi)
• Drumstick (shevga), spinach, amaranth (rajgira), methi (fenugreek leaves)
• Whole dals in large amounts, kidney beans (rajma), black chana
• Fruit juices, coconut milk, buttermilk in large quantities
• Salt substitutes (LoSalt, Nu-Salt - contain KCl)
• Chocolates, cocoa, groundnuts in bulk

STRICTLY AVOID (High Phosphorus)

• Milk and dairy in excess (>100-150 mL/day limit)
• Paneer in large quantity
• Whole wheat atta in excess
• Cola drinks (hidden phosphoric acid)
• Processed foods, packaged snacks, preservatives
• Organ meats (liver, kidney)
• Bran, nuts in large quantity
• Fish bones

STRICTLY AVOID (High Sodium)

• Pickles (achar), papad, chutney with salt
• Namkeen, farsan, chakli, bhujia
• Salty biscuits, salted butter
• Packaged soups, stock cubes
• Extra salt at table
• Soy sauce, processed cheese

POTASSIUM REDUCTION TECHNIQUE (Leaching)

This is important for Indian vegetables - boiling helps reduce potassium by up to 50%:

• Peel and chop vegetables into small pieces
• Soak in large amount of water for 2-4 hours, change water once
• Boil in fresh water, discard boiling water
• Do not use the boiling water as soup/dal base
• This applies to all vegetables before cooking

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MEAL PLAN - TYPICAL DAY

Meal Timing (Aligned with Insulin: 0 units morning, 3 units afternoon, 3 units evening)

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EARLY MORNING (6:30-7:00 AM) - Before insulin

Light, no fluid overload

• 1 small cup (100 mL) lukewarm water with 2-3 soaked almonds (limited - 2-3 only, soaked to reduce oxalate/phosphorus)
• OR: 1 thin roti (30g) with 1 tsp ghee (small snack only if BSL permits)

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BREAKFAST (8:00-8:30 AM)

Low potassium, low phosphorus, moderate carbohydrate

• Idli x2 (made from semolina/rava, NOT fermented rice-urad - fermented batter is slightly higher in phosphorus; rava idli is safer)
• With 1-2 tsp coconut chutney (fresh, small quantity - coconut is moderate K+, limit)
• OR white rice pongal (no dal/lentil pongal - dal is high phosphorus) - 1 small bowl
• 1 small cup (100 mL) tea or coffee - without milk or with max 50 mL milk

• 1 small bowl poha (rice flakes) cooked with onion, turmeric - NO potato
• 1 small cup thin tea

• 2 small rotis (white maida or 50:50 atta:maida) - using less whole wheat reduces phosphorus
• With 1 tsp ghee
• Small katori (50g) of leached and boiled lauki (bottle gourd) sabzi

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MID-MORNING (10:30 AM)

Small frequent meal to address poor appetite

• Apple (100g) - apple is one of the SAFEST fruits in CKD (low K+, low P)
• OR: 2-3 plain Marie biscuits (low salt variety)
• OR: Small bowl puffed rice (murmura) - plain, no salt
• Water 50-80 mL

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LUNCH (1:00-1:30 PM) - Insulin 3 units given

Main meal - highest calorie content

1. Rice: 1 medium bowl (150-180g cooked) - white rice preferred over brown rice (brown rice has more phosphorus and potassium). Can be slightly sticky rice (low GI with fat).
2. Dal: 1/2 small katori (60-70 mL) - Moong dal (yellow) or toor dal (small amount). Important: dal is moderate in phosphorus and potassium - LIMIT quantity. Dilute and thin dal is better. Do NOT have thick dal or dal makhani.
3. Vegetable sabzi (1 small katori - 80-100g cooked):
   • Best choices (low K+, low P after leaching):
     • Lauki (bottle gourd) ✓✓
     • Tinda (Indian round gourd) ✓✓
     • Parwal (pointed gourd) ✓✓
     • Gilki/turai (ridge gourd) ✓✓
     • Cucumber (in sabzi form, lightly cooked) ✓
     • Cabbage (boiled and drained) ✓
     • Cauliflower (small quantity, boiled first) ✓
     • French beans (small quantity, boiled) ✓
   • Cooked with minimal salt, turmeric, jeera, small amount of oil (1 tsp refined oil or ghee)
4. Roti: 1 small roti (thin, 30-35g, can be added if appetite allows)
5. No salad with raw tomato, raw onion in excess - these add K+
6. Curd/yogurt: AVOID or max 1-2 tsp - dairy adds phosphorus; buttermilk is high K+

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EVENING SNACK (4:30-5:00 PM)

Light, low K+

• Murmura (puffed rice) 1 small cup - plain, no salt
• OR: 2-3 arrowroot biscuits
• OR: Small piece (100g) of pear or apple (safe in CKD)
• Avoid: banana, orange, grapes, chickoo, guava (all high K+)
• Small cup tea (50 mL milk max)

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DINNER (7:30-8:00 PM) - Insulin 3 units given

Moderate, not heavy (poor appetite - make it palatable and small volume)

1. Khichdi - 1 medium bowl:
   • Made with white rice + very little moong dal (1:3 ratio dal:rice)
   • With ghee 1 tsp, jeera, haldi
   • This is the IDEAL meal for this patient - easy to eat, soft, low K+, acceptable protein
2. OR Soft roti x2 + leached vegetable sabzi (lauki/tinda)
3. Soup (if tolerated): Clear thin soup from boiled lauki or ash gourd (petha) - discard boiling water, use fresh water to make thin soup with no salt or very minimal salt
4. NO heavy nighttime meal - CHF patients have positional breathlessness; heavy meals worsen it

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BEDTIME (10:00 PM)

Only if blood sugar drops at night

• 2-3 plain crackers/arrowroot biscuits if BSL <120 at bedtime
• Otherwise nothing - prevent fluid overload

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FLUID MANAGEMENT TABLE

Practical tip: Give patient a marked 800 mL bottle each morning. All fluids for the day must come from this bottle. When it is empty, no more fluid until next day.

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SPECIAL CONSIDERATIONS FOR THIS PATIENT

For Uremic Anorexia / Poor Appetite:

• Small, frequent meals (5-6 times a day) rather than 3 large meals
• Serve food warm - cold food is less appealing to uremic patients
• Soft texture preferred - hard chewing is tiring for elderly
• Mild seasoning (turmeric, jeera, small amount of amchur for taste without salt)
• Avoid strong smells during cooking - uremic patients have heightened sensitivity to odors
• Lemon juice (small amount) can enhance palatability without adding potassium in small quantity
• Avoid forcing food - small but consistent intake is better than one forced large meal

For Diabetes (BSL 131.7 fasting - acceptable):

• Avoid all simple sugars: Sugar, jaggery (gur), honey, sugarcane juice, sweet tea, fruit juices, mithai
• Low glycemic index foods: white rice (smaller portions), idli/dosa (smaller portions)
• No skipping meals - insulin is given afternoon and evening; skipping will cause hypoglycemia
• Spread carbohydrates evenly across all meals - do not concentrate carbs at one sitting
• If BSL rises post-meal: reduce rice portion, replace with more sabzi

For Heart Failure / Fluid Overload:

• Strict sodium <2g/day = roughly 1/4 tsp of salt across the ENTIRE DAY in all cooking
• No adding salt at table
• No pickles, papad, namkeen
• Weigh patient every morning (same time, after voiding, before eating) - document in diary

For Hyperkalemia (K+ 5.98):

• Leach all vegetables without exception
• No fruit juices (even small amounts of juice concentrate)
• Avoid coconut water entirely
• Monitor K+ every 1-2 weeks while dietary changes are made
• Inform patient/family: do NOT add salt substitutes - they contain potassium chloride

For Hyperphosphatemia (P 5.27):

• Limit dairy (milk, curd, paneer) to max 100 mL milk equivalent/day
• Take calcium carbonate tablet with meals (this acts as a phosphate binder - already partly covered by the antacid being prescribed, but aluminium hydroxide should be replaced with calcium carbonate 500 mg with each main meal for phosphate binding)
• Avoid cola drinks, processed packaged foods

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SAMPLE WEEKLY ROTATION (Indian Context, Pune)

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FOODS TO COMPLETELY AVOID (Quick Reference Card for Family)

SAFE FRUITS (Low K+, Low P) for This Patient

• Apple - best choice ✓
• Pear - safe ✓
• Watermelon (small slice, 100g) - moderate K+ but high water content - count toward fluids
• Papaya (100g, ripe) - moderate, occasional

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SUPPLEMENTS ALREADY PRESCRIBED - DIETARY INTERACTIONS

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MONITORING THROUGH DIET

• Weight (daily) - target losing 0.5-1 kg/week until euvolemia, then stable
• Urine output (daily) - document in mL
• BSL - fasting + 2 hours post-lunch (minimum)
• Serum K+ - recheck in 1 week after dietary K+ restriction
• Serum creatinine + urea - every 1-2 weeks

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SUMMARY TABLE

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Note on Sterile Pyuria: Given persistent sterile pyuria (60-80 pus cells/HPF) for 2+ years with no bacterial growth on standard culture, the treating physician should urgently investigate for Genitourinary Tuberculosis - send urine for AFB smear x3 early morning samples and CBNAAT (GeneXpert). This is not addressed by the current prescription and could be a treatable cause of the ongoing renal deterioration.

Disclaimer: This diet plan is for clinical guidance only and should be reviewed and finalized by a qualified renal dietitian familiar with the patient's complete clinical picture, cultural food preferences, and current blood investigations.

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COMPREHENSIVE DIFFERENTIAL DIAGNOSIS CHART

80F | T2DM + HTN + Nephropathy + CRF + Acute CHF + Sterile Pyuria + Hyperkalemia

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HOW TO READ THIS CHART

• Clinical basis (why it fits this patient)
• Investigations to confirm or rule out
• Treatment if POSITIVE

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DOMAIN 1: RENAL PARENCHYMAL DISEASE (Primary Problem)

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DD 1.1 - DIABETIC NEPHROPATHY (Kimmelstiel-Wilson Disease)

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DD 1.2 - GENITOURINARY TUBERCULOSIS (GUTB)

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DD 1.3 - ACUTE INTERSTITIAL NEPHRITIS (AIN)

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DD 1.4 - RENAL PAPILLARY NECROSIS (RPN)

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DD 1.5 - HYPERTENSIVE NEPHROSCLEROSIS

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DOMAIN 2: CARDIAC (Heart Failure)

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DD 2.1 - HFpEF (Heart Failure with PRESERVED Ejection Fraction)

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DD 2.2 - HFrEF (Heart Failure with REDUCED Ejection Fraction)

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DD 2.3 - CARDIORENAL SYNDROME Type 1 or 2

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DOMAIN 3: METABOLIC / ELECTROLYTE ABNORMALITIES

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DD 3.1 - HYPERKALEMIA (K+ 5.98 mmol/L) - CONFIRMED

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DD 3.2 - METABOLIC ACIDOSIS (Presumed - HCO3- not done)

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DD 3.3 - SECONDARY HYPERPARATHYROIDISM / CKD-MBD

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DD 3.4 - ANEMIA OF CKD (AoCKD) - CONFIRMED

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DOMAIN 4: URINARY / INFECTIOUS

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DD 4.1 - COMPLICATED UTI / PYELONEPHRITIS (Bacterial - Culture Negative)

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DD 4.2 - XANTHOGRANULOMATOUS PYELONEPHRITIS (XGP)

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DOMAIN 5: DIABETES-RELATED

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DD 5.1 - HYPOGLYCEMIA RISK (On 40 IU Insulin + CKD)

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DD 5.2 - DIABETIC AUTONOMIC NEUROPATHY

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DOMAIN 6: HYPERTENSION-RELATED

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DD 6.1 - HYPERTENSIVE EMERGENCY / URGENCY

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MASTER SUMMARY TABLE

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IMMEDIATE PRIORITY INVESTIGATIONS (Do TODAY)

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Disclaimer: This chart is for clinical decision support only. All management decisions require the treating physician's clinical judgment with full access to the patient.