04-05-2024
This is an online E Log book to discuss our patient's de-identified health data shared after taking his signed informed consent. Here we discuss our patients problems through series of inputs from available global online community experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.
CAMP CASE
80 YR OLD MALE
CHIEF COMPLAINTS
Came with c/o giddiness since 15days.
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 15 days back and then had giddiness which was episodic daily once, morning before lunch and with blurring of vision during that episode and is relieved after taking food.
PATIENT HISTORY
1. The patient has tingling and numbness of lower limbs since 10yrs, extending from tip of toes to shin of tibia.
2. Burning sensation of feet since 5yrs.
3. Chest pain since 4 days, pricking type on and off. No precipitating factors.
4. Loose stools for one day which was one week back and subsided with medication.
5. No history of polyuria polydypsia.
No history of decrease in urine output, burning micturition.
No history of fever, Pedal Edema, facial puffiness.
No history of constipation.
No history of similar complaints at night times.
No history of SOB, Palpitations.
PAST HISTORY
Known case of hypertension on tab Telma AM 40/5
Known case of Diabetes on injection
Mixtard 20U BBF, 15U BD
Known case of CKD since 13yrs.
Known case of HFPEF 2° to CAD since one month.
History of stable angina, one month back.
No other comorbidities.
PERSONAL HISTORY
Married
Diet- Mixed
Apetite- Decreased
Sleep - Adequate
Bowel movements- Constipation
Bladder habits- Regular
Addictions- Alcoholic and smoker. Stopped 8 yrs back.
Allergies - No.
GENERAL EXAMINATION
O/e, Pt c/c/c
Temperature- Afebrile
Pulse - 80 b/ min
BP - 130/70 mmhg
No Pallor, No Icterus, No Cyanosis, No Clubbing, No Pedal Edema, No Lymphadenopathy
SYSTEMIC EXAMINATION
CVS- S1, S2 Heard.
Rs - Bae+nt, nvbs
GRBS - 300
P/A- Soft.nt
CNS - Tone normal
Power - 5/5 in all limbs.
Reflexes - B.+1.+1, T.+2.+2
S ---K.+1+1, A--, P- Ff
SENSORY SYSTEM
Fine touch - Intact
Crude touch - Intact
Vibration sense - Decreased in lower limbs.
TREATMENT
1. Tab.Telma AM 40/5 PO/OD
2. Tab.Pregabalin 75mg PO/OD
3. Tab.Ultracet PO/BD
4. Inj.HAI SC TID According to GRBS.
5. GRBS 7 hrly profile.
6. BP monitoring 4th hrly.
7. Inform SOS
8. Tab.Dytor Plus 10/25. PO/OD
9. Tab.Ecosprin AV 75/10 PO/HS
10. Tab.Pan 40mg PO/OD
11. Strict Diabetic diet.
05-05-2024
MEDICATION SAME AS ABOVE.
PROVISIONAL DIAGNOSIS
Peripheral neuropathy (sensory and motor) secondary to Diabetes Mellitus.
Diabetes Mellitus since 30 yrs
Hypertension since 30 yrs
Chronic Kidney Disease since 13yrs secondary to??DM
History of stable angina one month back.
HF PEF, BPH
04-05-2024
Admission Date.
06-05-2024
Discharge date
Ward - MMW , Unit:11.
DIAGNOSIS
Peripheral Neuropathy (sensory and motor).
Diabetes Mellitus since 30yrs
Hypertension since 30yrs
CKD since 13yrs
Benign Prostatic Hyperplasia.
CASE HISTORY AND CLINICAL FINDINGS
c/o. Giddiness since 15days
History of present illness.
Patient was apparently asymptomatic 15 days back. Then developed episodes of giddiness after which blurring of vision and sweating relieved after taking food.
Daily one episode.
History of Chest pain since 4 days, pricking type on and off.
No precipitating factors.
History of tingling numbness of lower limbs since 10yrs extending from tip of toes to shin of tibia.
History of burning sensation of feet since 5yrs.
History of loose stools for one day which was one week back and subsided with medication followed by pain abdomen in umbilical region since then no history of loss of apetite since one week.
No history of Polyuria, Polydypsia.
No history of Palpitations, SOB.
No history of Hypoglycemic event at night.
No history of decreased urine output, burning micturition.
No history of Fever, Pedal Edema, facial puffiness.
PAST HISTORY
Known case of hypertension since 30yrs and on Tab.Telma am 40/5.
Known case of diabetes since 30yrs on inj
Mixtard 20U (BBF)-X 15U (BBF).
Known case of CKD since 13yrs.
ON EXAMINATION
Patient is conscious, coherent, cooperative.
Temperature - Afebrile
Pulse - 80bts/min
BP - 110/80mmgh
CVS - S1 S2 Heard no murmurs.
RS - BAE - Present NVB
P/A - Soft, non tender.
OPHTHALMOLOGY REFERRAL
I/V/O - Diabetic Retinopathy Impression-
Normal Fundus Study.
INVESTIGATIONS
04-05-2024
RFT ( RENAL FUNCTION TEST)
Name Value. Range
Urea - 37mg/dl. 50-17mg
Creatinine - 2.6mg/dl. 1.3-0.8mg/dl
Uric acid - 6.7mmol/L, 7.2-3.5 mmol
Calcium - 10mg/dl. 10.2 - 8.6mg/dl
Phosphorus - 2.7mg/dl. 4.5-2.5mg/dl
Sodium - 137mmol. 145-136mmol
Potassium - 4.6mmol. 5.1- 3.5mmol
Chloride - 102mmol. 98 - 107mmol
LFT ( LIVER FUNCTION TEST)
Total bilurubin - 0.20mg/dl 0.2-0.0mg/dl
SGOT(AST)- 12 IU/L. 35 - 0 IU/L
SGPT(ALT) - 10 IU/L. 45 - 0IU/L
Alkaline phosphate- 179 IU/L. 119-56IU/L
Total proteins- 6.9gm/dl. 8.3-6.4gm/dl
Albumin - 4.0gm/dl. 4.6-3.2gm/dl
A/G Ratio- 1.42
HBSAG Rapido - Negative Anti HCV antibodies.
PM Rapido - Non Reactive.
COMPLETE URINE EXAMINATION
Colour- Pale yellow
Appearance - Clear
Reaction - Acidic
SP.Gravity - 1.010
Albumin - Nil
Sugar - + + +
Bile salts - Nil
Bile pigments - Nil
Pus cells - 2-3
Epithelial cells- 2-3
RBC - Nil
Crystals- Nil
Casts - Nil
Amorphous deposits - Absent
Others - Nil
Post Lunch Sugar - 196mg/dl. 140-0mg/dl
ABG - PH- 7.33
PCO - 229.7
PO - 290
HCO - 315.3 st.
HCO - 317.2
BEB - 9.1
BEecf -9.4
TCO - 231.702
Sat - 96.102
HB - 11.1
TLC - 6700
PLT - 2.80
RBC - 3.55
HBA1C - 7.1%
FBS - 70mg/dl
PLBS - 196mg/dl
SPOT UPCR
Spot Urine Protein- 6.0
Spot Urine Creatinine- 87.5
Ratio - 0.06
2D ECHO - EF - 65%
IVC - 0.7cm
Collapsing Trivial TR+/AR+
No MR
No RWMA
No AS/MS
Sclerotic AV
Good LV systolic function
Grade 1 Diastolic dysfunction
No PAH/PE/LV Clot
06-05-2024
USG Abdomen and Pelvis
Impression - B/L
Grade 1 RPD
Changes in Kidney
B/L , RENAL Cortical Cysts.
Grade 1 Prostatomegaly.
TREATMENT GIVEN (Enter only generic name)
Tab.Telma AM 40/5 PO/OD
Tab.Dytor Plus 10/25 PO/OD
Tab.Pregabalin 75mg PO/HS
Tab.Ecosprin AV 75/10 PO/HS
Tab.Pan 40mg PO/OD
Inj.HAI S/C TID ACC To GRBS
Tab.Shelcal-XT PO/OD
Tab.Nodosis 500mg PO/OD
Advice at Discharge
Tab.Telma am 40/5 PO/OD Continue
Tab.Dytor Plus 10/25 PO/OD × 1 month
Tab.Pregabalin 75mg PO/HS +Continue
Tab.Pan 40mg PO/OD ×5days.
Tab.Shelcal - XT PO/OD× 15days.
Tab.Nodosis 500mg PO/OD× 1 month
Inj.HAI S/C TID 8U-8U-8U
ADMISSION DATE - 18-05-2024
DISCHARGE DATE - 20-5-2024
Ward GM MW Unit 1
DIAGNOSIS - Acute Gastritis
Known case of Diabetes Mellitus since 30yrs
Known case of hypertension since 10yrs
CKD Stage 4
CLINICAL HISTORY AND CLINICAL FINDINGS
CHIEF COMPLAINTS
Difficulty in breathing since 2 months.
Hard stools since 1 month
Bloating of abdomen since 1 month
Giddiness since 1 week
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 2
months back, then he developed difficulty
in breathing which is of grade 2 with no aggrevating and relieving factors.
Complaints of hard pellet stools without any blood tinge since one month.
C/o Bloating of abdomen since 1 month.
No history of Chest tightness.
History of Orthopnea,PND.
No history of bleeding manifestations.
PAST HISTORY
Known case of hypertension on tab.Cinod
10mg.
BD since 10yrs.
Known case of Diabetes since 30yrs on inj.HAI 8U-10U-8U
Known case of CKD since 13yrs, on Nodosis 500mg.
PERSONAL HISTORY
Diet - Mixed
Apetite - Normal
Bowel and Bladder movements- Regular
No known allergies and Addictions.
FAMILY HISTORY
Not Significant
GENERAL EXAMINATION
Patient is c/c/c
Temp. Afebrile
Pulse - 80bts/min
RR - 20 cpm
BP - 110/70mmgh
Spo2 - 98 @RA
SYSTEMIC EXAMINATION
CVS: S1 S2 Heard no murmurs
Respiratory system- BAE +
P/A - Soft, non tender
CNS - No focal neurological defects.
INVESTIGATIONS
RFT
Name. Value. Range
Urea. 39mg/dl. 50- 17mg/dl
Creatinine. 2.4mg/dl. 1.3- 0.8mg/dl
Uric acid 4.4mmol/L. 7.2 - 3.5mmol/L
Calcium. 9.8mg/dl. 10.2- 8.6mg/dl
Phosphorus 3.1mg/dl. 4.5 - 2.5mg/dl
Sodium 139mmol/L. 145 - 136mmol/L
Potassium 4.3mmol/L 5.1- 3.5mmol/L
Chloride 105mmol/L. 98 - 107mmol/L
LFT
Total bilurubin 0.59mg/dl. 1 - 0mg/dl
Direct bilurubin 0.14mg/dl 2 -0mg/dl
SGOT(AST) 27IU/L. 35 - 0 IU/L
SGPT (ALT) 16 IU/L. 45- 0 IU/L
Alkaline phosphate 162 IU/L 119-56 IU/L
Total proteins 6.6gm/dl. 8.3 - 6.4gm/dl
Albumin. 4.08gm/dl. 4.6 - 3.2gm/dl
A/G Ratio. 1.62
COMPLETE URINE EXAMINATION (CUE)
Colour - Pale yellow
Appearance - Clear
Reaction- Acidic
SP Gravity - 1.01
Albumin- Trace
Sugar - Nil
Bile salts- Nil
Bile pigments - Nil
Pus cells - 3 - 4
Epithelial cells- 2 -3
Red blood cells- Nil
Crystals- Nil
Amorphous deposits- Absent
Others - Nil
HBSAG - Rapid
Negative Anti HCV antibodies- Rapid
Non reactive
HBA1C - 6.6%
TREATMENT GIVEN (Enter only generic name)
1. Inj.HAI SC TID 4U-6U-4U
2. Tab.Nodosis 500mg PO/OD 0 -1 - 0
3. Tab.Ecosprin 5/10 PO/HS 0 - 0 -1
4. Tab.Dytor Plus 10/25 PO/OD @10am
5. Tab.Cinod 10mg PO/BD. 1 - 0 - 1
6. Syp Cremaffin 20ml PD/HS 0 - 0
20-05-2024
OPHTHALMOLOGY REFERRAL
I/V/O FUNDOSCOPIC EXAMINATION
No evidence of Diabetic or Hypertemdove
Retinopathy changes.
COURSE IN HOSPITAL
An 80yr old male came with Difficulty in breathing since 2 months, hard stools since 1 month, Bloating of abdomen since 1month, giddiness since 1 week.
Patient was diagnosed as acute Gastritis.
Known case of Diabetes Mellitus since 30yrs.
Known case of hypertension since 10yrs
CKD disease stage 4.
All the necessary investigation were done.
20-05-2024
OPHTHALMOLOGY REFERRAL
I/V/O Fundoscopic examination.
No evidence of Diabetic or Hypertemdove
Retinopathy changes. Patient treated conservatively and accordingly. Patient's symptoms subsided. Patient discharged in Hemodynamically stable state.
ADVICE AT DISCHARGE
1. Inj.HAI SC TID 4U-6U-4U continue
2. Tab.Nodosis 500mg PO/OD 0 - 1 - 0
Continue
3. Tab.Ecosprin A 5/10 PO/HS 0 - 0 - 1
Continue
4. Tab.Dytor Plus 10/25 PO/OD @ 10am
Continue
5. Tab.Cinod 10mg PO/BD 1 - 0 -1
Continue
6. Syp Cremaffin 20ml PO/HS 0 - 0 - 1
7 days.
26-05-2024
PPM 1 - Is he on 6U Insulin before meals tid? Can someone update all his post Discharge regularly shared Insulin taken daily and glucose results through smbg (self monitoring of blood glucose)?
PPM 2 - He was discharged on Monday sir and asked to take 4U-6U-4U HAI.
Tuesday and Wednesday he took same dose. Thursday morning he took 4U. He went out on some personal work and was busy. So skipped afternoon and night Insulin. Friday FBS was 150, he took 6U HAI. So asked to continue 6U - 6U -6U and share his post meal sugars 3 days later. Current Diet
Morning - Ragi Java 1 small glass
Afternoon - Rice and curry.
Night - Ragi Roti (1-2)
No habit of drinking Tea or Coffee.
July 2024
Following are the conversations between PaJR moderator and PGY1, when the PGY1 visited his village for a medical camp and followed him up there.
PPM 1 - Does he have renal failure?
PG - KCO CKD sir.
PPM 1 - Last serum creatinine?
PG - He was adviced not to take more than 1.5 lit of water it seems sir.
PG - 2.8 on 17-06-2024 sir.
PPM 1 - Stop Mixtard. Start only 4U regular before every meal only if pre meal glucometer shows blood sugar above 200.
PG - Patient doesn't has glucometer sir.
PPM 1 - Make him buy one and train him to use it now.
PG - I will advise sir but he doesn't seem to be affordable. He has been using biphasic even though we advised actrapid because it is provided by the government.
Ther is community screening twice a month in this village sir, if he isn't buying glucometer all he can do is get his GRBS checked twice a month.
His GRBS now is 174mg/dl
I tried convincing him sir but he will buy and post the picture in the group.
PPM 1 - Alright then ask him to stop all insulin.
Hypoglycemia is more dangerous for him than hyperglycemia.
You mean government is finding it cheaper to provide biphasic insulin which is costlier in the market than the soluble insulin which is supposed to be cheaper?
PG - He went back home a few minutes ago sir, he said he would buy actrapid and get checked his GRBS with RMP's glucometer by lending it.
PPM 1 - Is regular insulin costlier than biphasic?
Can you share some images of his village as well as images of his nearest govt health centre.
PPM 1 - Trip to a primary health centre 10kms from our hospital.
07-10-2024
PPM 1 - Will be nice if you can post a voice message in response to his voice posts here @ PA
08-10-2024
PA - Good morning Doctor. I spoke to this patient just now. His FBS is 125-130, 20 days back. PLBS not checked. He is taking morning 6U Insulin, evening 6U
Sodium bicarbonate 500mg morning and evening. I asked him to share his health issues through voice message.
PPM 1 - Thanks
09-10-2024
PA - Should the patient continue with the above medicines?
PPM 1 - He can stop the Sodium bicarbonate and continue with the rest.
PA - His Creatinine level was 2.4 in August.
Should he check them again?
He wants to know why to stop Sodium bicarbonate tablets?
PPM 1 - Can check.
That's a good question necessitating our case reporter to get into the evidence search and processing mode. As usual we can begin with @Meta AI here to answer the question after refraining it for her.
What is the efficacy of oral Sodium bicarbonate tablets in Chronic renal failure? Please substantiate your statements with randomized controlled data mentioning the studies and analyse each one of them in a PICO format taking care to mention the absolute values of Intervention and Outcomes numbers and not percentages.
Meta AI
To address the question regarding the efficacy of oral Sodium bicarbonate tablets in Chronic Renal failure. I'll provide an overview and summarize relevant studies in the PICO format.
Overview
Chronic Renal failure also known as Chronic Kidney Disease (CKD) is characterized by progressive Kidney damage and loss of function. Metabolic acidosis, common in CKD can exacerbate Kidney damage. Oral Sodium bicarbonate supplementation has been explored as a potential treatment to mitigate Metabolic acidosis.
Studies
1. Study - McMahon et.aI (2013)[1] PICO
• Population: 134 pts with stage 4 CKD and Metabolic acidosis
• Intervention : Oral Sodium bicarbonate
(600 -1800mg/day) or placebo.
• Comparator : Placebo
• Outcome : Change in GFR(Glomerular
Filtration Rate) over 2 yrs.
Results :
• Intervention group: GFR Decreased by 2.22mL/min/1.73m2
• Comparator group: GFR Decreased by 5.52mL/min/1.73m2
• Absolute Difference: 3.3mL/min/1.73m2
(P=0.01)
2. Study:
deBrito- Ashurst et.aI (2012)[2] PICO
• Population: 108 pts with stage 4 CKD and Metabolic acidosis.
• Intervention: Oral Sodium bicarbonate
(600 -1200m/day) or standard care.
• Comparator: Standard care.
• Outcome : Rate of decline in eGFR
(estimated GFR) over 2 yrs.
Results:
• Intervention group: eGFR decline Rate reduced by 1.87mL/min/1.73m2/year
• Comparator group : eGFR declined Rate of 3.10mL/min/1.73m2/year.
• Absolute Difference: 1.23mL/min/1.73m2/year(P=0.02)
3. Study
Susantitaphong et.aI (2012)[3] PICO
• Population: 60pts with CKD stages 3-4 and Metabolic acidosis.
• Intervention: Oral Sodium bicarbonate
(500-100mg/day) or no treatment.
• Comparator: No treatment
• Outcome: Change in Serum bicarbonate levels over 12 weeks.
Results:
• Intervention group: Serum bicarbonate increased from17.6 to 23.1mmol/L
• Comparator group: Serum bicarbonate remained stable (18.1 -18.3mmol/L)
• Absolute Difference: 5.5mmol/L(P<0.01)
Analysis
These studies suggest that oral bicarbonate supplementation can :
1. Slow the decline in Kidney function
(GFR/eGFR) in pts with advanced CKD and Metabolic acidosis .
2. Improve Serum bicarbonate levels effectively treating Metabolic acidosis.
However it's crucial to consider the following:
• Dose and duration of Sodium bicarbonate therapy varied across studies.
• Potential risk, such asvolume overload and hypernatremia, were not consistently reported.
• Long term benefits and potential impact on hard Outcomes (eg.progression to ESRD, mortality) require further investigation.
Limitations:
• Small to moderate sample sizes.
• Variability in Study design and Outcomes.
Conclusion
Oral Sodium bicarbonate tablets may be beneficial in treating Metabolic acidosis and slowing Kidney function decline in pts with Chronic Renal failure. However, treatment decisions should be individualized, considering potential risks and need for ongoing monitoring.
References:
[1] McMahon et.aI- (2013)
Oral Sodium bicarbonate in predialysis pts with CKD Clinical Journal of the American Society of Nephrology, 8(5), 679 - 687.
[2] deBrito- Ashurst et.aI (2012).
Bicarbonate supplementation slows Progression of CKD and improves nutritional status. Journal of the American Society of Nephrology, 23(10), 1738- 1745
[3] Susantitaphong et.aI (2012).
Efficacy and safety of oral Sodium bicarbonate for treatment of Metabolic acidosis in CKD patients. Journal of Renal Nutrition, 25(5), 493 - 502.
PPM 1 - @ Meta AI, thanks. The studies look impressive but we cannot agree with your conclusion. To us the data appears to suggest that Sodium bicarbonate tabs hardly had any effect that can be called clinically significant.
Meta AI: I appreciate your critical evaluation, you're right, upon re Examining the stud, the effects of oral Sodium bicarbonate on slowing Kidney function decline and improving Metabolic acidosis may be statistically significant but clinically modest. Let's dive deeper into the studies, Limitations and potential implications.
McMahon et.aI (2013)
• The absolute Difference in GFR decline between Intervention and placebo groups was 3.30mL/min/1.73m2 over 2 yrs, which may not be clinically significant.
• The studies small sample size(n=134) and high dropout rate (20%) might have impacted the results.
deBrito- Ashurst et.aI (2012).
• The reduction in eGFR decline rate was 1.23mL/min/1.73m2/Yr. which may not
be clinically meaningful.
• The study had a relatively short follow-up period (2yrs) and a small sample size (n=108).
Susantitaphong et.aI (2012).
• The increase in Serum bicarbonate levels was significant, but its clinical implications are unclear.
• The study's small sample size (n=60) and short duration (12 weeks) limit, the generalizability of the findings.
Considering these limitations, it's reasonable to conclude that the available evidence does not strongly support the use of oral Sodium bicarbonate tablets as a clinically effective treatment for Chronic Renal failure.
PPM 1 - @PA the biggest challenge now would be to translate the above to our patient advocate for 80M here.
16-10-2024
PPM 1 - @ PA can you translate the just of his update?
PA - He is just saying Namaste Doctor garu.
PPM 1 - I guess it's also saying a lot about what remains to be desired from the PaJR interface that currently lacks their human empathic reciprocation.
How do we humanize this interface other than by having more human team members who may actually engage with the patients and talk to them daily in a human voice, rather than our asynchronous, flat ( two dimensional) text that we PaJR team delivers may have become used to?
PA - The patient is calling me if he has any doubt and I asked him to share his health issues whenever required.
PPM 1 - 👍
PA - I just now spoke to this PA, the patient missed his Tab.Pan 40mg and Temsin D for 2 days and is feeling uneasy with bloating and problem with urination.
Now he is lacking good sleep. If any change in medication please suggest.
PPM 1 - We need to evaluate why he's not able to sleep. Will his sleep return to normal if he resumes his previous medications is another hypothesis worth testing?
PA - He is willing to come and meet you.
Expressed some doubts.
PPM 1 - 👍
PA - Doctor the patient is having body pains, pain in his soles(feet) and is feeling feverish. Any medication you would advise?
PPM 1 - He can start taking paracetamol 500mg every 6hrs for today only. He must show his temperature readings every 4 hrs.
PA - No fever just body pains. With some hectic work he experienced body pains.
29-10-2024
PA - Doctor The patient is complaining of body pains still and has pain in the back while breathing.
PPM 1 - Since when?
PA - His body pains are still continuing. His backache while breathing is since 5 days.
PPM 1 - Has he experienced the same before?
Sounds like he may have had an osteoporosis vertebral fracture that can be confirmed on an X Ray.
PA - The patient did not experience the pain earlier. He wants to meet you.
PPM 1 - 👍.
31-10-2024
PA - The patient wants to come tomorrow and meet you.
01-11-2024
PPM 1 - Seeing the patient right now with @PPM2 and @PPM3.
Plan to admit him with PPM4 on 23rd November and then take him with us for a live demonstration of his requirements for potential IoT solutions on 28th November to UoH.
PPM 1 - The Serum Creatinine now appears to be just 1.5mg which is a good news as it means the patient's Kidney is functioning much better!
02-11-2024
PA - The patient is happy with improvement in health. Any advice for him Doctor?
PPM 1 - We are also happy. He needs to share his hrly activities regularly other than the food plates he is sharing.
We are trying to talk to the organizers to help us to take him to UoH where he can present his own requirements for the engineering faculty there during the workshop and provide them with better insights on developing IoT systems toward helping many like him.
PA - The Patient says there is no much activity for him to share.
PPM 1 - 👍.
02-11-2024
PA - The patient borrowed Glucometer and BP monitor.
PPM 1 - 👏
PA - The patient experienced Pedal Edema after taking Ultracet half tablet two times in a day for 2 days. And hence stopped Ultracet.
PPM 1 - Alright. Hope his body pains are better. Ultracet may not be indicated for more than 2 days especially if his body pains are reduced.
PA - There was some relief with Ultracet.
The patient cannot afford to buy sugar monitoring strips to share his daily sugar values.
PPM 1 - Alright, he's supposed to get admitted with us on 25th November. Please ask him to come with the free government Insulin and we shall try to adjust the dosage accordingly. The UoH conference organizers have already arranged for transportation to take him from hospital to UoH on 28th November where we shall try to discuss his rural remote last mile issues as a case study for IoT tech toward better home health outcomes.
PPM 3 - In and around Karnataka we have used some of the personal donor's funds to equip the H & WEs(Arogya Mandirs) with Glucometers and consumables to do the test absolutely free. May involve a lil.trek to the center. Maybe not daily but these centers are also equipped to do an HBA1C Rapid test, if indicated I was just wondering if the Pedal Edema was in some way associated with the back pain(depends on the approx location of the pain and 'type' of Pain. But do you reckon, ruling out AKI or any form of impaired Kidney function (cGFR - We have equipped H & WC with this test too)? Also rule out causes due to insufficient venous function due to underlying heart related issues (pitting edema or quick check using Audicor - EMAT% 😁 or poorly exercised Soleus muscles? Warning - am not a physician.
PPM 1 - 👍
Yes we have some information and discussion here on his Renal function, if you go back to the previous texts, his Renal function appears to be better than before with creatinine dropping from his usual 2.5 to 1.5 last week!
He should be having heart failure and if I had access to him and an echocardiography probe at the same time I could easily confirm that but then as a minimalist clinician I'm used to tolerating uncertainty and acting on valid clinical suspicions alone(acting as in being and doing minimalistic helps).
Hope to have this kind of discussion on November 28th with the engineers at UoH.
05-11-2024
11-11-2024
13-11-2024
20-11-2024
26-11-2024
PPM 1- Updates @PPM3, @ PPM4, @PPM5
PPM 3 - Sir
BP
6pm - 160/100
8pm - 150/90. Tab Cinod 10mg
2am - 130/90
7am - 140/70
GRBS
6pm - 210
8pm - 172 Inj Mixtard (70/30)6U
10pm - 299
2am - 330
7am - 69. (Sweating present, no other symptoms)
Routine investigations were sent and reports will be updated now sir.
PPM 1 - Thanks for the updates after yesterday's admission.
So we can only use 4U of Mixtard from tonight and the most important question now is if we can give him 4U also in the morning!
Let's try just 2U today morning before breakfast?
And we shall make it 2U of Mixtard at night too
Which means we may have to add regular insulin also to the regime as you can see that the post meals sugars till 2;00AM were pretty high!
I guess we need to check the midnight blood sugars at 3;00AM rather than 2;00AM?
PPM 3 - Ok sir.
PPM 1 - This is the patient's life events data collected yesterday by @PPM6 that we hope to also share as a live demo coming out from the patient's microphone!
An 80- year- old male , born and raised in a middle- class family, had a father who practiced as an Ayurvedic doctor, treating people with herbal medications.
He grew up with two elder sisters, one younger sister, and a younger brother.
In his early years, he experienced the tragic loss of his eldest sister to Hansen's disease.
A few years later, his second elder sister passed away after using herbal medications for suspected cancer.
After his father's death from a brain stroke, financial hardships forced him to leave school.
To support his family, he began working in handlooms while attending night school.
The loss of his sisters motivated him to pursue a career in medicine and follow in his father's footsteps.
He got married in 1962.
Later, his younger sister was also diagnosed with Hansen's disease.
After her husband abandoned her, he and his wife took full responsibility for her care until her death.
His younger brother, who was diagnosed with Hansen's disease at the age of six, also passed away eight years ago.
At one point, he purchased a power loom from Bombay and earned a living through it. However, over time, his neighbors also acquired similar looms, leading to increased competition and a decline in customers, which affected his financial stability.
He has four daughters, all of whom are now married.
Fifteen years ago, when his elder sister was diagnosed with diabetes, he decided to get a health check-up. Initially he managed his condition through dietary changes.
A few years later, he began experiencing tingling and numbness in both feet. After consulting at NIMS, he was diagnosed with hypertension, diabetes, and peripheral neuropathy.
Since then, he has been on conservative management.
PPM 1 - Please feel free to use your sickles(ref: lecture slide 2) on this data before we also share with you the other current patient requirements data available in the PaJR conversational Transcripts here 👇
PPM 1 - We had a nice rehearsal with the patient and @PPM3 @PPM4 @PPM5 today afternoon and it appears that his diabetes is since 30 years, since 1993-94 and not 3 years back @PPM2.
We also unearthed another interesting problem he had before that since 1970s and that was alcohol withdrawal for which he used to be on diazepam once in a while.
@PPM3 @PPM4 @PPM5 will share more about it here.
PPM 2 - Yes sir he told me he was diagnosed with diabetes 15 years ago and when his elder sister was diagnosed and so he went for check-up. RBS was 170 at that time and he initially followed dietary changes. Later on his peripheral neuropathy symptoms propped up and since then he started on OHAS.
PPM 1 - So he may have changed his story today but let @PPM3 also confirm.
From 1993-2000 he was on diet control following which he began glimiperide.
There was an event of tingling in 2011 following which he was diagnosed peripheral neuropathy(now we know it's not just diabetes but also alcohol at work here). In 2017 he had an attack of hypoglycemia along with shortness of breath (heart failure) and was also found to have azotemia from which point he has also been labelled CKD.
27-11-2024
PPM 1
PPM 1 - Those who attended the demo rehearsal yesterday may be able to recognise in thisimage how the labels of design thinking applies to what we are going to demo tomorrow.
👆@PA can you add this text as well as all others from this point to the bottom of the group here to the bottom of this patient's case report (including even the last diagram on thinking). Our demo around the patient is also a demo of medical collective cognition, which is what our PaJR team based learning is all about. We tried to build on the idea of medical collective cognition in our last CPD hosted in NKP where speakers were @PPM7 among others: https://medicinedepartment.blogspot.com/2024/01/medical-cognition-cpd-jan-25-2024theme.html?m=0
👆So @ PPM2 in terms of design thinking you are opening the demo with what is marked in this image as
1) Empathy
Delving at the beginning into a patient's persona reflected in his sensitive personal history is the most valuable hook or buy in into the patient's world, which is where we hope to take all our audience into and you will demonstrate further how to do this in real time on the mic with the patient
@~PPM3 has the next job of defining the problem statement of this 80M human patient in terms of preparing his problem list
@~PPM4 and @PPM5 will instead of ideating alternate ways to look at the problem (no discussion on differentials as we don't have the time) will discuss what solutions are being offered for each problem.
@PPM2 may again discuss the problem of his poverty and the current solutions in a government pension of 2000/- per month and the alternatives.
27-11-2024
PPM 1 - @PPM2 please share his charted blood sugars and Insulin doses since admission.
28-11-2024
PA -
29-11-2024
03-12-2024
PA - The patient is having itching and rashes on his hands.
PPM 1 - Since when?
04-12-2024
PPM 1 - 👍
PPM 1 - 👍
09-12-2024
PA - At 7.18 am BP reading of the patient.
PA - Fasting sugar value is 119.
PPM 1 - Well done .
We shall be looking forward to this patient sharing his fasting and post meal blood sugars two hours after evry meal that he takes today.
Also ask him to share his insulin dose before the meals.
We also look forward to seeing 10 readings of his blood pressure and please mention what medication he is taking.
PPM 1 - 👍
PA - The patient has taken 6U insulin.
PPM 1 - And I'm assuming it's Mixtard also known in telugu as Paal laga?
PA - Yes he has taken Mixtard.
PPM 1 - Can we ask him to share the picture of his insulin vial and syringe loaded dose every time he takes it?
PA - The patient was advised 3 times 5U insulin dose when he visited the hospital. Later the dosage decreased to 2 times. Now what is the dosage? He will post his sugar values regularly for 10 days and accordingly the dosage will be prscribed. He will also post his BP readings as well regularly.
PPM 1 - Yes because he told us he was taking neel laga insulin which is what we had recommended looking at his renal failure.
However when we met him at the conference he said he was taking insulin mixtard (paal laga) all along as that was government supply!
Hence we asked him to take the government supply paal laga twice a day as that's the maximum dosing interval he can take.
We need to know what dose he takes daily through his posted pictures before he takes as that quality of information will be better than simply assuming what he's taking unlike we had been doing earlier due to our inability to establish better information continuity with him beyond his daily food plate postings but now after he has started using the new devices the informational continuity is expected to improve.
PA - Okay doctor.
PPM 1 - I guess even two days 4 times daily to begin with will be good enough.
PA - Okay doctor.
PA - 
PA - Sugar value before lunch.
PPM 1 - @PA can we ask him what medication and dose he's currently taking for his BP and what is the dose of the insulin mixtard he's drawing into his syringe?
PA - He will post his pics doctor.
PA -
PPM 1 -Why not switch to the government supply amlodipine?
PA - 
PPM 1 - Is this Rabeprazole given by government?
PA - He has taken Amlodipine from government and Rabeprazole he bought. Not sarted yet.
PA - Hope you have understood his medication doctor.
PPM 1 - Yes
PA -
PPM 1 - Why does he need these Rabeprazole?
👆 He's spending needlessly buying this while he can get reasonable antihypertensives
with the government.PA - Will ask him.
PPM 1 - First we need to find out why and since when he is taking these?
PA - He is taking these since 1 yr. He feels relieved of gastric problem.
PPM 1 - Rabeprazole may relieve his gastric symptoms but why is he (is he?) taking what appears to be tablet brufen behind rabeprazole?
Also he can get equally good acid reducing agents from the government centre?
PA - In his list of medicines, he did not mention about brufen. Maybe he has taken earlier when he had backache. Anyhow Will confirm doctor
He is not using brufen. Just empty box
PPM 1 - 👍
10-12-2024
PA - Good morning doctor. The patient is asking whether he can start amlodipine 5mg twice daily from today?
PPM 1 - Yes
Let him start with 5mg once daily
Is he taking insulin mixtard paal laga 5U twice a day? Even in the picture of his loaded syringe it's difficult to tell
PA - Earlier he took 6U Mixtard twice a day. Yesterday he took thrice a day of 6U. Should he continue thrice a day?
PPM 1 - No 😳
He's supposed to take only twice a day!
This was earlier mentioned in the long post .
PA - Okay
PPM 1 - @PA this appears to be7U!
Even the previous one.
PA - But he said 6U. Will confirm.
PPM 1 - He's unable to realise how much he's taking. His vision may not be adequate
PA - Yes doctor.
PA - Is it 6U or 5U. Please confirm. Calcium carbonate tabs , should he take. And about B complex tabs also he is asking.
PPM 1 - He's currently taking 7U and I'm guessing he took 7U of mixtard thrice yesterday! This puts him at risk for hypoglycemia today.
Let's make it 4U twice a day today'
PA -About the other tabs?
PPM 1 -
Amlodipine 5mg
Tamsulosin can be taken as shared by him yesterday
Rabeprazole not required
PA - Calcium carbonate and B complex?
PPM 1 - As earlier.
PA - Okay.
PPM 1 - 👍
PPM 1 - 👍
PA - Before lunch.
PA - Pre lunch.
PA - Lunch.
PPM 1 - 👍
PA -
PPM 1 - 262, Is this post lunch? @PA
I guess he took his insulin only before breakfast?
PA - Yes doctor.
He took 7U insulin before breakfast. Now pre dinner how much should he take?
PPM 1 - 4U
PPM 1 - 4U
Ask him to share the image of his loaded syringe before he injects
PA - Okay.
PA - The patient took Dytor 10mg yesterday morning 1 tab and today morning 1 tab. Just informing you.
PPM 1 - How long has he been taking that? Was he taking it regularly or intermittently?
PA - Not regularly, only when he has pedal edema.
PA - Not regularly, only when he has pedal edema.
PPM 1 - 👍
PA -
PPM 1 - 👍
PPM 1 - 👍
PPM 1 - Tablet Avomine (generic name: Promethazine theoclate)25mg.
PPM 1 - Two hour post lunch? 👆 While mixtard 6U didn't work for his post breakfast, mixtard 5U appears to have done wonders for his post lunch and now we'll need to be careful with the pre dinner.
@PA let him not take any mixtard before dinner and if at all he has to take let it not be anything more than 2U tonight.
25-01-2025
147 at 7.37am 👆
PPM 1 - @PA @PPM2 mixtard huddled twice a day between breakfast 6U and lunch 7U appeared to do fairly well for this ptient yesterday.
PPM 1 - Micro infinitesimal foot steps breaking ground.
PPM 1 - Let's see how much calorigenic these turn out to be but then yesterday he didn't do the post lunch after 2 hours.
PA - Dinner ragi roti and ladiesfinger curry.
PPM 1 - @PA he needs to turn the syringe properly before taking the picture so that the numbers are visible.
PA -
11-12-2024
Fasting sugar value
PPM 1 - 5U of Mixtard government supply.
PA - Breakfast
Fasting sugar value
Lunch
PA - The patient did not get Avomine tabs prescribed by you.
The patient is having giddiness since morning.
PPM 1 - Tablet Avomine (generic name: Promethazine theoclate)25mg.
PA - 
PPM 1 - 4.5U mixtard government supply.
PA - The patient wants to know why he was prescribed Avomine.
PPM 1 - It's for his giddiness. It's unfortunately named avomine but it's actually for giddiness.
PA - Okay doctor.
PA - The patient is not getting this medicine nearby to his place.
PPM 1 - It's available in our hospital @PPM3
We often prescribe it
Otherwise he can try
Tablet Cinnarizine 25 mg tid
PA - Okay.
PA -
PPM 1 - While we can see that the dose he has eventually loaded is 4.5U. Can we ask him what dose he thought he had loaded.
Because we may need to increase the dose so it will be important to factor this.
PA - Yesterday you said he should take 4U. So it must be 4.
PPM 1 - No he doesn't always do what we want! He has his own thoughts so I needed to know exactly.
If he's thinking 4 and increasing only 0.5U in error then we will need to factor that in our increase.
Either way we will have to play safe and ask him to increase to 5U twice daily
PA - He says he is loading 4U and when he is taking the pic it is coming to 4.5U. So finally how much is he supposed to take?
PA - Yes doctor it is government supply.
PA - The patient forgot to take 4.5U mixtard yesterday before dinner. So he called me at 10.40pm and asked if he could take it at that time. To the best of my knowledge I said he can take.
PA - Yes that's what he said.
PA - The patient is using Bedahistine for loss of balance and giddiness. Should he continue?
PA -
PA - The patient is asking remedy for his pedal edema.
13-12-2024
PPM 1- 👆 it's still 4.5
He can take 5U which may become 5.5U but it's likely to be a safe margin of error @PA.
PA - Okay doctor.
PA - The patient experienced burning sensation on the right side of his body from head to back and had an urge to pass motion and later found relief after an hour. This he experienced from 2-3am.
PPM 1 - 👍
PPM 1 - 👍Perfect 5U.
14-12-2024
PPM 1 - So @PA 5U mixtard is max he can take at night.
Let's see how the 5U mixtard works out for his breakfast and lunch today.
PA - Okay doctor.
PPM 1 - 👍
PPM 1 - 👍
15-12-2024
PPM 1 - @PA while the 5U mixtard at night worked well for his fasting sugars yesterday (he's yet to post today's fasting but based on yesterday's, it's likely to be okay), his post dinner isn't well controlled and depending on how the 5U at dinner affects his fasting he may simply have to live with a post dinner high of 300 or if the fasting allows we may be able to increase the pre dinner mixtard slightly but let's see how his fasting plays out on the current dose over the next few days.
PA - 
PPM 1 - @PA the food he's taking appears to be causing the hyperglycemia as per the data you shared yesterday, which is also strangely very well responsive to fasting.
PA - Skipping dinner is not his strategy , just happened yesterday as he had late lunch.
PA - Doctor the patient is asking whether he has to share his sugar levels or can stop.
PPM 1 - Well his post dinner sugars are still high and if we need to adjust his pre dinner mixtard insulin he would need to at least share the 2 hours post dinner and fasting if not the post breakfast and post lunch.
PPM 2 - Isolated diastolic hypotension? Age related ventricular atrophy?
PPM 1 - 👍
16-12-2024
PPM 1 - @PA going by his fasting sugars it would be unsafe to increase his pre dinner insulin dose from 5U mixtard
Let him from now on just share once a week his fasting and post meal two hour after breakfast lunch and dinner.
PA - Okay doctor.
PPM 1 - 👍
22-01-2025
PA - BP reading is 149/61, PR 73 at 7.30am.
Sugar value is 143mg/dl at 7.32am
Insulin taken 5U.
PPM 1 - 👍
PA - Post breakfast sugar value is 333mg/dl.
PPM 1 - 😮
PPM 1 - What was his dose today?
PA - 5U, any change in dosage for the above sugar vlue?
PPM 1 - No because it's mixtard so it will be difficult to decide unless we can see all his fasting, and other two hour post meal sugars today and tomorrow.
PA - Okay.
275 at 12.51pm.
PPM 1 - 275mg/dl at pre lunch? He just needs to do it two hours after every meal.
PPM 1 - How much is this dose?
We can ask him to increase it by 2U.
PA - 5U
PPM 1 - Doubtful.
Yes I mean he may not always realize how much dose he's taking.
He needs to take the image of the syringe such that the numbers are visible.
PA - Okay
23-01-2025
PA - Fasting value is 114mg/dl.
PPM 1 - 👍
PPM 1 - @PA the numbers in the syringe markings need to be clearly visible as shown here 👇
https://www.seelingo.in/product/hmd-dispovan-1ml-insulin-syringe-31g-x-6mm-u-40-multi-100-pcs-pack/?sku_id=53151&ads_source=google&gad_source=1&gclid=Cj0KCQiAy8K8BhCZARIsAKJ8sfSCergIUnVBXWYgdu8cbUBLlj0g1YM327or8XUshubDaqAFoXhOs6AaAoOsEALw_wcBPPM 1 - Unable to decide how much to increase unless i know how much he's taking! @PPM2
Let me check this particular brand of the syringe graduations which is named polymed as far as I can read.
Again unable to
match👇
This is going to be tricky but going by his high values we may have to ask him to take the mixtard again before lunch now! This will make it TID and apparently he has done it before without our supervision and let's hope supervision and monitoring will help now @PA @PPM2.
PA - Doctor, he says since he switched to jowar rawa from jowar fine flour , his sugar levels have increased. Does it make so much difference is his question. Now he wants to know how much and how many times , insulin he has to take. He is regularly taking 5U according to him. Yesterday you increased it to 7U. Now finally how much he has to take is his doubt.
PPM 1 - Taking 5U twice?
He once said that he was even taking mixtard thrice?
PA - Twice.
PPM 1 - Did he take before lunch today? Was going to make it thrice as per his previous strategy. We need to see his post two hours of lunch blood sugars.
PA - I asked him to take before lunch also after seeing your message. He was asking the dosage.
PPM 1 - 👆this syringe needed to have been rotated slightly anticlockwise before taking the image so that the numbers would become visible.
PPM 1 - We have to tell him to share the image so that we can verify the numbers in the syringe, which currently we are unable to see in the syringe images he's sharing.
Unless we are sure about the dose he's taking, it's difficult to decide the dose he needs to be taking.
PPM 1 - Okay thanks to your case report @PA I checked the previous images of the syringe with the numbers visible and think this is 5.
So he has taken 5 mixtard in the morning before breakfast and 5 now before lunch today. Let's see how much his two hour post lunch shows.
24-01-2025
PPM 1 - @PA I'm guessing this is 6 units even though the number is not visible just by deducing it from the visible images in your case report
Also I'm guessing that the patient took mixtard thrice yesterday and hence the fasting looks good although now we have to be even more vigilant to prevent him from going into hypoglycemia
So I'm guessing he won't require mixtard thrice today and we may be able to work out his mixtard routine at largely twice a day with some intervening days where it would need to be made thrice all through hyperlocal monitoring @PPM2.
PA - He skipped his dinner yesterday and hence the sugar level is low. And Mixtard dose yesterday was twice.
PPM 1 - Thanks!
This is another strategy that may not have been documented well enough in the past? @PPM2
It's modern day version would be "glucometer blood sugar guided intermittent fasting toward optimizing hyperglycemia!"
Wonder if anyone has studied it well beyond our current n of 1 strategy here?
@Meta AI
What are your thoughts on:
"glucometer blood sugar guided intermittent fasting toward optimizing hyperglycemia!"
Wonder if anyone has studied it well beyond our current n of 1 strategy in this patient here?
Fascinating topic! Using a glucometer to guide intermittent fasting for optimizing hyperglycemia management is a highly individualized and innovative approach. While I couldn't find specific studies on this exact method, there are related research areas that might provide valuable insights:
# Relevant Research Areas
1. Continuous Glucose Monitoring (CGM) and Intermittent Fasting: Studies have explored the use of CGM to monitor glucose levels during intermittent fasting, showing improved glucose control and reduced hyperglycemia (1, 2).
2. Personalized Nutrition and Glycemic Control: Research has demonstrated the effectiveness of personalized nutrition approaches, including intermittent fasting, in improving glycemic control and reducing hyperglycemia (3, 4).
3. Glucose Monitoring and Behavioral Change: Studies have shown that regular glucose monitoring can lead to behavioral changes, such as improved diet and exercise habits, resulting in better glycemic control (5).
# Future Research Directions
To move beyond the "n of 1" strategy, future studies could investigate:
1. Randomized Controlled Trials (RCTs): Conduct RCTs to compare the effectiveness of glucometer-guided intermittent fasting with standard care or other interventions.
2. Large-Scale Observational Studies: Analyze data from large cohorts of patients using glucometer-guided intermittent fasting to identify patterns, outcomes, and potential predictors of success.
3. Machine Learning and Predictive Analytics: Develop machine learning models to predict individual responses to glucometer-guided intermittent fasting based on demographic, clinical, and glucose data.
# Conclusion
While specific studies on glucometer-guided intermittent fasting are limited, related research areas provide a foundation for understanding the potential benefits and challenges of this approach. Future studies should aim to systematically investigate its effectiveness, optimal implementation, and potential for personalized diabetes management.
References:
1. Klein et al. (2019): "Continuous glucose monitoring and intermittent fasting in type 2 diabetes." Journal of Clinical Endocrinology and Metabolism, 104(11), 5338-5346.
2. Sullivan et al. (2020): "Intermittent fasting and continuous glucose monitoring in patients with type 2 diabetes." Journal of the Academy of Nutrition and Dietetics, 120(3), 432-441.
3. Hall et al. (2019): "Personalized nutrition and glucose control in type 2 diabetes." Nutrients, 11(11), 2531.
4. Zeevi et al. (2015): "Personalized nutrition by prediction of glycemic responses." Cell, 163(5), 1079-1094.
5. Polonsky et al. (2017): "Continuous glucose monitoring and behavioral change in type 2 diabetes." Journal of Clinical Endocrinology and Metabolism, 102(11), 3944-3953.
PPM 1 - @Meta AI I'm hoping that your articles in the reference lists that you appear to have started sharing like perplexity these days aren't confabulations. I'm hoping @PA may be able to google these references! individually and confirm that they aren't confabulations.
Meta AI - I apologize for any concern! I'm a large language model, my responses are generated based on patterns and associations in the data I was trained on. While I strive to provide accurate and reliable information, I'm not perfect and sometimes may generate fictional or inaccurate references.
To confirm the validity of the references I provided, I encourage you to fact-check them. You can try searching for the article titles, authors, and publication details on academic databases such as:
- Google Scholar ((link unavailable))
- PubMed ((link unavailable))
- Web of Science ((link unavailable))
If you're unable to find any of the references I provided, it's likely that they are fictional or inaccurate. I appreciate your diligence in verifying the information!
Please let me know if there's anything else I can help you with!
PPM 1 - @PA the food he's taking appears to be causing the hyperglycemia as per the data you shared yesterday, which is also strangely very well responsive to fasting.
This made me take another look at his yellow paste he's taking and I suspect that's the highly calorigenic culprit!
What is that yellow paste? Why does it need to be pasty? Is it because he can't chew?
PPM 1 - @PA looks like he has adopted a strategy of taking mixtard before breakfast and lunch and then skipping dinner?
In that case let's support and monitor this strategy.
PA - The yellow paste is sorghum malt. According to him fine sorghum flour paste is not increasing his sugar levels but sorghum rawa which is not fine particles is causing high sugar levels. It is his perception.
PPM 1 - 👍
PA - Skipping dinner is not his strategy , just happened yesterday as he had late lunch.
It is pasty as it has to be boiled.
PPM 1- 👍
If he had had dinner was he planning to re check his blood sugars and take another mixtard?
PPM 1 - Let's ask him to monitor and share all his post meal two hour values today and tomorrow.
PA - I asked him to monitor and share all his post meal two hour values today and tomorrow and Mixtard dosage only twice.
PPM 1 - Two hour post lunch? 👆 While mixtard 6U didn't work for his post breakfast, mixtard 5U appears to have done wonders for his post lunch and now we'll need to be careful with the pre dinner.
@PA let him not take any mixtard before dinner and if at all he has to take let it not be anything more than 2U tonight.
25-01-2025
147 at 7.37am 👆
PPM 1 - @PA did he take mixtard twice yesterday? One before breakfast and one before lunch?
PA - When I spoke to him yesterday, he said only once. As you advised it.
PPM 1 - Twice yesterday? Now 7U is clearer in the image. 👏
So an amazing insight till now with the limited data we have on his mixtard insulin and glucose outcomes @PPM3 (also check out his entire case report data in the description box particularly the one in the pajrcasereporter blog) is that mixtard appears to be better optimised if the bid dose intervals are closely huddled together at breakfast and lunch rather than the traditional breakfast and dinner!
PA - Should he continue with the above dosage?
PPM 1 - We need to see for a few days. Also four values of blood sugar before we can say with certainty that this strategy is helping him.
PA - Atleast for now twice?
PPM 1 - Yes but with sugar monitoring four times
Fasting
2 hours after breakfast
2 hours after lunch
2 hours after dinner.
PA - 7U - 7U?
PPM 1 - This was 6U before breakfast yesterday, which produced 330 which is high.
But 5U yesterday before lunch produced 182 which is fair.
We have increased morning to 7U today at 10:14AM.
We need to know what's the two hour post sugars at 12:14 PM today.
PA - He forgot to check post breakfast as he went out.
7.5U
PPM 1 - Will be keen to see his blood sugars at 17:17 and then also two hours after his dinner before he sleeps.
At 22.02
26-01-2025
PPM 1 - @PA @PPM2 mixtard huddled twice a day between breakfast 6U and lunch 7U appeared to do fairly well for this ptient yesterday.
PPM 2 - Groundbreaking! But are we micromanaging the sugars or improving broader outcomes?
PPM 1 - Micro infinitesimal foot steps breaking ground.
PPM 1 - 👆What is this that is so diabetogenic? @PA
PA - Sorghum java
PPM 1 - 6U 👆
PPM 1 - Let's see how much calorigenic these turn out to be but then yesterday he didn't do the post lunch after 2 hours.
PA - Maybe he did not check.
At 16.05
At 17.56 👆
PA - Post dinner 👆
PA - Fasting 👆
At 17.56 👆
PPM 1 - 6U turned out to be good for the blood glucose two hours after consuming similar liquid at lunch. Were they also sorghum java in a more dilute form? Why was the morning yellow paste associated with more hyperglycemia after 2 hours?
PA - This sorghum paste is concentrated one. 7U Mixtard before taking this paste.
PPM 1 - 👍
PA - You are absolutely right, it is diluted sorghum paste with buttermilk. 6U Mixtard.
PPM 1 - 👍
We'll need to also think about the differences in nutrients in the diluted, apparently non diabetogenic sorghum?
PA - Post dinner 👆
27-01-2025
PA - Fasting 👆
PPM 1 - 👍
PPM 1 - Again that dangerous diabetogenic paste! @PA
PA - Will talk to him.
PPM 1 - Let's also ask him if it tastes sweet.
PA - According to my knowledge it doesn't taste sweet.
Asked him to switch to Ragi java.
It tastes little sweet itseems.
PPM 1 - 👍
I was suspicious!
So what could account for the sweet taste which is no doubt hiding the sugars responsible for it's calorigenicity?
PPM 1 - Too much rice and too less legumes, fruits and vegetables.
PA - Maybe they can't afford.
PPM 3 - Can reduce rice by 25-40% from his plate...
PPM 1 - 👍
PPM 1 - This is the main social determinant of healthcare manifesting in action.
PA - Post lunch blood sugar is 263mg/dl.
PPM 1 - 👍
PA - Ragi roti and beans curry for dinner.
PPM 1 - 👍
PA - Post dinner sugar level is 218mg/dl
PPM 1 - Mixtard thrice!
The night dose should not have been more than 3U!
👆@PA please note today's fasting is 110 without any mixtard at night yesterday.
He should not have taken the third mixtard dose at the amount of dose he took just now!
He needs to anticipate and prepare for imminent hypoglycemia at midnight or early morning!
Keep glucose at hand.
PA - He did not take thrice. This pic was shared by mistake.
PPM 1 - Relief.
28-01-2025
PA - Fasting sugar level is 86mg/dl
6U Mixtard before breakfast and 7U before lunch.
PPM 1 - 👍
Breakfast ragi java.
PA - Lunch rice with ladies finger curry.
PPM 1 - 👍
PA - 7U mixtard before lunch.
PA - Post lunch sugar is 220mg/dl
PPM 1 - 👍
Post dinner sugar level is 322mg/dl.
PPM 1 - But as per his syringe picture he took 6U before lunch today? He also didn't check his sugars 2 hours after his breakfast today?
29-01-2025
PA - Fasting sugar 126mg/dl
6U mixtard.
PPM 1 - 👍
PA - Before lunch 7U mixtard.
Lunch rice with curry.
Post lunch sugar value is 343mg/dl
PPM 1 - From tomorrow let's increase to 8U before breakfast and 8U before lunch @PA.
PA - Yesterday he reduced the dosage of Mixtard thinking that his sugar was down as he had sweating.
Ragi paste for dinner.
PPM 1 - He should have checked the sugar at that time instead of guessing.
These images are showing the same previous dose of 6U and 7U and no reduction in his mixtard dose? @PA
Yesterday is showing 6U and 6U
He had 220, two hours after 6U yesterday. 343 after two hours of 7U at lunch today.
PA - When I spoke he told me that he reduced.
PPM 1 - Is there something in his diet today which he didn't share here or his activities that explain the reduced efficacy of the mixtard today?
Yes @PA day before yesterday it was 7U as seen here and he reduced by 1U yesterday and increased again by 1U today although paradoxically his sugars increased by 100mg today instead of decreasing with the 1U increment today.
PA - Okay
PA - Post dinner 190mg/dl at 21.31
Fasting 138mg/dl
Breakfast Ragi java for breakfast
PPM 1 - Just 1-2U increment appears to be reducing it a lot perhaps due to the NPH in the mixtard which is often unpredictable.
Oh okay. I didn't see this earlier! It hasn't changed much!
Currently a single peak of 347 once after lunch looks like endgame here! @Aditya
Any further move on the mixtard may change the fasting and post dinner drastically and dangerously.
PPM 2 - How about an oral tablet?
PPM 1 - Wouldn't be safe with his renal failure.
PPM 2 - Metformin?
Gliclazide.
Or worst case Sitagliptin. Just for the sugars as long term outcomes may not be relevant at this time.
Post dinner 323mg/dl
PPM 1 - 👍
yesterday's was much less. We are missing some data regarding his energy Input and output or other intervention here.
If the post dinner is like this then the pre lunch may be increased further to 10U tomorrow although the mismatch between yesterday's and today's is still nagging.
31-01-2025
BP at 8.08 is 145/55, PR 99.
Fasting sugar value is 112mg/dl.
Breakfast ragi java
8U Mixtard before breakfast.
At 10.30 BP is 125/61, PR 90
Post breakfast sugar value is 350mg/dl
PPM 1 - These breakfast plates are simply cereals and need to balanced with fruits and vegetables and legumes as suggested here 👇
PPM 1 - From the video of his home linked in his case report, we notice many trees and vegetable growing space.
PA - BP at 10.30am 125/61, PR 90
Sugar value after breakfast 350mg/dl.
Mixtard dose before lunch 10U.
BP at 14.07 is 135/62, PR 88.
Post lunch sugar value is 248mg/dl
PPM 1 - With the 10U mixtard taken before lunch today this fasting value may go further down into hypoglycemia tomorrow if other parameters of diet and exercise remain same as yesterday @PA.
PA - Dinner ragi with curry.
Post dinner sugar value is 251mg/dl
PPM 1 - 👍
Yes let's hope his fasting is well tomorrow in which case we can keep this dose going.
01-02-2025
PA - Fasting sugar value is 140mg/dl
Brekfast ragi java.
Post breakfast sugar value is 429mg/dl.
10U mixtard.
Lunch ragi java with egg curry.
PPM 1 - Can be increased tomorrow to 9U before breakfast.
PA - Post lunch sugar 322mg/dl.
Post dinner 199mg/dl.
PPM 1 - 👍
02-02-2025
PA - Fasting sugar 88mg/dl
8U Mixtard.
Post breakfast 306mg/dl.
10U Mixtard.
Lunch with rice and Beans curry.
Post lunch 396mg/dl
PPM 1 - 👆 effect of 10U yesterday @PA Can't increase the pre lunch insulin more than that
It appears that he didn't increase his pre breakfast insulin to 9U today?
PA - It's my mistake, I forgot to inform him.
PPM 1 - 👍You are already doing the best among all of us!
PA - 🙏
Now he is stressed with his wife's health. She is having problem with her right hand fingers. Please check the reports and advise them.
PPM 1 - We need to examine her clinically.
From what I can recall from our meeting her last time we had diagnosed OA due to her metabolic syn and none of the above
We can ask him to also share his wife's two hour post meal sugars if he can check them for a day.
PA - Okay.
PA - Ragi with beans curry for dinner.
Post dinner 203mg/dl
PPM 1 - 👍
03-02-2025
PA - Fasting blood sugar 109mg/dl
9U Mixtard.
Ragi java for breakfast.
PPM 1 - Looks nearly 9.5U.
PA - Post breakfast sugar value 346mg/dl.
11U mixtard.
PPM 1 - 👆11U 😳 @PA
👆@PA we decided not to go above 10 but he seems to have loaded 11!
PA - He is saying as the sugar level is 346, he took 11U.
PPM 1 - He can't do that with Mixtard insulin. That can be done if he's taking plain insulin which is colourless like water but as the government is not providing it free of cost he's unable to buy it so he has two options either live with that 346 or buy plain insulin or risk hypoglycemia by increasing the dose arbitrarily on his own.
@PPM2 will it be feasible to explain the nitty gritties of mixtard, plain insulin and NPH insulin kinetics to this patient? If he could be explained in an understandable manner we could actually achieve holy grail I guess?
PA - Yes doctor, warned him to be careful with dosage.
PPM 1 - 👍
PPM 2 - Feasible yes but look at the plate down below!
PPM 1 - 👍
PA - Post lunch sugar value 300mg/dl.
At 18.30 Ragi with ladies finger curry.
Post dinner 278mg/dl.
04-02-2025
PA - Fasting sugar value 118mg/dl.
Breakfast ragi with ladies finger curry.
PPM 1 - Looks like his fasting today held ground inspite of his increasing pre lunch yesterday to 11U mixtard! I'm sure he compensated with his diet.
👆@PA let's increase this pre breakfast dose today to 11U and reduce the pre lunch dose to 10U.
PA - He has already taken 9U, pre breakfast.
PPM 1 - Well from tomorrow we can try to execute this plan letting him know that from the available data on his blood sugar values and the insulin doses he has received till now we would like to slowly optimise the proportion of insulin in favour of balancing it by taking slightly more dose before breakfast rather than before lunch.
PA - Okay.
PA - 11U Mixtard.
I hope you have warned him about his insulin dosage.
PPM 1 - Yes we had a good talk about it face to face today.
PA - 👍
Ragi jawa for dinner at 18.38.
Post dinner blood sugar at 21.00 is 223mg/dl
PPM 1 - 👍
05-02-2025
PA - Fasting sugar level at 8.19am
PA - Ragi with beans curry for breakfast.
PPM 1 - 😲
We were anticipating this @PA
Did he have any symptoms?
How much insulin did he take before breakfast? I'm guessing none?
PA - Your guess is right. Yesterday he couldn't eat anything so he skipped his dosage pre breakfast. No symptoms. He is okay. But his wife is not well. Body pains, knee, shoulder pains and is not able to do her routine activities.
Pre lunch insulin is 10U. Should he take insulin before dinner?
PPM 1 - Let's see his pre dinner today.
PA - Pre dinner today is 88mg/dl.
PPM 1 - Better not take insulin anymore today @PA
PA - Okay
Dinner with ragi and potato curry at 18.53
PPM 2 - I personally wouldn't recommend that. Would always advise for a lesser dose perhaps than completely skipping one.
06-02-2025
PPM 1 - This could be good when we uphold efficacy over harm.
In an elderly I would rather avoid harms.
PA - Fasting sugar 120mg/dl
PPM 1 - His fasting is 120 as shared now.
Off course we don't know his two hour post dinner and he may have benefitted from 4U of mixtard especially for his post dinner that I suspect could have been high.
Couldn't have given more as 2U of paal laga NPH in that 4U of 50/50 mixtard would have burned significantly into his today's fasting, which we now know is 120 without any NPH at night yesterday.
PA - 9U insulin, pre breakfast.
Post breakfast 249mg/dl.
PPM 1 - Yes I would have said yesterdays planned dose.
PA - Taken 9U
PPM 1 - Same as yesterday? The post breakfast is looking better than most days? Although we can still tweak it up slightly to optimize further.
07-02-2025
PA - Fasting sugar 114mg/dl.
PPM 1 - So currently it's 9U-9U-0U?
PA - 291mg/dl post breakfast.
PA - Post dinner 256mg/dl
09-02-2025
PA - Fasting sugar 73mg/dl.
Post breakfast 247mg/dl.
PPM 1 - Can increase to 10 only before breakfast tomorrow @PA.
PA - Post lunch 156mg/dl
PPM 1 - 👍
PA - Post dinner 264mg/dl.
PPM 1 - 👍
10-02-2025
PA - Fasting sugar 95mg/dl. 10U mixtard before breakfast.
PPM 1 - Two hours post breakfast not seen today?
Let's check two hours after this lunch.
PA - Post lunch sugar 257mg/dl
PPM 1 - 👍
PA - Post dinner sugar 223mg/dl
11-02-2025
PA - Fasting sugar 97mg/dl. 10U mixtard.
Post breakfast 246mg/dl
PPM 1 - @PA this looks dangerously close to 10U at lunch time!
We had agreed for 10U before breakfast and 9U before lunch for now?
PA - Post lunch 192mg/dl.
Post dinner 180mg/dl.
PPM 1 - 👍
12-02-2025
PA - Fasting sugar 87mg/dl.
Post breakfast 232mg/dl.
PPM 1 - @PA hope he will not take 10U again today during lunch but take not more than 9U.
PA - Post lunch 279mg/dl.
Post dinner 273mg/dl
PPM 1 - 👍
13-02-2025
PA - Fasting sugar 84mg/dl
Post breakfast 222mg/dl
Post lunch 183mg/dl
Post dinner 241mg/dl
14-02-2025
PA - Fasting sugar 82mg/dl. 10U Mixtard
Post breakfast 232mg/dl.
Pre lunch mixtard 9U.
Post lunch sugar 149mg/dl
Post dinner 230mg/dl
PPM 1 - 👍
15-02-2025
PA - Fasting sugar 86mg/dl
Post breakfast sugar 226mg/dl
Post lunch 250mg/dl
Post dinner 220mg/dl.
16-02-2025
PA - Fasting sugar is 101mg/dl.
Post breakfast 251mg/dl.
PA - Should the patient continue to post his sugar values or can stop as there is deficiency of sugar strips @PPM1 sir?
PPM 1 - Yes it has more or less stabilized and he may stop.
Is he also taking metformin tablets?
PA - He is not taking Metformin. Only 10U mixtard before breakfast and 9U mixtard before lunch.
PPM 1 - @PPM2 wonder why didn't start him on our current insulin sparing wonder drug metformin earlier? Is it because of his age or oh wait a minute now remembered it's his chronic renal failure.
Alright let's stop his monitoring for now and continue the same dose of insulin.
01-03-2025
PA Fasting sugar is 84mg/dl
PPM 1 - 👍
PA - Breakfast ragi with curry at 10.00am.
Post breakfast sugar level is 264mg/dl
Lunch
PA - Post lunch sugar level is 201mg/dl
PPM 1 - 👍
PA - Doctor, this patient forgot to take insulin before breakfast and took before lunch. He is asking if he should take now before dinner?
PPM 1 - Can.
PA - Thanks.
9U.
PA - Post dinner sugar 140mg/dl
02-03-2025
PA - 
PA - Breakfast ragi with curry.
PPM 1 - 👍
PA - Patient had dinner with ragi and pickle at 22.09
PPM 1 - 👍
03-03-2025
PA - 
PA - Breakfast upma.👆
At 12.48pm
PPM 1 - 👍
Dinner at 18.55
PPM 1 - 👍
04-03-2025
PA - Breakfast ragi with pickle.
10U Mixtard
PPM 1 - 👍
PA - 9U mixtard, before lunch.
Lunch with rice and curry.
Dinner ragi and chutney.
05-03-2025
PPM 1- 👍
PA - 9U mixtard before lunch
Lunch rice with cucumber curry.
Dinner ragi with cucumber curry.
PPM 1 - 👍
06-03-2025
PA - 10U pre breakfast.
Breakfast ragi with chutney
PPM 1 - 👍
PA - 9U Mixtard before lunch
Lunch rice with curry.
PPM 1 - 👍
PA - Dinner ragi with dal.
07-03-2025
PA - 10U mixtard before breakfast.
For breakfast ragi with chutney.
PPM 1 - 👍
PA - 9U mixtard before lunch.
PPM 1 - 👍
08-03-2025
PA - 08.35am
08.38 am
PPM 1 - 👍
Lunch at 13.22
PPM 1 - 👍
Dinner at 20.25
PPM 1 - 👍
09-03-2025
Insulin at 09.30am
Breakfast at 9.43am
Lunch at 12.55pm
Pre lunch insulin at 12.55pm
PPM 1 - 👍
Dinner at 19.20pm
10-03-2025
Breakfast at 9.26am
Pre breakfast insulin at 9.25am
PPM 1 - 👍
PA - Insulin at 14.24
Lunch at 14.25
PPM 1 - 👍
Dinner at 19.29
PPM 1 - 👍
11-03-2025
PA - Insulin at 8.47am
PPM 1 - 👍
PA - Dinner at 19.29.
Breakfast at 8.50am
Insulin at 13.02
Lunch at 13.02
[12-03-2025 09.29] PA: Insulin
Breakfast at 09.33
Pre lunch insulin at 12.32
Lunch at 12.33
[12-03-2025 19.41] PA: Ragi with chutney for dinner.
PPM 1 - 👍
[13-03-2025 08.32] PA: 10U insulin before breakfast. And ragi with chutney for breakfast.
PPM 1 - 👍
[13-03-2025 12.32] PA: Pre lunch 9U insulin and later had lunch with rice and curry.
[16-03-2025 08.27] PA: 
PA - Sugar value is 114 mg/dl.
PA - Breakfast ragi with chutney
Post breakfast at 10.40am sugar value is 303mg/dl
PA - Pre lunch insulin 9U
[16-03-2025 12:58] PPM 1: Two hours post breakfast? No insulin taken before that?
[16-03-2025 13:33] PA: This is pre breakfast dose at 08.27am 10U
[16-03-2025 14:37] PA: As usual ragi with some chutney.
[16-03-2025 15:25] PPM 1: Sweet chutney?
[16-03-2025 15:27] PA: I don't think it is sweet. But will confirm.
[16-03-2025 15:35] PA: It is chicken soup with masala.
[16-03-2025 15:36] PA: Yesterday he had two bananas
[17-03-2025 7.31] PA: Fasting sugar 198mg/dl
[17-03-2025 08.33] PA: Before breakfast 10U insulin., Breakfasr ragi.
[17-03-2025 12.08] PA: Lunch
PPM 1 - 👍
[17-03-2025 19.27] PA: Ragi with chicken masala gravy.
[18-03-2025 08.38] PA: 10U insulin. Ragi breakfast.
[18-03-2025 12.32] PA: 9U Insulin, lunch rice and curry.
PPM 1 - 👍
[18-03-2025 20.54] PA: Dinner rice with bottle gourd curry.
[19-03-2025 07.53] PA: 10U insulin, Ragi with chutney breakfast.
[19-03-2025 12.37] PA: 9U insulin and lunch rice with curry.
[19-03-2025 20.17] PA: Dinner ragi with curry.
PPM 1 - 👍
[20-03-2025 08.41] PA: 10U Insulin, breakfast ragi with chutney and curry.
[20-03-2025 12.54] PA: Lunch rice with curry
[20-03-2025 19.45] PA: Dinner Ragi with chutney
[21-03-2025 10.13] PA: 10U Insulin
[22-03-2025 08.40] PA: 10U insulin, breakfast ragi with ladiesfinger curry.
[22-03-2025 09.35] PPM 1: 👍
[23-03-2025 08.27] PA: 10U Insulin, breakfast ragi with chutney
[23-03-2025 12.38] PA: 9U insulin, Lunch rice with curry
[24-03-2025 08.09] PA: 10U insulin, breakfast ragi with chutney.
[24-03-2025 12.42] PA: 9U Insulin, Lunch rice with curry.
PPM 1 -👍
[25-03-2025 08.34] PA: 10U Insulin and ragi breakfast
[25-03-2025 12.00] PA: 9U Insulin, Lunch rice with curry.
[25-03-2025 16.57] PPM 1: 👍
[25-03-2025 18.37] PA: Sugar value is 79mg/dl
[25-03-2025 19.05] PA: Dinner ragi with chutney
[25-03-2025 21.18] PA: Post dinner sugar 178mg/dl.
[26-03-2025 08.53] PA: 10U Insulin and breakfast ragi with curry.
[26-03-2025 14.40] PA: 9U Insulin, lunch rice with egg curry
[26-03-2025 19.09] PA: Ragi with chutney for dinner.
[27-03-2025 09.24] PA: 10U Insulin and ragi for breakfast.
[27-03-2025 12.02] PPM 1: 👍
[27-03-2025 13.29] PA: 9U Insulin, followed by lunch rice with curry.
[27-03-2025 21.20] PA: Dinner ragi with curry
[28-03-2025 08.21] PA: 10U Insulin followed by breakfast with ragi and chutney.
[29-03-2025 08.03] PA: 10U Insulin followed by breakfast with ragi and curry.
[29-03-2025 08.32] PPM 1: 👍
[29-03-2025 12.26] PA: Lunch rice with drumstick and tomato curry. Pre lunch insulin 9U.
[29-03-2025 13.09] PPM 1:
[30-03-2025 08.42] PA: 10U Insulin followed by breakfast ragi and sambar.
[30-03-2025 12.11] PA: 9U Insulin and lunch rice with drumstick curry.
[30-03-2025 12.51] PPM 1: 👍
[31-03-2025 08.38] PA: 10 U Insulin and breakfast ragi
[31-03-2025 09.20] PPM 1: 👍
[31-03-2025 12.33] PA: 9 U Insulin, Lunch rice with curry.
[31-03-2025 15.01] PPM 1: 👍
[01-04-2025 09.19] PA: 10U Insulin and ragi breakfast.
[01-04-2025 12.26] PA: 9U Insulin and lunch rice with curry.
[01-04-2025 14.33] PPM 1: 👍
[01-04-2025 19.03] PA: Dinner ragi with chutney.
[02-04-2025 08.40] PA: 10U Insulin and ragi breakfast
[02-04-2025 12.02] PA: 9U Insulin, Lunch rice with curry
[02-04-2025 12.18] PPM 1: 👍
[02-04-2025 19.22] PA: Dinner ragi with chutney
[03-04-2025 08.46] PA: 10U Insulin and breakfast ragi with brinjal curry.
[03-04-2025 10.25] PPM 1: 👍
[03-04-2025 12.06] PA: 9U Insulin and lunch rice with brinjal curry.
[03-04-2025 18.57] PA: Dinner ragi with brinjal curry
[03-04-2025 19.36] PPM 1: 👍
[04-04-2025 08.53] PA: 10U insulin and breakfast ragi with leafy dal and curry.
[04-04-2025 09.31] PPM 1: 👍
[04-04-2025 09.34] PPM 1: @PPM3 I understand analysing your metabolic syn cases by the CPD date around this topic will be difficult.
The other option is to call this metabolic syn expert patient a day prior to the CPD and conduct this patient centred learning session around metabolic syn that we did recently in UoH 👇
You can guide our campus students @PPM4 and @~PPM5 to do it.
[04-04-2025 12.21] PA: 9U Insulin and lunch rice with leafy dal.
[04-04-2025 19.07] PA: Dinner ragi
[05-04-2025 08.09] PA: 10u Insulin, breakfast ragi.
[05-04-2025 08.30] PPM 1: 👍
[05-04-2025 11.55] PA: 9U Insulin, Lunch rice with curry
[05-04-2025 16.48] PPM 1: 👍
[05-04-2025 18.20] PA: Dinner ragi with curry
[05-04-2025 19.31] PPM 1: 👍
[06-04-2025 07.59] PA: 10U Insulin and breakfast ragi with chutney and garlic
[06-04-2025 12.14] PA: 9U Insulin and lunch rice with curry
[06-04-2025 19.10] PA: Dinner lemon rice
[07-04-2025 08.27] PA: 10U Insulin and breakfast ragi with chutney
[07-04-2025 12.09] PA: 9U Insulin and lunch rice with curry
[07-04-2025 19.00] PA: Dinner ragi with chutney
[08-04-2025 07.54] PA: 10U Insulin and breakfast ragi with chutney
[08-04-2025 12.04] PA: 9U Insulin and lunch rice with cofta curry
[08-04-2025 19.24] PA: Ragi for dinner.
[09-04-2025 07.25] PA: Fasting sugar 110mg/dl, 10U Insulin and ragi breakfast.
[09-04-2025 10.17] PPM 1: 👍
[09-04-2025 12.10] PA: 9U Insulin. Lunch rice with egg curry
[09-04-2025 14.08] PA: Post lunch sugar 169mg/dl
[09-04-2025 21.48] PA: Rice and dal.
[09-04-2025 08.29] PA: 6U Insulin, Vermicelli upma
[09-04-2025 13.30] PA: 6U Insulin, rice and curry
[09-04-2025 16.04] PPM 1: 👍
[11-04-2025 08.24] PA: 6U Insulin and breakfast ragi with chutney.
[11-04-2025 20.13] PA: Dinner ragi with chutney
[11-04-2025 20.53] PPM 1: 👍
[12-04-2025 08.39] PA: 6U Insulin and ragi breakfast.
PPM 1: 👍
[12-04-2025 12.23] PA: 6U Insulin and lunch rice with curry and chutney.
[12-04-2025 16.28] PPM 1: 👍
[13-04-2025 09.01] PA: 6U Insulin and ragi breakfast with tomato chutney.
[13-04-2025 13.27] PA: 6U Insulin and lunch rice with egg curry.
[14-04-2025 08.54] PA: 6U Insulin and ragi breakfast.
[14-04-2025 10.41] PPM 1: The patient's Hba1c is 5.4 done with HPLC
[14-04-2025 10:54] PA: Okay. He just now called me and informed. Did you notice he has reduced his insulin dosage to 6U, pre breakfast and pre lunch. He says his sugar level is very low of 70mg/dl (fasting) hence reduced insulin dose since 4-5 days.
[14-04-2025 12:26] PPM 1: Oh! But then he never shared his sugar values!
[14-04-2025 12:27] PPM 1: Since when? And he needs to check how much is the sugar after his dose change
[14-04-2025 12:32] PA: We asked him to share his sugar values weekly once. Recently his post lunch and fasting were well within range. So he reduced.
[14-04-2025 19:32] PA: Someone advised him to take methi seeds soaked in water. When he took continuously for 3 days his sugar levels dropped and had sweating, and when checked his PLBS was 70mg/dl. He gradually reduced insulin from 10 to 9 to 8.... Alongwith that he is also taking pepper churna, this also helped him to reduce his sugar levels and finally he is taking 6U insulin. Now he wants to know whether he can continue the home remedies.
[14-04-2025 20:39] PPM 1: Can.
@PPM 2 is this a good example of PaJR detecting how one may go about integrating different types of intervention (some that are from different worldviews of medical practice) in the same patient?
[14-04-2025 20:43] PPM 2: Yes definitely. Need more reliability and validity in patterns but yes I agree with the cross talk among interventions
[15-04-2025 07.53] PA: 6U Insulin and breakfast ragi with chutney.
[15-04-2025 09:40] PPM 1: 👍
[15-04-2025 19.28] PA: 6U Insulin, dinner rice with chutney.
PPM 1: 👍
[16-04-2025 08.31] PA: Fasting sugar 155mg/dl, 6U Insulin, Breakfast ragi with chutney.
[16-04-2025 08.43] PPM 1: 👍
[16-04-2025 12.16] PA: 6U Insulin, Lunch rice with curry.
[16-04-2025 14.28] PA: 137mg/dl
[16-04-2025 16.45] PPM 1: 👍
[17-04-2025 08.08] PA: 6U Insulin, Breakfast ragi
[17-04-2025 09.33] PPM 1: 👍
[17-04-2025 13.14] PA: 6U Insulin, Lunch rice with egg curry.
[17-04-2025 15.27] PA: PLBS 178mg/dl
[17-04-2025 19.20] PA: Dinner ragi with egg curry
[17-04-2025 22.14] PPM 1: 👍
[18-04-2025 08.37] PA: 6u Insulin, ragi with chutney
[18-04-2025 11.09] PPM 1: 👍
[18-04-2025 12.19] PA: 6U Insulin, Lunch rice with curry
[18-04-2025 12.48] PPM 1: 👍
[19-04-2025 08.06] PA: 6U Insulin, Breakfast 08.09.
[19-04-2025 12.36] PA: 6U Insulin, Lunch rice with curry
[19-04-2025 12.52] PPM 1: 👍
[22-04-2025 07.40] PA: Fasting sugar 186mg/dl, Insulin 6U
[22-04-2025 10.40] PA: Post breakfast 237mg/dl
[22-04-2025 11.57] PA: 6U Insulin, Lunch rice with curry.
[22-04-2025 13.17] PPM 1: 👍
[22-04-2025 14.17] PA: Post lunch sugar 183mg/dl
[22-04-2025 21.53] PA: Post dinner sugar 213mg/dl.
[23-04-2025 06.45] PA: Fasting sugar 214mg/dl
[23-04-2025 07.16] PPM 1: Fasting? How much insulin did the patient take yesterday?
[23-04-2025 14.35] PA: 6U today.
[23-04-2025 14:40] PA: 6units for 8am
[23-04-2025 14:43] PA: 6units 12pm
[23-04-2025 16:42] PPM 1: 6U mixtard twice a day?
[24-04-2025 07:24] PA: Yes Dr garu korra java sugar peruguhunnadi insulin. 6units kante akkuva vadavalàyuna telapagalaru
[24-04-2025 17:04] PA: Okay ga undi. Ippudu insulin ekkuwa ga avasaram ledu
[25-04-2025 06.59] PA: BP 128/46, PR 76. Fasting sugar 123mg/dl.
[25-04-2025 09:41] PPM 1: Is the high pulse pressure as in this reading consistent? Will need more readings to figure that out @PPM 2 @CR
[25-04-2025 12.10] PA: BP 153/66, PR85, Insulin 6U, Lunch rice with ladiesfinger curry and tomato chutney.
[25-04-2025 13:27] PPM 2: Would expect age related Aortic insufficiency as the likeliest cause.
[26-04-2025 09:32] PPM 1: 👍
[25-04-2025 15.17] PA: BP 123/58, PR 76
[26-04-2025 08.42] PA: Fasting sugar 163mg/dl, Insulin 6U, Breakfast ragi with curry.[26-04-2025 09.32] PPM 1: 👍
[26-04-2025 16.24] PPM 1: Reviewed the patient now in hospital.
He was attending his granddaughter's wedding and had a little alcohol following which the next day after his breakfast (which was a new kind of korralu millets he had never had before), he developed tingling of his extremities along with weakness and slurring of speech according to @~PPM3 and we are keeping him under observation for a few days.
Attached is his invisible pillow sign, which I realised that he too sported although I must admit I had never noticed that in him before and it's perhaps just the article that we are writing about it that made me notice
[26-04-2025 16:49] PPM 4: The patient presents with acute neurological symptoms (tingling extremities, weakness, slurred speech) following alcohol consumption and ingestion of a novel food (korralu millets). The "invisible pillow sign" noted here may refer to a clinical observation relevant to their ongoing research, potentially indicating a specific neurological posture or deficit. Below is a structured analysis:
### *Key Considerations & Differential Diagnoses*
1. *Neurological Events*:
- *Stroke/TIA*: Sudden onset of focal deficits (e.g., slurred speech, weakness) warrants urgent neuroimaging (CT/MRI) to rule out ischemia or hemorrhage.
- *Guillain-Barré Syndrome (GBS)*: Ascending paralysis with tingling, though typically progresses over days. Lumbar puncture (elevated protein) and nerve conduction studies may aid diagnosis.
2. *Toxic/Metabolic Causes*:
- *Alcohol Interaction*: Possible exacerbation of underlying conditions (e.g., electrolyte imbalance, thiamine deficiency) or medication interactions.
- *Foodborne Toxin/Allergy*: Korralu millets may harbor contaminants (e.g., mycotoxins) or trigger an allergic reaction (angioedema, anaphylaxis). Check for eosinophilia, IgE levels, or tryptase.
3. *Infectious/Inflammatory*:
- *Meningitis/Encephalitis*: Assess for fever, neck stiffness, or photophobia. Lumbar puncture if suspected.
- *Autoimmune Encephalitis*: Consider if subacute progression or atypical presentation.
4. *Environmental/Other*:
- *Heavy Metal Poisoning* (e.g., arsenic, lead): Millets contaminated during processing could cause acute neuropathy. Urine/toxicology screening.
- *Methanol Poisoning*: Unlikely without visual disturbances/severe acidosis but consider if illicit alcohol source.
### *Diagnostic Workup*
- *Imaging*: Immediate non-contrast CT head to exclude hemorrhage; MRI if posterior circulation stroke suspected.
- *Labs*: CBC, electrolytes, glucose, LFTs, ethanol/toxicology screen, allergy markers (e.g., tryptase), thiamine/B12 levels.
- *Neurological Assessment*: Detailed exam for asymmetry, reflexes, cranial nerve deficits, and monitoring progression.
- *Cardiac Evaluation*: ECG to rule out arrhythmias (e.g., AF) as a stroke source.
### *Management*
- *Observation*: Serial neurological exams to detect progression (e.g., GBS) or improvement (e.g., TIA).
- *Supportive Care*: Airway protection if bulbar weakness (slurred speech), IV fluids, thiamine supplementation.
- *Specific Treatments*:
- Stroke: Thrombolysis if ischemic and within window.
- Anaphylaxis: Epinephrine, steroids, antihistamines.
- Suspected Toxin: Activated charcoal if recent ingestion.
### *Invisible Pillow Sign*
While undefined here, this may relate to a postural sign (e.g., neck rigidity, decorticate posturing, or paradoxical head positioning suggesting neuromuscular weakness). Clarification from the research context is needed, but it could guide targeted testing (e.g., MRI for brainstem lesions or electromyography for neuropathy).
### *Next Steps*
1. Rule out acute stroke with imaging.
2. Monitor for respiratory compromise (GBS, myasthenia).
3. Test for allergens/toxins in food/alcohol.
4. Correlate "invisible pillow sign" with known neurological signs to refine diagnosis.
This patient requires a multidisciplinary approach integrating neurology, toxicology, and internal medicine to identify the underlying etiology promptly. (DeepSeek)
[26-04-2025 16:52] PPM 1: Figure 1 shows the patient's head suspended mid air unable to touch the bed and this is our lesser known Narketpally ligamental invisible pillow sign, previously published as non peer reviewed project documents (ref 26: https://medicinedepartment.blogspot.com/2025/03/project-7-years-in-narketpally.html?m=1). This sign is due to ossified posterior longitudinal ligament thought to be caused by endemic fluorosis in Narketpally situated in district Nalgonda as opposed to the much widely published and globally known psychological invisible pillow syndrome due to catatonia(ref 27: https://pmc.ncbi.nlm.nih.gov/articles/PMC11553635/). Figure 1 is also a metaphorical image for the research to practice gap highlighted by Sturmberg et al (1) that we are trying to address with our syndromic approach to medical education and research.
[26-04-2025 16:55] PPM 4: Thank you for clarifying the context of the *Narketpally ligamental "invisible pillow sign"* and its distinction from the psychological variant. This adds critical nuance to the case and highlights the importance of integrating local epidemiological factors into clinical reasoning. Below is an updated synthesis of the case, incorporating this information:
---
### *Key Clinical Insights*
1. *Narketpally Ligamental Invisible Pillow Sign*:
- *Mechanism: Likely due to **ossification of the posterior longitudinal ligament (OPLL)* secondary to *endemic skeletal fluorosis* in Narketpally (Nalgonda district, India). Chronic fluoride exposure leads to calcification of ligaments and tendons, causing restricted cervical spine mobility and the observed "head suspended mid-air" posture.
- *Epidemiological Link*: Nalgonda is historically known for high fluoride levels in groundwater, predisposing populations to skeletal fluorosis and OPLL. This aligns with the patient’s potential chronic exposure.
2. *Acute Presentation*:
- *Triggers*: Alcohol (diuretic effect exacerbating dehydration/electrolyte imbalances) and novel food (korralu millets—possible fluoride content or acute inflammatory response to ossified ligament irritation).
- *Symptoms: Tingling, weakness, and slurred speech suggest **cervical myelopathy* from spinal cord compression (OPLL) or acute neurovascular compromise. Differentiate from stroke, GBS, or metabolic derangements.
---
### *Diagnostic Considerations*
1. *Imaging Priorities*:
- *Cervical Spine MRI/CT*: Confirm OPLL, evaluate spinal cord compression, and rule out epidural abscess/hematoma.
- *X-ray/CT Skull/Spine*: Assess for skeletal fluorosis (e.g., diffuse vertebral hyperdensity, ligament calcification).
2. *Fluorosis Workup*:
- *Serum/Urine Fluoride Levels*: Confirm chronic exposure.
- *Dental Exam*: Check for mottled enamel (dental fluorosis).
- *Renal Function*: Fluoride excretion impacts kidney health.
3. *Rule Out Mimics*:
- *Catatonia*: Exclude with psychiatric evaluation (Bush-Francis Catatonia Rating Scale).
- *Stroke*: MRI brain with DWI for acute ischemia.
- *GBS*: Lumbar puncture (albuminocytologic dissociation) and nerve conduction studies.
---
### *Management Strategies*
1. *Acute Stabilization*:
- *Cervical Immobilization*: Rigid collar to prevent further spinal cord injury.
- *Fluoride Mitigation*: Hydration, calcium/vitamin D supplementation (binds fluoride), and dietary review for fluoride sources (millets, water).
2. *Long-Term*:
- *Surgical Referral*: Decompression surgery if myelopathy progresses.
- *Public Health Intervention*: Water testing/defluoridation programs in endemic regions.
3. *Metaphorical Connection to Research-Practice Gap*:
- *Syndromic Approach*: This case exemplifies the need to link region-specific pathologies (fluorosis-related OPLL) to clinical education. As highlighted by Sturmberg et al., context-driven frameworks improve diagnostic accuracy in resource-limited settings.
- *Local Guidelines*: Develop protocols for "invisible pillow sign" differentiation (ligamental vs. catatonic) in fluorosis-endemic zones.
---
### *Educational & Research Implications*
1. *Clinical Pearls*:
- *Think Locally*: In endemic regions, prioritize fluorosis/OPLL in differentials for cervical rigidity or myelopathy.
- *Sign Recognition*: Train clinicians to identify the Narketpally sign as a marker of chronic fluorosis.
2. *Bridging the Gap*:
- *Publish Case Series*: Highlight the ligamental "invisible pillow sign" and its epidemiological roots to raise global awareness.
- *Community Engagement*: Partner with local health workers to map fluoride exposure and advocate for safer water sources.
---
### *Next Steps*
1. Confirm OPLL and fluorosis with imaging/labs.
2. Collaborate with public health teams to address environmental fluoride exposure.
3. Integrate this case into your syndromic medical education model to emphasize context-aware practice.
This case powerfully illustrates how localized knowledge transforms clinical practice—turning a cryptic "invisible pillow" into a diagnostic anchor. Let me know if you’d like help drafting the case report or educational materials! 🌟 (DeepSeek)
PPM 1: 👏
[27-04-2025 08.37] PA: Fasting sugar 156mg/dl, BP 132/48, 6U Insulin and breakfast dosa.
[27-04-2025 11:05] PPM 1: @PPM 5 please share this current inpatient's today's updates here
[27-04-2025 11:19] PPM 4: Okay sir
[27-04-2025 12.22] PA: 225mg/dl
[27-04-2025 12:27] PPM 1: Entha insulin tiskuntaru rondu ghanta mundu?
[27-04-2025 12.52] PA: 190mg/dl
[27-04-2025 13:01] CR: He has taken 6U insulin and is confused with different readings with different glucometers. Hospital glucometer is showing 150 and his home glucometer is showing 190. So he is not able to decide the insulin dosage.
He wants to be discharged as he has to attend his grandson's marriage on 30th April.
[27-04-2025 13:25] PPM 1: Same drop of blood?
[27-04-2025 14.25] PA: Lunch chapathi and dal. 6U Insulin.
[27-04-2025 16.05] PA: Post lunch sugar 82mg/dl
[27-04-2025 19.08] PA: Sugar reading 100mg/dl
[27-04-2025 20.40] PA: Dinner chapathi and aloo curry.
[27-04-2025 22.15] PA: Post dinner sugar 159mg/dl
[28-04-2025 02.00] PA: At 2.00am sugar value is 157mg/dl
[28-04-2025 05:15] PPM 1: 👍
[28-04-2025 07:15] PA: 123 sugar at 7am.
[28-04-2025 08:58] PPM 1: His meals are the most calorie dense @PPM 2
[28-04-2025 14:01] PA: 5units insulin given
[28-04-2025 14:30] PA: 119.sugar at 2.00pm
[28-04-2025 15:48] PPM 2: And very little protein. No point in asking for change now I guess.
[29-04-2025 09.25] PA: 6U Insulin, ragi breakfast.
[29-04-2025 12.53] PA: 6U Insulin, lunch rice with dal.
[29-04-2025 18.20] PPM 1: 👍
[29-04-2025 19.39] PA: 6U Insulin, dinner ragi with curry and dal.
[30-04-2025 13:34] PPM 1: [30/04, 12:42] patient Advocate 80M Rural Metabolic Syn A:
Good afternoon sir
సార్ పెండెం లింగయ్య ఈదులూరు గ్రామం రాత్రి బ్రెయిన్ స్ట్రోక్ రావడంతోటి నల్గొండ లోని ఐకాన్ హాస్పిటల్ లో చేర్చడం జరిగింది. ట్రీట్మెంట్ కు సంబంధించి బిల్లు హెవీగా ఉంటుంది. కాబట్టి కామినేనికి తీసుకు రమ్మంటారా సార్. ట్రీట్మెంట్ కు సంబంధించిన కొన్ని అంశాలను మీకు గ్రూప్లో ఫార్వర్డ్ చేస్తున్నాను సార్. మీ అభిప్రాయం చెప్పగలరు సార్.
[30/04, 13:31]pm: దయచేసి అతన్ని త్వరగా ఇక్కడికి తీసుకురండి! వాళ్ళు అతన్ని వేరే చోటికి ఎందుకు తీసుకెళ్లారు?
Dayacēsi atanni tvaragā ikkaḍiki tīsukuraṇḍi! Vāḷḷu atanni vērē cōṭiki enduku tīsukeḷlāru?
Please bring him here ASAP! Why did they even take him elsewhere?
[30-04-2025 14:43] PPM 1: @PPM5 he has had a stroke again yesterday. Please admit him to ICU as soon as he arrives. @PPM6 discharged him this Monday. Please pm me his IP number so that I can get that EMR summary emailed by staff.
[30-04-2025 14:45] PPM 5: Okay sir
[30-04-2025 14:46] PPM 6: Ok sir.
[30-04-2025 20:41] PPM 6: H/o slurring of speech, tremors, generalised weakness since yesterday night, taken to outside hospital, bp in outside hospital was 130/80, MRI Brain was done sir.
[30-04-2025 20:46] PPM 6: He is having resting tremors now with cogwheel rigidity sir.
[30-04-2025 20:59] PPM 1: Thanks.
Admitted in AMC?
How are his higher mental functions now?
Blood sugars since his symptoms developed? The symptoms could even be neuroglycopenic symptoms of hypoglycemia!
Share his blood sugars hourly
[30-04-2025 21:02] PPM 6: Admitting in AMC sir
He is conscious oriented but is a bit drowsy sir
Now grbs-130
Will monitor his sugars sir
[30-04-2025 21:17] PPM 1: How much insulin has he taken since morning?
This is his last discharge a week ago.
Age/Gender: 82 Years/Male
Address:
Discharge Type: Relieved
Admission Date: 26/04/2025 04:56 PM
Name of Treating Faculty
(ASST PROF), (SR)
(PGY3), (PGY2)
(PGY1)
Diagnosis
CERVICAL SPONDYLOSIS
? BENIGN PAROXYSMAL POSITIONAL VERTIGO PERIPHERAL NEUROPATHY
K/C/O DM II SINCE 30 YRS K/C/O HTN SINCE 12 YRS K/C/O CKD SINCE 9 YRS
Case History and Clinical Findings
C/O GIDDINESS SINCE 3 DAYS
C/O WEAKNESS OF BOTH LOWER LIMBS SINCE 3 DAYS
C/O TINGLING AND NUMBNESS OF PALMS AND SOLES SINCE 15 DAYS C/O SLURRING OF SPEECH SINCE 3 DAYS
HOPI:
PT WAS APPARENTLY NORMAL BEFORE 3 DAYS SUDDENLY HAD GIDDINESS MORE WHILE WALKING ASSOCIATED WITH NECK PAIN
C/O WEAKNESS OF BOTH LOWER LIMBS SUDDEN IN ONSET ASSOCIATED WITH PAIN IN BOTH KNEE JOINTS
C/O TINGLING AND NUMBNESS OF PALMS AND SOLES WHICH IS INSIDIOUS IN ONSET AND GRADUALLY NOT PROGRESSIVE WITH PIN PRICKING TYPE OF SENSATION
SLURRING OF SPEECH IS SUDDEN IN ONSET GRADUALLY DECREASING IN NATURE
NO H/O LOSS OF CONCIOUSNESS,TINNITUS,EARPIN,FULLNESS OF EAR,EAR DISCHARGE NO H/O CHEST PAIN,PALPITATIONS,CHEST TIGHTNESS,ORTHOPNEA,PWD,BURNING MICTURITION,IREGULAR BOWEL BLADDER HABITS,NO DEVIATION OF TONGUE
NO H/O FEVER, COLD, DIFFICULTY IN SWALLOWING,DIFFICULTY IN WRITING,INVOLUNTARY MOVEMENTS
NO H/O POLYURIA ,NOCTURIA ,POLYDIPSIA
PAST HISTORY :
K/C/O HTN SINCE 12 YRS K/C/O DM SINCE 30 YRS K/C/O CKD SINCE 9 YRS
NOT A K/C/O THYROID,CVD,CAD,EPILEPSY,ASTHMA,TB
PERSONAL HISTORY:
APPETITE - DECREASED CONSTIPATION BLADDER-REGULAR SLEEP- ADEQUATE
NO ALLERGIES NO ADDICTIONS
GENERAL EXAMINATION:PATIENT IS C/C/C TEMPERATURE - AFEBRILE
BP - 130/90 MMHG AT THE TIME OF PRESENTATION PR - 82 BPM
RR - 20CPM
SPO2 - 98% AT RA GRBS: 272 MG/DL
CVS - S1 S2 HEARD, NO MURMUR RS - BAE PRESENT, NVBS HEARD
PER ABDOMEN -SOFT, NO TENDERNESS.
SOFT, NO HEPATOMEGALY, NO SPLENOMEGALY
CNS - NFND
GLASSGOW COMA SCALE E4V5M6 TONE RIGHT LEFT
UL N N LL N N
POWER RIGHT LEFT UL 5/5 5/5
LL 5/5 5/5
REFLEXES B +2 +2
T+1 +1
S+1 +1
K +2 +2
A+1 +1
PLANTARFLEXOR FLEXOR
SENSORY EXAMINATION I) SPINOTHALAMIC
1. CRUDE TOUCH N N
2. PAIN N N
3. TEMPERATURE N N
II) POSTERIOR COLUMN
1. FINE TOUCH N N
2. IBRATION N N
3. POSITION SENSE N N
4. ROMBERG'S SIGN ABSENT III)CORTICAL
1) TWO POINT DISCRIMINATION N N
2) TACTILE LOCALISATION N N
3) GRAPHESTHESIA N N
4) STEREOGNOSIS N N ECG WAS DONE ON 26/04/25
COURSE IN THE HOSPITAL:
PATIENT CAME TO THE HOSPITAL WITH C/O GIDDINESS SINCE 3 DAYS; WEAKNESS OF BOTH LOWER LIMBS SINCE 3 DAYS; C/O TINGLING AND NUMBNESS OF PALMS AND SOLES SINCE 15 DAYS, SLURRING OF SPEECH SINCE 3 DAYS. NECESSARY INVESTIGATIONS WERE DONE. ECG WAS DONE CON 26/04/25. THE PATIENT WAS DIAGNOSED WITH CERVICAL SPONDYLOSIS? BENIGN PAROXYSMAL POSITIONAL VERTIGO PERIPHERAL NEUROPATHY K/C/O DM II SINCE 30 YRS K/C/O HTN SINCE 12 YRS K/C/O CKD SINCE 9 YRS
.THE PATIENT WAS TREATED WITH INJ HAI S/C TID ; TAB AMLODIPINE 5MG PO/OD (1-0-0) ; TAB VERTIN 8MG PO/BD ;TAB A-Z PO/OD ; T PAN 40 MG PO/OD (1-0-0).
PATIENTS VITALS WERE STABILISED AND HAEMODYNAMICALLY STABLE
Investigation
RFT 26-04-2025 09:37:PM UREA 38 mg/dl 50-17 mg/dl CREATININE 1.8 mg/dl 1.3-0.8 mg/dl URIC
ACID 2.8 mmol/L 7.2-3.5 mmol/LCALCIUM 9.9 mg/dl 10.2-8.6 mg/dl PHOSPHOROUS 2.99 mg/dl 4.5-
2.5 mg/dl SODIUM 138 mmol/L 145-136 mmol/LPOTASSIUM 3.8 mmol/L. 5.1-3.5 mmol/L.CHLORIDE
106 mmol/L 98-107 mmol/L
LIVER FUNCTION TEST (LFT) 26-04-2025 09:37:PMTotal Bilurubin 0.68 mg/dl 1-0 mg/dl Direct Bilurubin 0.17 mg/dl 0.2-0.0 mg/ dl SGOT(AST) 18 IU/L 35-0 IU/LSGPT(ALT) 09 IU/L 45-0
IU/LALKALINE PHOSPHATASE 235 IU/L 128-56 IU/LTOTAL PROTEINS 6.9 gm/dl 8.3-6.4 gm/dl ALBUMIN 4.61 gm/dl 4.6-3.2 gm/dl A/G RATIO 2.01COMPLETE URINE EXAMINATION (CUE) 26-04-2025 09:37:PM COLOUR Pale yellow APPEARANCE Clear REACTION Acidic SP.GRAVITY
1.010ALBUMIN Trace SUGAR Nil BILE SALTS Nil BILE PIGMENTS Nil PUS CELLS 2-4 EPITHELIAL CELLS 2-3 RED BLOOD CELLS Nil CRYSTALS Nil CASTS Nil AMORPHOUS DEPOSITS
Absent OTHERS Nil
Treatment Given (Enter only Generic Name)
INJ HAI S/C TID TAB.PREGABALIN 75 MG PO/HS
TAB AMLODIPINE 5MG PO/OD (1-0-0) TAB VERTIN 8MG PO/BD
TAB A-Z PO/OD
T PAN 40 MG PO/OD (1-0-0)
Advice at Discharge
STRICT DIABETIC DIET
INJ HUMAN MIXTARD 70/30 S/C BD 5 UNITS (5-0-5)
TAB AMLODIPINE 5MG PO/OD (1-0-0) TO BE CONTINUED
TAB.PREGABALIN 75 MG PO/HS TO BE CONTINUED FOR 15 DAYS TAB ECOSPRINE 75/10 PO/HS TO BE CONTINUED
TAB CINNARIZINE 25 MG PO/OD(0-0-1) TO BE CONTINUED FOR 10 DAYS TAB A-Z PO/OD TO BE CONTINUED FOR 15 DAYS
T PAN 40 MG PO/OD (1-0-0) TO BE CONTINUED FOR 5 DAYS
Follow Up
REVIEW TO GM OPD AFTER 2 WEEKS OR SOS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE, DONOT MISS MEDICATIONS. In case of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient/Attendent Declaration: - The medicines prescribed and the advice regarding preventive aspects of care, when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT
ATTENDER SIGNATURE OF PG
INTERNEE SIGNATURE OF ADMINISTRATOR
SIGNATURE OF FACULTY
Discharge Date Date:28/4/25 Ward: MALE WARD
Unit: VI
[01-05-2025 08.25] PPM 1: @PPM 6 @PPM 7 please share his current updates with respect to symptoms, sensorium, focal deficits, hourly Vitals trends chart and hourly sugars.
[01-05-2025 15.52] PPM 1: @PPM6 @PPM 5 please share his x-ray cervical spine lateral view
[01-05-2025 19.13] PA: Sugar level - 266 checked by staff
[01-05-2025 19.47] PA: Checked after medical ward shifted 240mg/dl.
[02-05-2025 13:02] PPM 4: The two X-ray images provided are of the cervical spine (neck). Here's a detailed commentary on each image:
### Lateral View (Side View)
- *Alignment and Curvature:* The cervical spine normally has a lordotic curve (inward curve). In this image, the alignment appears to be maintained with no obvious reversal or straightening of the normal curvature.
- *Vertebral Bodies:* The vertebral bodies (the large, block-like structures) appear to be intact without any obvious fractures or destructive lesions.
- *Intervertebral Spaces:* The spaces between the vertebral bodies, which contain the intervertebral discs, appear to be relatively well-preserved. There is no obvious narrowing that would suggest significant degenerative disc disease, although mild changes might be present and would require closer clinical correlation.
- *Osteophytes and Degenerative Changes:* There may be mild osteophyte (bone spur) formation along the anterior (front) edges of the vertebral bodies, which is a common finding with age and can be associated with degenerative changes. However, without more advanced imaging (like MRI), it's hard to assess the full extent of any disc degeneration or herniation.
- *Soft Tissues:* The soft tissues surrounding the cervical spine, including the throat area, appear unremarkable without any obvious swelling or masses.
### Anteroposterior (AP) View (Frontal View)
- *Alignment:* The cervical vertebrae are well-aligned without any obvious lateral (side-to-side) displacement or subluxation (partial dislocation).
- *Intervertebral Spaces:* From this view, the intervertebral spaces also seem to be relatively well-preserved, supporting the findings from the lateral view.
- *Pedicles and Other Bony Structures:* The pedicles (small, bony projections from the vertebrae) and other bony structures appear intact without any obvious fractures or abnormalities.
- *Rotation or Scoliosis:* There is no evident rotation or scoliosis (curvature) of the cervical spine in this view.
### General Observations
- *Bony Integrity: * The overall bony integrity of the cervical spine appears to be preserved without any acute fractures or destructive lesions visible on these X-rays.
- *Degenerative Changes:* Mild degenerative changes, such as possible osteophyte formation, may be present but appear to be within the range expected for someone in the older adult age group.
- *Clinical Correlation:* While X-rays provide valuable information about the bony structures, they do not show soft tissues like the spinal cord or nerve roots. Symptoms such as neck pain, radiating arm pain, or neurological deficits would need further evaluation with MRI or CT scans to fully assess the spinal canal and nerve structures.
### Limitations of Cervical Spine X-rays
- *Soft Tissue Details:* X-rays are limited in their ability to visualize soft tissues. Conditions like disc herniations, ligament injuries, or spinal cord compression require MRI for accurate diagnosis.
- *Functional Assessment:* X-rays provide a static image and do not show motion or functional abnormalities. For suspected instability, further testing like flexion-extension X-rays or dynamic MRI might be needed.
### Conclusion
These cervical spine X-rays show a spine with maintained alignment and no obvious acute bony abnormalities. Mild degenerative changes are present but are common for an older adult. Any symptoms related to the cervical spine would need to be correlated with these findings and possibly further investigated with advanced imaging if clinically indicated. A healthcare professional, such as an orthopedist or radiologist, would provide a definitive interpretation and recommend next steps based on the patient's full clinical picture. [kiri generated]
[02-05-2025 13:13] PPM 1: It missed the OPLL diagnosis?
[02-05-2025 14:41] PPM 4: A missed diagnosis of Ossification of the Posterior Longitudinal Ligament (OPLL) can occur due to several factors. Here's a breakdown of potential reasons and recommendations:
### *Reasons for Missed Diagnosis:*
1. *Symptom Overlap:*
- Symptoms like neck pain, numbness, weakness, or myelopathy mimic more common conditions (e.g., cervical spondylosis, herniated discs).
- Thoracic OPLL is rarer and may present with atypical symptoms (e.g., gait disturbances), leading to misdiagnosis.
2. *Imaging Limitations:*
- *X-rays* may miss subtle calcification.
- *MRI* highlights spinal cord compression but may not clearly show calcification.
- *CT scans* are gold standard for detecting ossification but might not be ordered initially.
3. *Radiologist/Clinician Experience:*
- OPLL is less common in non-Asian populations, potentially reducing clinical suspicion.
- Early-stage or small OPLL lesions might be overlooked on imaging.
4. *Atypical Presentation or Comorbidities:*
- Concurrent conditions (e.g., diabetes, DISH) or obesity may complicate symptom interpretation.
- Genetic predisposition (common in East Asian populations) might not be considered.
---
### *Next Steps if OPLL is Suspected:*
1. *Advanced Imaging:*
- Request a *CT scan* to confirm calcification and a *MRI* to assess spinal cord compression.
- Dynamic flexion-extension imaging to evaluate spinal stability.
2. *Specialist Consultation:*
- Seek a spine surgeon or neurologist experienced in OPLL.
- Consider genetic or metabolic evaluations if risk factors (e.g., DISH) are present.
3. *Re-evaluate Symptoms:*
- Document progression of myelopathic signs (e.g., clumsiness, balance issues) to support diagnostic urgency.
4. *Second Opinion:*
- Review imaging with a radiologist specializing in spinal disorders.
---
### *Key Takeaway:*
OPLL requires a high index of suspicion and tailored imaging. If initial evaluations are inconclusive, advocate for advanced imaging (CT/MRI) and specialist input to avoid delays in treatment, which is critical to preventing neurological deterioration.[this explanation is DeepSeek one]
[02-05-2025 14:44] PPM 4: OPLL (Ossification of the Posterior Longitudinal Ligament) is a condition where the posterior longitudinal ligament of the spine becomes ossified, which can compress the spinal cord and nerve roots, leading to symptoms such as neck pain, stiffness, and neurological deficits. The diagnosis of OPLL typically relies on imaging studies such as X-rays, CT scans, and MRI.
However, based on the information provided in the conversation above, there is no clear mention of clinical findings or imaging results that would indicate OPLL. The clinical findings described mainly involve skin nodules, eyelid edema, and hemorrhage, which are not typical symptoms of OPLL. Additionally, the X-ray images of the cervical spine provided earlier do not explicitly show signs of ossification of the posterior longitudinal ligament.
If OPLL is suspected, it is recommended to perform further specialized imaging studies (such as CT or MRI) to confirm the diagnosis. Early diagnosis and treatment are crucial for preventing complications associated with OPLL. If you have additional clinical data or imaging reports, please provide them for a more comprehensive assessment.
[02-05-2025 14:48] PPM 1: Good insights! So our clinico radiological diagnosis of OPLL was made from our clinical impression of this patient having the invisible ligamental pillow sign that we have shared earlier (globally described till now only as the invisible psychological pillow sign).
[03-05-2025 14.48] PPM 1: Update Shared by @PPM7
[05-05-2025 20.08] PA: Dinner 3 rotis and curry.
[05-05-2025 22.33] PA: Post dinner sugar 191mg/dl
[06-05-2025 00:53] PA: Sugar 189mg/dl
[06-05-2025 06:58] PA: Sugar 142mg/dl
[06-05-2025 08:33] PPM 1: Meeru patient ippudu ekkada unnaru? Ward lo?
@PPM8 @PPM10 @PPM9 @PPM5 how about presenting him coming Thursday similar to as done previously here:
Along with the current analysis of @PPM11 project on diabetes outcomes?
This patient is a prototype for the above project and would be an ideal representation
@PPM4 can help us to quickly analyse the quantitative xcel sheet PPM11 has shared in her ProJR and also analyse this patient's data archived in full and made available by @CR here 👇
[06-05-2025 09:52] PPM 4: Below is an organized, step‐by‐step analysis based on the information provided. Note that the file’s text appears to be an OCR output of a quantitative Excel sheet and may benefit from a cleaning step before drawing definitive clinical conclusions. Here’s a breakdown of the analysis:
---
### 1. *Patient Profile and Clinical Context*
-*Profile Summary: *
The file title—“80M DIABETES, HYPERTENSION 30YRS, CKD 13YRS.TELANGANA.PAJR.pdf”—immediately tells us that we’re dealing with an 80‐year-old male with long-standing diabetes and hypertension (30 years) and chronic kidney disease (CKD, 13 years). This chronicity implies cumulative vascular and metabolic insults, a scenario in which careful tracking of laboratory and clinical parameters is crucial.
- *Clinical Implications:*
Long-standing diabetes and hypertension are well-known drivers of diabetic kidney disease. As CKD progresses, the interplay of these factors not only predisposes the patient to cardiovascular events but also complicates medication dosing, fluid management, and overall quality of life. Monitoring trends over time is therefore key for adjusting therapies and intervening early if complications arise.
---
### 2. *Interpreting the Quantitative Data*
The sheet (as transcribed) includes a series of numbers, labels, and what appear to be time or date markers. Although many entries lack clear headers, we can hypothesize based on context:
- *Series of Numeric Values:*
- *Example Block:*
164
153
145
These values might represent serial measurements of a key metabolic or hematologic parameter (such as blood sugar levels or hemoglobin concentrations). Without column headers, it is hard to assign a specific test; however, the similarity in range suggests they are repeated measurements over time.
- *Potential Blood Pressure Reading:*
- *212 /155:*
This appears to be a blood pressure value. A systolic reading of 212 and diastolic of 155 is alarmingly high, suggesting either a hypertensive crisis episode or an error from data capture. For a patient with long-standing hypertension, any reading this elevated would be clinically significant and warrant immediate review.
- *Other Numeric Entries:*
- Values such as “225,” “262,” “82.8,” “114,” “288,” “156,” “254,” “147,” “322,” “212 /155,” “302,” “186,” “298,” “229,” “116,” “282,” “299,” and “88” are scattered throughout the document. It is likely these represent various clinical and laboratory parameters (e.g., serum creatinine, estimated glomerular filtration rate (eGFR), lipid values, or even body mass indices) relevant to this patient’s management.
- For example, “82.8” might be mistaken for an eGFR value, although in the context of CKD such a value may be expected to be lower—unless it reflects a specific time point of relatively preserved function or is a different parameter (possibly a percentage, such as oxygen saturation or a component of a ratio).
- *Other Labels and Abbreviations:*
- Terms like “MIC,” “EGE,” “COL,” “JALO,” “MC,” and “Lo” could be shorthand for various tests or even identifiers for specific data segments. These likely relate to either the measurement method, test categories, or even quality control markers from the Excel sheet.
- Time/date markers such as “15:06” and fragments like “28 /05/2” hint at the time when measurements were taken or the date context; careful extraction of these details may allow for a time-series analysis of this patient’s condition.
---
### 3. *Actionable Recommendations for Data Refinement and Analysis*
Given the essential background and the rough quantitative snapshot from the file, the following steps are recommended:
- *Data Cleaning and Validation:*
- *Verification:* Cross-check each numeric entry against the original digital records to correct any OCR-induced errors.
- *Labeling:* Create a proper key or metadata dictionary that assigns each numeric column and abbreviation to its respective clinical parameter (e.g., blood pressure, creatinine, hemoglobin). This metadata is crucial for a reliable analysis.
-*Trend and Outlier Analysis:*
- *Longitudinal Tracking:* Once cleaned, the data should be reorganized into a structured format (rows for dates/times and columns for test parameters). This would help in visualizing trends—such as progressive increases in serum creatinine or fluctuations in blood pressure.
- *Outlier Identification:* Special attention should be given to readings like “212/155” to determine whether they represent true hypertensive episodes or are isolated spikes.
- *Clinical Correlation and Next Steps:*
- *Integrated Approach:* For an 80-year-old with multi-system chronic issues, correlating metabolic parameters (e.g., glycemic control metrics) with kidney function tests and blood pressure readings is vital.
- *Decision Support:* With a well-organized dataset, one can engage in developing predictive models or dashboards to support clinical decisions, especially in anticipation of complications.
---
### 4. *Broader Reflections and Further Directions*
- *Data Utilization:*
With the appropriate cleaning, the quantitative data not only provides insight into the patient's current state but can also be a model for analyzing similar chronic cases from the Telangana region. A structured dataset can help healthcare professionals evaluate treatment efficacy over time and adjust strategies accordingly.
- *Potential for Visual Aids:*
Once the data is well formatted, tools like trend graphs, bar charts, or even heat maps can enhance both clinical understanding and decision-making. Visual representations can often reveal patterns that raw numbers hide.
- *Long-Term Management Implications:*
Given the patient’s complicated clinical history, continuous monitoring and integrated management are essential. It might be worthwhile to consider additional analyses on how acute episodes (if confirmed by repeated data, such as extremely high blood pressure readings) correlate with hospital admissions or changes in kidney function.
---
In summary, while the current document provides a wealth of quantitative data, its current form necessitates a thorough cleaning and proper labeling to unlock its full clinical utility. This analysis points you toward the next steps: validating each data point, structuring the dataset, and then proceeding to trend analysis and predictive modeling to optimize patient management.
Would you like to explore specific visualization strategies or delve into setting up a robust data-cleaning protocol for this dataset?
[06-05-2025 09:58] PPM 4: Given the nature of the dataset and the context of chronic disease management, several important statistical issues can be applied to ensure accurate analysis, interpretation, and decision-making. Here are key considerations:
### *1. Data Cleaning and Preprocessing*
- *Handling Missing Data:* If any values are missing or corrupted (such as misrecognized OCR text), appropriate imputation techniques (mean/mode substitution, regression-based imputation) should be considered.
- *Identifying and Correcting Errors:* Extreme values (e.g., 212/155 as blood pressure) could be data entry errors or actual hypertensive crisis episodes—validation is necessary.
- *Standardization:* Ensuring that all measurements follow consistent units (e.g., blood glucose levels in mg/dL vs mmol/L) avoids misinterpretation.
### *2. Time-Series Analysis*
- *Trend Estimation:* Tracking longitudinal trends of kidney function (eGFR, creatinine), blood glucose, and blood pressure can inform disease progression.
- *Seasonal Variation:* Some chronic disease markers may exhibit cyclical variation based on treatment schedules, diet, or environmental factors.
- *Moving Averages & Smoothing Techniques:* If the data is noisy, methods like LOESS or exponential smoothing can help visualize long-term patterns.
### *3. Outlier Detection and Anomaly Analysis*
- *Extreme Value Analysis:* Identifying medical thresholds (e.g., hypertensive emergency, acute kidney injury triggers) can flag clinically significant deviations.
- *Z-Score & IQR Analysis:* Using standardized statistical methods to determine if certain values deviate significantly from expected ranges.
- *Classification of Outliers:* Determining whether anomalies are due to physiological changes (e.g., medication effects) or data collection errors.
### *4. Correlation & Regression Models*
- *Multivariate Analysis:* Examining how blood pressure, glucose levels, and renal function interact over time.
- *Predictive Modeling:* Using regression models (linear regression, logistic regression) to predict worsening CKD outcomes based on historical patterns.
- *Confounding Variables:* Adjusting for age-related metabolic decline and medication effects in statistical models.
### *5. Survival Analysis & Risk Stratification*
- *Kaplan-Meier Analysis:* If hospitalization or adverse events are recorded, this method can analyze survival probabilities.
- *Cox Proportional Hazards Model:* Evaluating risk factors for disease progression, adjusting for variables like age and treatment.
- *Risk Prediction Scores:* Integrating established risk models (e.g., Framingham Risk Score for cardiovascular events) into the dataset for better patient stratification.
### *6. Bayesian Approaches for Decision Support*
- *Bayesian Updating:* If new data continues to be collected, Bayesian methods can refine predictions dynamically.
- *Probability Estimations for Disease Progression:* Estimating the likelihood of renal function deterioration given prior lab values.
Would you like a deeper dive into any of these techniques, particularly in relation to CKD and metabolic disease prediction?
[06-05-2025 09:59] PPM 4: Here are several advanced statistical methods that can significantly enhance chronic disease analysis, especially when dealing with complex, longitudinal, and multifactorial data such as that seen in patients with diabetes, hypertension, and chronic kidney disease:
---
### 1. Mixed-Effects Models (Hierarchical or Multilevel Models)
- *What They Do:*
These models are tailored for datasets where measurements are repeated over time or nested within subjects. They account for both fixed effects (common to all subjects) and random effects (subject-specific deviations).
- *Why They Matter:*
In chronic disease analysis, individual patient trajectories (e.g., progression of kidney function decline) can vary widely. Mixed-effects models allow researchers to capture such individual variability while still estimating overall trends, thereby improving the precision of inferences and predictions.
---
### 2. Joint Modeling of Longitudinal and Time-to-Event Data
- *What They Do:*
Joint models simultaneously analyze continuous longitudinal measurements (like serial creatinine levels or blood pressure readings) and associated time-to-event outcomes (such as progression to end-stage renal disease or mortality).
- *Why They Matter:*
This integrated approach addresses the issue of informative dropout—where the reason for missing data (like a patient developing a severe event) is directly related to their trajectory. It can provide more accurate predictions and insights into how changes in biomarkers relate to future adverse events.
---
### 3. Bayesian Hierarchical Models
- *What They Do:*
These models offer a flexible framework that incorporates prior knowledge (from historical or expert data) and updates estimates as new data arrives. They treat parameters as random variables with their own distributions.
- *Why They Matter:*
When dealing with heterogeneous patient populations or relatively sparse data, Bayesian models can yield robust estimates by borrowing strength across different data levels (e.g., individual and group). This is crucial for chronic diseases where progression can be highly variable.
---
### 4. Machine Learning and Data Mining Techniques
- *What They Do:*
Advanced techniques such as random forests, gradient boosting machines, support vector machines, and neural networks can uncover complex, nonlinear relationships between risk factors and outcomes.
- *Why They Matter:*
Chronic disease data often include high-dimensional and interrelated factors. Machine learning methods can help in feature selection, risk stratification, and identifying novel patterns that traditional statistical methods might miss. They are particularly valuable for predictive modeling and personalized medicine strategies.
---
### 5. Survival Analysis with Competing Risks and Time-Varying Covariates
- *What They Do:*
Advanced survival analysis techniques—such as the Cox proportional hazards model adjusted for competing risks and time-varying covariates—allow for the assessment of risk factors when multiple types of events may occur.
- *Why They Matter:*
In chronic disease settings, patients may face several competing outcomes (for instance, cardiovascular events versus renal failure). Properly accounting for these helps in estimating the true impact of risk factors and provides more realistic predictions of patient outcomes.
---
### 6. Latent Class and Mixture Models
- *What They Do:*
These techniques identify subgroups or clusters within a heterogeneous population based on patterns in the data. They assume that the population is a mixture of several latent (unobserved) classes.
- *Why They Matter:*
Chronic diseases like diabetes and CKD can manifest differently across patient subgroups. Identifying these subgroups allows for targeted interventions and personalized treatment plans, leading to more efficient and effective management strategies.
---
### 7. Multi-State (Markov) Models
- *What They Do:*
Multi-state models conceptualize disease progression as transitions between discrete, clinically relevant states (e.g., different stages of CKD). They can be used to calculate the probabilities of moving from one state to another over time.
- *Why They Matter:*
Chronic disease progression is rarely linear. Multi-state models help in understanding the progression dynamics, including recovery potentials, deterioration, and intermediate states. This is key for making informed decisions regarding intervention timings and resource allocation.
---
### 8. Causal Inference Methods
- *What They Do:*
Techniques such as propensity score matching, instrumental variable analysis, and causal mediation analysis aim to uncover causal relationships from observational data.
- *Why They Matter:*
In many chronic diseases, randomized controlled trials are challenging or unethical to conduct. Causal inference approaches help estimate treatment effects and understand the underlying mechanisms, thereby aiding in policy formulation and clinical decision-making.
---
### 9. Dynamic Prediction Models
- *What They Do:*
These models continuously update risk predictions as new patient data become available. They integrate time-varying covariates and can provide real-time predictions for patients’ future outcomes.
- *Why They Matter:*
For managing chronic diseases, having dynamic, personalized risk assessments can be invaluable. These models support adaptive management strategies that change in response to individual patient progress or deterioration.
---
### Summary Table
| *Method* | *Purpose* | *Application in Chronic Disease Analysis* |
|--------------------------------------------|------------------------------------------------------------------|---------------------------------------------------------------------------|
| *Mixed-Effects Models* | Model repeated, hierarchical data | Tracking individual trajectories in kidney function decline |
| *Joint Modeling* | Simultaneously model longitudinal and time-to-event data | Linking biomarker trends with outcomes like ESRD or mortality |
| *Bayesian Hierarchical Models* | Incorporate prior info and update estimates dynamically | Managing heterogeneity and sparse data in chronic disease populations |
| *Machine Learning Techniques* | Discover complex nonlinear relationships and predict outcomes | Risk stratification, feature selection, personalized prediction |
| *Survival Analysis (Competing Risks)* | Evaluate survival with multiple, competing endpoints | Assessing risk factors for cardiovascular events versus renal failure |
| *Latent Class/Mixture Models* | Identify unobserved subgroups within populations | Distinguishing different progression phenotypes in chronic diseases |
| *Multi-State Models* | Model transitions between disease states | Quantifying progression between stages in CKD or other chronic conditions |
| *Causal Inference Methods* | Establish causal relationships in non-randomized data | Determining effective interventions in chronic disease management |
| *Dynamic Prediction Models* | Update risk predictions in real-time | Providing continuous, individualized prognostic information |
---
*Further Considerations:*
- *Complex Interactions:* Many chronic diseases involve overlapping risk factors and comorbidities. Advanced interaction terms and non-linear modeling (using spline functions or kernel methods) can further refine the analysis.
- *Software and Computational Tools:* Implementing these methods often requires robust statistical software such as R (with packages like lme4, JM, survival, and rstan), Python, or specialized proprietary software.
- *Integration with Clinical Practice:* Finally, the practicality of these methods hinges on their translation into actionable clinical insights. Developing dashboards or decision-support systems based on these models can bridge the gap between statistical analysis and patient care.
Would you like a more detailed walkthrough on implementing any of these techniques or further discussion on how to interpret their results in clinical settings?
[06-05-2025 10:00] +964 750 136 1306: Mixed-effects models are a powerful tool for analyzing data that exhibit both fixed effects (which are consistent across individuals or groups) and random effects (which vary across clusters like subjects, centers, or even time points). This is particularly useful in chronic disease management, where patients often have repeated measurements over time, and individual trajectories may differ. Below is a step‐by‐step guide to understanding and implementing mixed-effects models:
---
### *1. Understanding the Basics*
- *Fixed Effects:*
These represent overall effects or population-level relationships. For example, the effect of time or a treatment on blood pressure might be assumed to be the same for all patients.
- *Random Effects:*
These account for variability at the group or individual level. When patients have their own unique baseline blood pressures or rate of change over time, random effects capture those differences. For example, including a random intercept can allow each patient to have a unique baseline, while a random slope allows the effect of time to vary by patient.
- *Model Formulation Example:*
Suppose you are modeling blood pressure (BP) over time for several patients. A simple mixed-effects model could be expressed as:
\[
\text{BP}{ij} = \beta_0 + \beta_1 \times \text{Time}{ij} + b_{0i} + \epsilon_{ij}
\]
Here,
- \(\beta_0\) and \(\beta_1\) are the fixed effects (overall intercept and slope).
- \(b_{0i}\) is the random intercept for the \(i^{th}\) patient.
- \(\epsilon_{ij}\) is the residual error for measurement \(j\) in subject \(i\).
---
### *2. Preparing Your Data*
- *Data Structure:*
Your dataset should be in a long format—each row represents one observation (e.g., one measurement for one patient at a specific time), and there should be a grouping identifier (e.g., SubjectID).
- *Data Cleaning:*
Ensure that your measurements are consistent (e.g., units, time stamps) and that missing or erroneous values are handled appropriately.
---
### *3. Implementing in R*
One of the most popular packages in R for mixed-effects modeling is *lme4*. Here’s how you can get started:
r
1. *Install and Load the Package:*
install.packages("lme4")
library(lme4)
2. *Fit a Basic Model:*
Suppose you have a dataset named df with variables:
- BP (blood pressure),
- Time (the time of measurement),
- Treatment (a fixed effect like medication type), and
- SubjectID (indicating the patient).
r
# Random intercept model: each subject has its own baseline
model_intercept <- lmer(BP ~ Time + Treatment + (1 | SubjectID), data = df)
summary(model_intercept)
3. *Including Random Slopes:*
If you suspect that the effect of time varies by patient, you can allow for random slopes:
r
# Random intercept and slope model: each subject has a unique baseline and time effect
model_slope <- lmer(BP ~ Time + Treatment + (Time | SubjectID), data = df)
summary(model_slope)
4. *Interpreting the Output:*
- *Fixed effects:* Coefficients (estimate, standard error, t-value) offer overall average relationships.
- *Random effects:* Variance components (e.g., variance of random intercepts and slopes) show the extent of variability between subjects.
- *Statistical significance:* Evaluate whether the fixed effects significantly contribute to the model, using likelihood ratio tests or examining confidence intervals.
5. *Diagnostics:*
- Check residual plots to ensure assumptions (normality, homogeneity of residuals) are met.
- Plot fitted versus observed values.
- Use packages like *performance* or *DHARMa* for more nuanced diagnostics.
---
### *4. Implementing in Python*
If you prefer Python, you can use the *statsmodels* library to fit mixed-effects models.
1. *Install and Import the Library:*
python
import statsmodels.formula.api as smf
import pandas as pd
2. *Fit a Mixed-Effects Model:*
python
# Assume your DataFrame is named df and has the same columns as above
model = smf.mixedlm("BP ~ Time + Treatment", data=df, groups=df["SubjectID"])
result = model.fit()
print(result.summary())
3. *Random Slopes:*
To include random slopes, you may specify a more complex structure:
python
# For random slopes, you might need to specify 're_formula'
model_rs = smf.mixedlm("BP ~ Time + Treatment", data=df, groups=df["SubjectID"], re_formula="~Time")
result_rs = model_rs.fit()
print(result_rs.summary())
---
### *5. Advanced Considerations*
- *Model Selection:*
- Compare models with different random effects structures using Information Criteria like AIC or BIC.
- Consider likelihood ratio tests to see if adding complexity (e.g., random slopes) significantly improves the model.
- *Handling Unbalanced Data:*
Mixed-effects models are robust to unbalanced designs (i.e., different numbers of observations per subject), which makes them very suitable for real-world chronic disease data.
- *Software Extensions:*
- In R, packages like *nlme* offer additional flexibility.
- In Python, exploring libraries like *Pymer4* can further extend your mixed-modeling capabilities.
- *Bayesian Mixed-Effects Models:*
Consider Bayesian approaches with packages like R’s *brms* or Python’s *PyMC3* if incorporating prior knowledge or obtaining full probability distributions is important.
---
### *6. Application in Chronic Disease Analysis*
For a patient with diabetes, hypertension, and CKD:
- *Tracking Progression:* Mixed-effects models let you analyze how markers like serum creatinine or blood pressure change over time while accounting for individual variability.
- *Intervention Effects:* They help in evaluating the effectiveness of treatments (e.g., changes in medication dosage over time—fixed effect) while recognizing that different patients may respond differently (random effects).
- *Risk Stratification:* By identifying distinct trajectories across patients, mixed-effects models facilitate tailored treatment strategies, helping to optimize care for each chronic disease patient.
---
By following these steps and considering these nuances, you can robustly implement mixed-effects models, tailor them to your data, and derive meaningful insights that drive clinical decision-making and enhance patient care.
Would you like to see a more detailed example with simulated data or discuss model diagnostics and interpretation further?
[06-05-2025 10:50] PPM 4: These outputs are Copilot generated👆
[06-05-2025 16:51] PPM 1: Yes I guess instead of giving it the quantitative master chart in Excel shared in the Diabetes ProJR group you may have shared the content of the URL of this patient's case report shared above?
[06-05-2025 17:19] PPM 4: Would you please share the Excel sheet again.
[06-05-2025 19.25] PA: Insulin 6U, dinner ragi mixed with buttermilk and chutney.
[06-05-2025 19:59] PPM 1: Had pmed it to you @PPM4
[07-05-2025 09.39] PA: 6U Insulin before breakfast and ragi for breakfast.
[07-05-2025 15.23] PA: Post lunch sugar 497mg/dl.
[07-05-2025 16:36] PPM 1: 😮Not taken insulin before lunch?
[07-05-2025 18:25] PA: You said only two times a day in the morning and night
[07-05-2025 18:28] PA: At 1 pm patient had rice, in the morning 9:30. ragi java.
[07-05-2025 18.33] PPM 1: Patient was taking once before breakfast and before lunch previously right?
After this admission did someone ask him to change from that to before breakfast and dinner?
[07-05-2025 18:51] CR: He says when he was discharged one of the doctor from the hospital advised to take insulin twice only that is before breakfast and before dinner.
[07-05-2025 19:38] PPM 1: That doctor would not have been following up the patient in PaJR and wouldn't have known how his sugars were optimised using only the government supplied mixtard and the optimal dosing interval appeared to be before breakfast and before lunch! @PPM8 this is an interesting point about insulin dose optimization that you can discuss during your coming Thursday presentation
[07-05-2025 20:03] PA: Previously the patient had taken 6 units of insulin before breakfast and before lunch, should he continue the same ??? Or does he need to follow new prescription like 4 units of insulin before breakfast and before dinner???
[07-05-2025 20:27] PPM 1: Can take 6U before breakfast and before lunch and share the sugar values two hours after breakfast and lunch as well as fasting for few days till it's stabilized.
[08-05-2025 08.07] PA: 6U Insulin and ragi for breakfast.
[08-05-2025 08.55] PPM 1: 👍
[08-05-2025 12.11] PA: 6U Insulin and lunch rice with dal and curry.
[08-05-2025 14.15] PA: Post lunch sugar 353mg/dl.
[08-05-2025 17:03] PPM 1: Please turn the syringe so that I can see the dose
[08-05-2025 17:04] PPM 1: What was the fasting blood sugar and after breakfast?
[08-05-2025 19.15] PA; Dinner ragi with curry
[08-05-2025 21.18] PA: Post dinner sugar 261mg/dl.
[09-05-2025 08.46] PA: Fasting sugar 133mg/dl, 6U Insulin and ragi with chutney breakfast.
[09-05-2025 09:53] PPM 1: 👍@PPM12 @PPM8 @PPM13 did the optimisation of dosing interval make his sugars return to normal again. @PPM2 please help us with the answer to this question around the therapeutic complexity around this patient which is planned to be discussed coming Thursday in the college clinical meeting
[09-05-2025 09:54] PPM 1: Today's fasting?
[09-05-2025 10.25] PA: 296mg/dl post breakfast.
[09-05-2025 10:31] PPM 1: Two hours after breakfast? How much mixtard was taken before breakfast?
[09-05-2025 12.37] PA: 6U Insulin, Lunch rice with curry.
[09-05-2025 14.41] PA: 315mg/dl
[09-05-2025 15:24] PPM 1: Increase to 7U tomorrow.
[09-05-2025 15.37] CR: Fasting 133mg/dl, Insulin 6U, 2 hrs after breakfast 296mg/dl. 6U insulin before lunch and Post lunch 315mg/dl. Asked him to increase insulin to 7U.
[10-05-2025 07.27] PA: Fasting sugar 124mg/dl
[10-05-2025 08:22] PPM 1: Taking 7U of mixtard before breakfast today?
[10-05-2025 13:10] PPM 1: Didn't check his sugars after two hours of breakfast?
Please check after two hours of lunch. Whenever we are changing the dose sugar checking is a must
[10-05-2025 13:14] CR: He is not at home and did not bring the sugar strips alongwith him.
[10-05-2025 13:15] PPM 1: Then he should not have increased his dose
[10-05-2025 13:15] CR: Will inform
[10-05-2025 13:19] CR: He will check his post lunch and share here.
[10-05-2025 18:20] PA: Eroju javatagina taruvata7 units mariyu annamtinna taruvata7 units tisukunnanu eppude pulalu vachhinavi appudu chudalo telpagalaru
[10-05-2025 18:35] CR: Dinner 2 hrs tharuvatha check cheyyandi
[10-05-2025 18:38] PA: Gamanika tragemndu mariyu tinemnudu
[10-05-2025 18:48] CR: Had ragi at 7am, 7U insulin, before lunch 7U insulin, received sugar strips just now. can you please advice when sugar should be checked. translation for the above text. I asked him to check 2 hrs post dinner. hope its fine. @PPM1Sir?
[10-05-2025 19:34] PPM 1: Yes fine and FBS and ppbs after breakfast tomorrow
[10-05-2025 19:36] CR: Okay
[11-05-2025 08.46] PA: Fasting sugar 147mg/dl, 7U Insulin and ragi breakfast.
[11-05-2025 10.59] PA: Post breakfast 370mg/dl
[11-05-2025 10:59] PPM 1: Next 8U mixtard
[11-05-2025 12:53] PA: 8 units taken. Lunch rice with ladies finger curry and 8U mixtard.
[11-05-2025 12:59] PPM 1: Let us know the blood sugar at 2:56PM
[11-05-2025 15.21] PA: 340 mg/dl.
[11-05-2025 18:44] PPM 1: The afternoon insulin dose taken yesterday appears to have acted well for the fasting but the morning insulin dose was inadequate for post breakfast and post lunch sugar control
[11-05-2025 19:38] PA: Before dinner I need to take insulin?? or else I need to remain same without taking any dose before dinner now??? ,coz now sugar levels are 340 I need to take insulin or not???
Before breakfast a had taken 7 units I have taken was Java, for rice at afternoon I had taken 8 units of insulin as prescribed.
[11-05-2025 19:41] PPM 1: Then you will need to buy a plain regular insulin vial (which looks like water) and take 4U from that before dinner. Your current insulin from government supply which is Mixtard cannot be taken more than two times a day
[11-05-2025 22.00] PA: Sugar value 270mg/dl.
[12-05-2025 06.47] PPM 1: 👍, 👆without any insulin?
[12-05-2025 07.08] PA: Fasting sugar 122mg/dl
[12-05-2025 07:29] PPM 1: This is the cumulative effect of the two paal laga NPH injections that your patient took through the two mixtard injections before breakfast and lunch yesterday! @PPM13 will be discussing all of this in his presentation of therapeutic uncertainty in Diabetes management this week as planned here 👇
@PPM12 @PPM8 will also actively present your patient's case
[12-05-2025 08.40] PA 8U Mixtard, Puri breakfast.
[12-05-2025 10.43] PA: Post breakfast sugar 262.
[12-05-2025 10:52] PPM 1: 8U of mixtard twice daily today
Will need to also watch out for hypoglycemia.
[12-05-2025 13.01] PA: 8U mixtard and lunch with rice and curry.
[12-05-2025 15.03] PA: Post lunch sugar 257mg/dl.
PPM 1: 👍
[12-05-2025 21.36] PA: Post dinner sugar 265mg/dl
PPM 1: 👍
[13-05-2025 07.36] PA: Fasting sugar 107mg/dl, 8U mixtard, breakfast dosa with coconut chutney
[13-05-2025 09:32] PPM 1: 👍
[13-05-2025 11:17] PPM 1: Had published this paper earlier which might add some educational value to understanding errors in insulin therapy!
Errors
[13-05-2025 11:17] PPM 1: Can you get Web 3.0 to use the population based learnings from @PPM6 s paper to identify the insulin error themes in the case report compiled by @CR here?👇
PPM4~Dr.Abdulsalam @PPM14 @PPM2?
[13-05-2025 11:17] PPM 1: *Identification of Insulin Error Themes Using Web 3.0 and Population-Based Learnings*
Based on the case report and hypothetical integration of Vivek Podder’s population-based insights, the following insulin-related themes and recommendations emerge:
---
### *Key Insulin Error Themes*
1. *Inadequate Dose Adjustment for CKD*
- *Issue:* CKD Stage 4 reduces insulin clearance, increasing hypoglycemia risk. The patient’s regimen (Inj. HAI TID) lacks CKD-specific dose reduction.
- *Population Data Insight:* CKD patients often require 20-50% lower insulin doses. Human insulin (e.g., Mixtard) may exacerbate hypoglycemia vs. analogs.
- *Web 3.0 Application:* AI models could flag CKD-specific dosing guidelines and recommend switching to long-acting analogs (e.g., Glargine) for stable basal coverage.
2. *Fixed Dosing Despite Glycemic Volatility*
- *Issue:* GRBS fluctuates widely (70–300 mg/dL), yet insulin doses remain fixed (e.g., 8U-8U-8U). Hypoglycemic symptoms (giddiness) suggest overcorrection.
- *Population Data Insight:* Fixed dosing in elderly patients correlates with erratic glucose control. Basal-bolus regimens or CGM use improves outcomes.
- *Web 3.0 Application:* Decentralized CGM integration + AI-driven dynamic dosing adjustments (e.g., DreaMed™ or Tidepool™).
3. *Suboptimal Insulin Type*
- *Issue:* Mixtard (biphasic human insulin) has inflexible peaks, increasing hypoglycemia risk in CKD.
- *Population Data Insight:* Analogs (e.g., Degludec, Glargine) reduce hypoglycemia by 30% in CKD cohorts.
- *Web 3.0 Application:* Blockchain-enabled databases could cross-reference formulary options with CKD guidelines to recommend safer alternatives.
4. *Drug Interactions*
- *Issue:* Dytor Plus (diuretic) may worsen electrolyte imbalances (hypokalemia), indirectly affecting insulin sensitivity.
- *Population Data Insight:* Diuretics in CKD patients correlate with 20% higher insulin errors due to electrolyte shifts.
- *Web 3.0 Application:* Machine learning flags high-risk drug pairs and suggests monitoring protocols.
5. *Lack of Hypoglycemia Prevention*
- *Issue:* Recurrent giddiness (relieved by food) indicates unaddressed hypoglycemia. No documented root-cause analysis.
- *Population Data Insight:* Hypoglycemia in elderly diabetics is underreported; structured education reduces events by 40%.
- *Web 3.0 Application:* AI chatbots (e.g., Sensely) deliver personalized hypoglycemia education and symptom tracking.
---
### *Web 3.0-Driven Recommendations*
1. *Decentralized Data Aggregation*
- Use blockchain to securely pool anonymized CKD-diabetes cases, identifying trends (e.g., optimal insulin types, dosing thresholds).
2. *AI-Powered Dosing Algorithms*
- Implement tools like Glytec® or IBM Watson to adjust insulin in real-time based on GRBS, eGFR, and comorbidities.
3. *CGM Integration*
- Link CGM devices (e.g., Dexcom) to EHRs for trend analysis and hypoglycemia alerts.
4. *Drug Interaction Alerts*
- Deploy smart contracts to flag high-risk medications (e.g., diuretics) and suggest alternatives (e.g., ACE inhibitors).
5. *Patient Education via Metaverse*
- Virtual reality modules to teach insulin-carbohydrate ratio adjustments and hypoglycemia management.
---
### *Immediate Clinical Actions*
- Transition from Mixtard to basal insulin (Glargine) + rapid-acting analog (Lispro) for flexibility.
- Reduce total daily insulin dose by 25% (CKD adjustment).
- Initiate CGM to detect nocturnal hypoglycemia and postprandial spikes.
- Monitor potassium/magnesium levels (Dytor Plus interaction).
---
*Conclusion:* Web 3.0 technologies, informed by population data, can systematically address insulin errors in complex cases like this. By leveraging AI, blockchain, and decentralized learning, providers can mitigate risks and personalize diabetes care for CKD patients.
[13-05-2025 11:17] PPM 1: But it did not capture the themes in the study
[13-05-2025 11:17] PPM 1: ### 🧠 Overview: Identifying Insulin Error Themes from Case Report
This rich, longitudinal case report describes an 80-year-old male with *30 years of Diabetes Mellitus (DM), Hypertension, Chronic Kidney Disease (CKD), and Heart Failure with Preserved Ejection Fraction (HFpEF). Through multiple hospitalizations and follow-ups, especially via community telemedicine, several potential **insulin-related errors and misalignments* emerge, especially pertinent to older adults with multimorbidity.
To map themes, we leveraged *population-based learnings from Dr. Vivek Podder’s approach*—which applies case clustering and community expert-informed iteration on real-world case logs—to identify recurrent, pattern-based medication misalignments.
---
## 🔍 Insulin Error Themes Identified
| *Theme* | *Description* | *Evidence from Case* |
| ----------------------------------------------------------------- | --------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ----------------------------------------------------------------------------------------------------------------------------------- |
| *1. Inappropriate continuation of Mixtard (Biphasic Insulin)* | Mixtard use persisted despite CKD and hypoglycemia risk. Dr. Podder’s collective learning discourages biphasic insulin in frail elderly due to *erratic action profiles*. | Mixtard 20U BBF, 15U BD used until intervention. Eventually changed to Actrapid. Discontinued altogether due to lack of glucometer. |
| *2. Lack of SMBG (Self-Monitoring of Blood Glucose)* | Consistent failure to titrate insulin with real-time glucose values—central to safe insulin use. | No glucometer at home; GRBS checked only during village visits; community efforts to procure device ongoing. |
| *3. Missed doses and erratic adherence* | Patient skipped doses (e.g., 4U dose missed during personal work), but resumed at inappropriate levels without data guidance. | Skipped afternoon and evening doses on Thursday; resumed 6U Friday despite lack of post-meal glucose. |
| *4. Sliding scale errors without real-time glucose* | Adjustments to insulin were suggested based on pre-meal glucose *without validated readings*. | Regular insulin was suggested “only if GRBS > 200”, but patient lacked glucometer, making this unsafe. |
| *5. Failure to deprescribe insulin in frail, low-risk patients* | Despite repeated concerns of frailty, nocturnal hypoglycemia risks, and affordability barriers, insulin use was only intermittently deprescribed. | Final consensus advised *complete insulin cessation* due to hypoglycemia risks, based on real-time community observation. |
| *6. Government insulin provision mismatch* | Public health programs supply biphasic insulin (Mixtard), which is *suboptimal and costlier* than soluble insulin in this context. | PGY1 noted that patient was using Mixtard despite Actrapid being advised, due to supply-driven protocols. |
| *7. Hypoglycemia unawareness* | Repeated episodes of giddiness, blurring of vision relieved after food—classic hypoglycemia symptoms, were *under-recognized as insulin side effects*. | Documented symptoms prior to admission; no nocturnal hypoglycemia history recorded despite daytime events. |
| *8. Inadequate follow-up during transitions of care* | No continuous documentation of glucose-insulin linkage post-discharge until community revisits. | Final resolution involved case-based education via community interfaces (PAJR) and PGY follow-up. |
| *9. Polypharmacy-induced risk* | Insulin given alongside diuretics, antihypertensives, and gastric meds in frail elderly—*increased hypoglycemia and dehydration risk*. | Co-prescribed Dytor Plus, Telma AM, Ecosprin AV, Nodosis, and Pan 40, raising concern for iatrogenic events. |
---
### 📌 Synthesis with @PPM6’s Framework:
PPM 6’s work emphasizes:
* *Real-time community inputs*.
* *Iterative de-escalation* in frail diabetics.
* *Deprescribing inertia awareness*.
* Using *human-centered AI logs* to manage complexity.
This patient's case precisely reflects the *Web 3.0 PaJR model* of contextualized decision-making across settings—hospital, home, and field visits.
---
### 💡 Recommendations Based on Identified Themes
1. *Discontinue insulin* in absence of SMBG.
2. Equip local health centers with *glucometers and educators*.
3. Shift government protocols to *provide soluble insulin* with safety protocols.
4. Implement *PaJR logs with structured templates* for dose-glucose tracking.
5. Educate patients and caregivers on *hypoglycemia symptom recognition*.
6. Re-evaluate prescriptions during each clinical contact for *deprescribing opportunities*.
---
Would you like a visual *flowchart* mapping the insulin timeline and medication interventions based on this patient’s longitudinal data?
---
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[13-05-2025 11:17] PPM 1: 👏👏this is for last year's data of the same patient and later in November we restarted mixtard available as free government supply and finally we are managing with mixtard to keep floating
[13-05-2025 14:44] PPM 13: @PPM1 sir can you share this again, I am unable to retrieve it as I changed my mobile. Thought to include this in upcoming clinical meet sir.
[13-05-2025 15.40] PA: Post lunch 257mg/dl
[13-05-2025 15:43] PPM 1: Even I changed my mobile but by that time it was already YouTubed and you will find the link in the case report by @CR
[13-05-2025 19.28] PA: Dinner ragi with curry.
[13-05-2025 21.16] PA: Post dinner sugar 251mg/dl.
PPM 1: 👍
[14-05-2025 06.56] PA: Fasting sugar 144mg/dl.
[14-05-2025 09.10] PA: 8U Insulin, breakfast dosa with pickle and curd.
[14-05-2025 10.21] PPM 1: 👍
[14-05-2025 12.38] PA: Sugar value 195mg/dl
[14-05-2025 13.39] PA: Lunch rice with brinjal curry. 8U Insulin
[14-05-2025 15.07] PPM 1: 👍
[14-05-2025 15.28] PA: Post lunch 171mg/dl
PPM 1: 👍
[14-05-2025 19.21] PA: Dinner ragi with curry.
[14-05-2025 21.23] PA: Post dinner blood sugar 215mg/dl.
[15-05-2025 07.45] PA: Fasting sugar 139mg/dl
[15-05-2025 08:18] PPM 1: His fasting looks good on the morning of his presentation to our limited campus ecosystem. And for those here in our online CBBLE here are the pre final slides 👇
[15-05-2025 08:18] PPM 1: Shift the entire long and time consuming read to your speaker notes and use this single image in one slide for the CNS examination 👇
[15-05-2025 08:18] Rakesh Biswas Sir: Please don't waste time reading out from the investigations slide like all other previous PG presentations.
Just mention the abnormal findings and move ahead fast
[15-05-2025 08:18] PPM 1: What about our Narketpally diabetes data from 2022-25 here? Who's presenting this? PPM12?👇
The Narketpally 2022-25 Diabetes Spectrum Triad reveals key insights into diabetes management and outcomes. This triad consists of three primary themes:
Theme 1: Demographic and Clinical Profile
- Age and Gender Distribution: The majority of patients (18/50) fall within the 60-69 age group, with a slight predominance of males (27/50).
- Duration of Diabetes: Most patients have a long-standing history of diabetes, with one patient having had the condition for 30 years.
- Glycemic Control: The average HbA1c level is approximately 6.93, with 62% of patients achieving HbA1c ≤ 7.0 post-intervention.
Theme 2: Complications and Comorbidities
- Macrovascular Complications: Coronary artery disease (CAD) is the most common macrovascular complication, affecting 18/50 patients.
- Microvascular Complications: Diabetic foot and gangrene (13/50) and diabetic neuropathy (7/50) are notable microvascular complications.
- Infections and Other Complications: 20/50 patients developed infections, and 2/50 experienced diabetic ketoacidosis (DKA).
Theme 3: Outcomes and Factors Influencing Outcomes
- Mortality and Survival Rates: The mortality rate is 32% (16/50), with sepsis/multi-organ dysfunction syndrome (MODS) being a leading cause of death.
- Factors Influencing Outcomes: Timely intervention, diet compliance, and regular dialysis positively impact outcomes, while delayed presentation, non-compliance, and addictions (alcohol/smoking) negatively affect outcomes.
- CKD and Mortality: 16% (8/50) of patients with CKD succumbed to the disease, highlighting the importance of managing renal complications.
[15-05-2025 08:18] PPM 1: [15/05, 07:52]: Start sharp at 9:00AM even if the bus is late
Both presenters should finish by 9:40AM each getting 20 minutes.
[15-05-2025 08.29] PA: 8U Insulin
[15-05-2025 08:35] PPM 1: 👍
[15-05-2025 08:35] PPM 1: Is this mixtard?
[15-05-2025 10.36] PA: Post breakfast sugar value 261mg/dl
[15-05-2025 12.49] PA: 8U insulin. Lunch rice with curry.
[15-05-2025 13:07] PPM 1: 👍
[15-05-2025 14.52] PA: Post lunch sugar value 132mg/dl
[15-05-2025 16:55] PPM 1: 👆@CR the above two were today's presentation of this patient.
[15-05-2025 19.54] PA: 
[17-05-2025 21.17] PA: Post dinner 165mg/dl.
[15-05-2025 21.45] PA: Post dinner sugar 236mg/dl.
[15-05-2025 22:39] PPM 1: Doesn't look like it. It looks too watery? Even the vial appears to be plain insulin. Is he getting this from the government health center?
[15-05-2025 22:39] PPM 1: Can he turn the vial a little and share this image again?
[15-05-2025 22:42] PPM 2: https://www.1mg.com/drugs/humarap-40iu-ml-injection-14552
Actrapid biosimilar
[16-05-2025 07:01] PPM 1: Exactly so has the Telangana government revised it's insulin purchase and programmatic implementation policy or has this been purchased by the patient himself?
[16-05-2025 08.00] PA: Fasting sugar 114mg/dl
[16-05-2025 08:10] PPM 1: ఇది మీ దగ్గరలోని ప్రభుత్వ ఆరోగ్య కేంద్రం ద్వారా సరఫరా చేయబడిందా లేదా మీరు కొనుగోలు చేశారా?
Idi mī daggaralōni prabhutva ārōgya kēndraṁ dvārā sarapharā cēyabaḍindā lēdā mīru konugōlu cēśārā?
Has this been supplied by your nearest government health center or did you purchase this?
[16-05-2025 09:13] PA: I purchased in medical shop
[16-05-2025 09:23] PA: I have been using this for 2 to 3 days
[16-05-2025 09:26] PA: Can you tell me which insulin should I use out of these 3
[16-05-2025 10:06] PPM 1: You are asking after patient is already using one of them since 2-3 days without informing us till we noticed the colour of his syringe drawn insulin! @CR @PPM2
[16-05-2025 11:56] PPM 1: If your patient took the newly purchased plain watery insulin today you can increase the dose unlike mixtard where we were unable to increase it beyond a certain point.
How much plain watery insulin did the patient take today 2 hours before checking this blood sugar value of 270?
[16-05-2025 12:03] CR: Spoke to his relative and asked to share the details.
[16-05-2025 12:13] CR: At present the patient is taking Actrapid 9U. Should he continue or switch back to the previous one Mixtard. If so how much dosage. He couldn't get Mixtard as there was deficiency, and hence switched to Actrapid.
[16-05-2025 12:20] PPM 1: We can slowly increase actrapid dose here and add NPH twice a day to it once before breakfast and once before dinner.
Today before lunch he can take 6U of actrapid and can add 6U of NPH to it that he should have added before breakfast today
I hope he is aware that he needs to first draw the actrapid into the syringe and then later draw the NPH
[16-05-2025 12:28] CR: Actrapid is now going to be finished, so can he go back to Mixtard? Dosage?
[16-05-2025 12:42] PPM 1: Mixtard was started and sustained as a last ditch attempt at optimizing with whatever was available to him from government sources.
We need to resolve the complex dilemma (of which insulin to continue) by finding out if he can afford continuing to buy plain watery insulin along with the government supplied mixtard or NPH
[16-05-2025 13:59] CR: Patient is taking Humarap insulin since 3 Days. Asked them to mention the dosage and time of taking
[16-05-2025 14.02] PA: The patient is taking Humarap daily before breakfast 9U, and before lunch 9U.
[16-05-2025 14:11] PA: Today, Before lunch he is taking Actrapid 4.5 U Nph 4.5 U
[16-05-2025 14:27] PPM 14: Sir, the patient advocate thought 9U meant 4.5 each NPH and Actrapid, but I clarified to them regarding the dosage.
For now, they took 4.5U of actrapid and NPH, they want to know if this is okay for now and if they can start taking 6U of actrapid and NPH from tomorrow onwards.
[16-05-2025 14:32] PPM 1: That will depend on today's two hours post lunch which should be available at 16:24
[16-05-2025 16.23] PA: Post lunch 188mg/dl
[16-05-2025 16:31] PPM 1: @PPM14 best is he takes 6U watery actrapid and mixes with 6U milky NPH tomorrow at breakfast and again takes 6U actrapid before lunch tomorrow and 6U tonight before dinner
[16-05-2025 16:54] PPM 14: No NPH at dinner tonight sir?
[16-05-2025 16:56] PPM 1: Oh sorry! Yes NPH at dinner too
[16-05-2025 16:57] PPM 14: Okay sir, will let them know.
[16-05-2025 20:16] PPM 14: Sir, I was not able to contact them before the patient’s dinner today, despite calling them. They are asking about tomorrow’s insulin dose.
[16-05-2025 21.16] PA: Post dinner sugar 198mg/dl
[16-05-2025 21:28] PPM 1: How much insulin taken before dinner today?
[16-05-2025 21:29] PPM 1: Tomorrow's dose was mentioned above?
[16-05-2025 21:29] PPM 14: They did not take this dose sir
[16-05-2025 21:30] PPM 1: Alright. Looks good without too
[16-05-2025 21:31] PPM 14: Okay sir, will re-inform them about this
[17-05-2025 06.24] PA: Fasting sugar 117mg/dl
[17-05-2025 08:26] PA: 6 units Actrapid 6 units NPH
[17-05-2025 08:32] PPM 1: 👍
[17-05-2025 10.32] PA: Post breakfast sugar 242mg/dl
[17-05-2025 12:33] PPM 1: @PPM14 tomorrow we can slightly increase the actrapid by +2 before breakfast. Let's keep a close watch for the two hour post lunch and dinner today
[17-05-2025 15.07] PA: Post lunch 163mg/dl.
[17-05-2025 16:03] PPM 1: 👍
[17-05-2025 19:12] PA: 6U Actrapid 6U NPH
[17-05-2025 19:32] PPM 1: 👍
PPM 1: 👍
[18-05-2025 07.50] PA: Fasting 103mg/dl
[18-05-2025 08:08] PA: Dr sar ninnatimadiri vadavalayuna telpagalaru inslin
[18-05-2025 08:46] PA: 6.5U Actrapid 6.5U NPH
[18-05-202510.55] PA: Post breakfast 165mg/dl
[18-05-2025 11:26] PPM 1: 👍
[18-05-2025 12:02] CR: Translation: Should the patient continue with the same dosage as yesterday. Please advise
[18-05-2025 12:35] PA: 7U actrapid
[18-05-2025 15.20] PA: Post lunch 130mg/dl
[18-05-2025 16:36] PPM 1: Yes but he appears to be increasing the dose by 0.5U himself today?
[18-05-2025 17:05] CR: He says @PPM14 asked him to increase. Now informed him to take 6.5 as per your advice.
[18-05-2025 17:11] PPM 14: Sir I was travelling today so I was not able to answer his call when he did, but yesterday I told him about Actrapid, not NPH as per this
[18-05-2025 17:25] PPM 1: No issues. His control is quite good today.
[18-05-2025 20.06] PA: 6.5U Actrapid, 6.5U NPH
[18-05-2025 20.08] PA: Dinner ragi with curry
[18-05-2025 20.54] PPM 1: 👍
[18-05-2025 22.17] PA: Post dinner sugar 106mg/dl.
[19-05-2025 08.42] PA: Fasting sugar 115mg/dl. 6.5U Actrapid 6.5U NPH
[19-05-2025 09:45] PPM 1: 👍 just 6+6 should be enough
[19-05-2025 12:24] PA: 6.5.u actrapid
[19-05-2025 12:43]CR: Informed him.
[19-05-2025 18.28] PA: 211mg/dl, 6U Actrapid, 6U NPH, Ragi for dinner.
[19-05-2025 19.12] PA: 6U Actrapid 6U NPH
[19-05-2025 21.30] PA: Post dinner sugar 136mg/dl.
PPM 1: 👍
[20-05-2025 08:27] PA: Actrapid 6 u and 6u Nph
[20-05-2025 09:59] PPM 1: 👍
[20-05-2025 10.37] PA: Post breakfast 194mg/dl
[20-05-2025 12:55] PA: Actrapid. 6U
[20-05-2025 15.27] PA: Post lunch 125mg/dl
[20-05-2025 15:50] Rakesh Biswas Sir: 👍
[20-05-2025 19.25] PA: 6U Actrapid and 6U NPH, Dinner ragi with egg curry.
[20-05-2025 19.40] PPM 1: 👍
[20-05-2025 21.37] PA: Post dinner 192mg/dl.
[21-05-2025 07.24] PA: 114mg/dl
[21-05-2025 07:30] PA: Actrapid u 6 and u 6 nph
[21-05-2025 08:08] PPM 1: 👍
[21-05-2025 09.38] PA: 182mg/dl
[21-05-2025 12:09] PA: Actrapid 6U
[21-05-2025 14.18] PA: 187mg/dl
[21-05-2025 16:29] PPM 1: 👍
[21-05-2025 18.41] PA: The patient's sugar has dropped to 60mg/dl and he is experiencing discomfort and weakness, should he take his pre dinner insulin dose?
[21-05-2025 19.34] PPM 1: From tomorrow morning reduce dose to 4U + 4U in the morning in view of today evening's hypoglycemia.
Can withhold tonight's dose.
[21-05-2025 19.59] PA: Okay doctor. Dinner ragi with curry.
[22-05-2025 07.52] PA: Fasting sugar 116mg/dl, 4U Actrapid, 4U NPH, Ragi roti and chutney for breakfast.
[22-05-2025 08:19] PPM 2: Apart from the food plate, I also see a touch of diabetic amyotrophy here?
[22-05-2025 08:29] PPM 1: Also visible in the morphologic phenotype images logged by @CR in the case report available in the description box
[22-05-2025 10.36] PA: 2 hrs after breakfast 243mg/dl
[22-05-2025 12:15] PA: Actrapid u 4
[22-05-2025 14.27] PA; Post lunch sugar 188mg/dl
[22-05-2025 18.46] PA: 4U actrapid and 4U NPH, dinner ragi roti with dal
[22-05-2025 21.02] PA: Post dinner sugar value 160mg/dl
[22-05-2025 21.33] PPM 1: 👍
[23-05-2025 08.01] PA: Fasting sugar 127mg/dl, Actrapid 3U + 3U NPH
[23-05-2025 08:17] PPM 1: 👆@CR yesterday with 4+4 it was 247 and it needed to have been at least kept the same today if not increased but it appears to have been further reduced to 3+3 today! Wonder why?
[23-05-2025 09:21] PPM 1: Is there no way one can automatically convert his voice messages to typed text? @PPM15 @PPM2
[23-05-2025 10:58] PPM 15: Do you see the transcribe link below the message? Meta AI does it noe
[23-05-2025 10:59] PPM 14: Trying transcribe now, seems to be a hard audio
[23-05-2025 11:03] PPM 1: Sometimes when I accidentally click on something in the WhatsApp interface it sends me a message saying voice isn't allowed but I guess it's just an isolated error quirk.
Yes I guess we can look forward to auto voice transcribe by WhatsApp sometime in the near future
[23-05-2025 11:39] PPM 15: Yikes it didn't get it at all.. what language was it?
[23-05-2025 11:44] PPM 15: మున్ను సంవత్సరా ఒక ఉండ్డ్ గ్రాత్ పోల్లా మల్లా సంవత్సరం ఉత్తిని.
మున్టి కాత్తకు, నేడి గాబర గాబర ఈంది, అదు తర్వాతా శక్కర ఏస్కున్నా, ఇంత సాలానం ఉంటే తీన్నా.
ಬಯಮ ಇಸಿ ಇಯಾಲಾ ಮಂಡ ಮಂಡ ತಿಸಕಂಟಿ ಇಂದನಾ, ತಿಸಕಂಟಿ ಇಂದನಾ, ಮರಿಯಾ ಅತನಾ ಇಂಕರಿಜನಾ, ಏದಿ ಸಈಯವಾಟರ�
[23-05-2025 11:44] PPM 15: This is what chatgpt got when I played it to it
[23-05-2025 12:10] CR: Yesterday night he felt weak and with sweating he thought sugar levels dropped and decided. I asked him not to change the dosage without consulting you, doctor.
[23-05-2025 12:26] PPM 1: Alright.
If he had checked his sugars that time it would have been clearer but I can understand the constraints of repeated checking
Either way his fasting sugars were good and didn't perhaps merit insulin dose reduction but then what is his two hour post insulin (3+3) blood sugars which was supposed to be done and shared by 10:00AM?
[23-05-2025 12:32] CR: No sugar strips
[23-05-2025 12:39] PPM 1: Not bad!
I could make out the part about his feeling palpitations and then taking sugar to counter a presumed hypoglycemia!
Here's the transliteration :
Munnu sanvatsarā oka uṇḍḍ grāt pōllā mallā sanvatsaraṁ uttini.
Munṭi kāttaku, nēḍi gābara gābara īndi, adu tarvātā śakkara ēskunnā, inta sālānaṁ uṇṭē tīnnā.
Bayama isi iyālā maṇḍa maṇḍa tisakaṇṭi indanā, tisakaṇṭi indanā, mariyā atanā iṅkarijanā, ēdi sa'īyavāṭara
[23-05-2025 13:15] PA: Actrapid 4U
[23-05-2025 19:15] PA: Actrapid 4U + 4 NPH
[23-05-2025 20:07] PPM 1: 👍
[23-05-2025 21.50] PA: Post dinner sugar value 218mg/dl.
[24-05-2025 08.16] PA: 116mg/dl, Actrapid 4U NPH 4U
[24-05-2025 10:11] PPM 1: 👆Tonight he can take actrapid 6U and NPH 4U @CR
[24-05-2025 10.32] PA: 210mg/dl
[24-05-2025 12:28] CR: Okay
[24-05-2025 12:39] CR: Before lunch only 4U Actrapid, no NPH? Is his doubt. Please advise. Before dinner 6U Actrapid and 4U NPH.
[24-05-2025 13:18] PPM 1: Yes
No NPH before lunch. Long acting NPH is taken only twice a day
4U or 6U actrapid doses cab be adjusted depending on his two hour post meal sugars
[24-05-2025 13:23] CR: Informed
[24-05-2025 14.50] PA: 187mg/dl
[24-05-2025 19:30] PA: Actrapid 6U NPH 4U
[24-05-2025 19.55] PPM 1: 👍
[24-05-2025 21.50] PA: 186mg/dl
[25-05-2025 07.21] PA: Fasting sugar 106mg/dl
[25-05-2025 07:24] PPM 1: Oh didn't see this earlier.
Let's not increase tonight's NPH. Let's keep it to Actrapid 6U and NPH 4U @CR
[25-05-2025 07:25] PPM 1: Today's before breakfast can be actrapid 6U and NPH can remain at 4U
[25-05-2025 07:53] PA: Actrapid 6U +4 NPH
[25-05-2025 10.06] PA: Post breakfast 223mg/dl
[25-05-2025 12:12] CR: Thank God, he understood. I repeatedly told him to check with the units even if he doesn't understand the text.
[25-05-2025 13:14] PA: Actrapid 4U
[25-05-2025 19.17] PA: Actrapid 6U NPH 4U
[25-05-2025 21.36] PA: Post dinner 185mg/dl
[26-05-2025 02.48] PA: Fasting sugar 49mg/dl
[26-05-2025 07:02] PPM 1: 👆How much insulin was taken at night?
[26-05-2025 07:30] PPM 1: 👆was it this dose of 6U 4U @CR
[26-05-2025 08.22] PA: 135mg/dl
[26-05-2025 08:33] PA: Actrapid 6U NPH 4U
[26-05-2025 08:34] PPM 1: What was yesterday's night dose of insulin that the patient took?
[26-05-2025 10:52] PA: Actrapid 6U + 4 NPH, Post breakfast 281mg/dl
[26-05-2025 11:17] CR: Yes doctor
[26-05-2025 12:33] PPM 1: Then we need to omit night NPH tonight. Only actrapid can be taken 4U at night.
[26-05-2025 15.00] PA: 208mg/dl
[26-05-2025 17:36] CR: Only for today?
[26-05-2025 19.47] PA: Actrapid 4U
[26-05-2025 20:33] PPM 1: Yes
[26-05-2025 20:34] PPM 1: For tomorrow and subsequent days we will decide after tomorrow's fasting
[26-05-2025 20:35] CR: Informed him
[26-05-2025 20.49] PA: Post dinner 219mg/dl
PPM 1: 👍
[27-05-2025 08.52] PA: 155mg/dl, Actrapid 5U NPH 4U.
[27-05-2025 09:09] PPM 1: 👍
[27-05-2025 11.12] PA: 262mg/dl
[27-05-2025 12.37] PA: Actrapid 6U, Lunch rice with curry
[27-05-2025 14.40] PA: 214mg/dl
[27-05-2025 16:30] PPM 1: @CR from tomorrow he can make all his actrapid insulins increased by+2
[27-05-2025 16:50] CR: At present he is taking 6. Now he should take 8U. Then NPH 4U to continue?
[27-05-2025 16:51] PPM 1: Yes
[27-05-2025 18:59] PA: 6U Actrapid,4U NPH
[28-05-2025 07.58] PA: 140mg/dl
[28-05-2025 08.26] PA: Actrapid 8U NPH 4U
[28-05-2025 08:36] PPM 1: 👍
[28-05-2025 12.56] PA: Actrapid 6.5U
[28-05-2025 13:15] PPM 1: He's also sharing the pics but not checking carefully to see if the numbers are visible
[28-05-2025 13:16] CR: Yes doctor, that's what I told him.
[28-05-2025 16:58] PPM 1: Just 5U would have been fine for this lunch. Let's see how the other outcomes of the +2 increment work out today but we can even think of not going up by +2 for tonight's dinner as planned yesterday
[28-05-2025 17:00] PPM 1: 👆the blood sugar wasn't checked following this breakfast today? @CR
[28-05-2025 17:07] CR: He was not at home to check his blood sugars. He was telling that by increasing actrapid by 2U would lower his sugar level.
[28-05-2025 20.11] PA: Blood sugar is 51mg/dl
[28-05-2025 20:12] PPM 1: Let him have his dinner with 2U of NPH only
[28-05-2025 20:13] PPM 1: Is he having any symptoms?
[28-05-2025 20:14] PPM 1: He was right
[28-05-2025 20:17] PPM 1: Instead of +2, it should have been a +1 or+0.5U increment for him
[28-05-2025 20:20] CR: Actually should he take insulin with this sugar level?
[28-05-2025 20:21] CR: He is feeling uneasy and sweating.
[28-05-2025 20.39] PA: NPH 2U
[28-05-2025 20:42] PPM 1: NPH is for tomorrow's breakfast
[28-05-2025 20:42] PPM 1: Has he eaten?
[28-05-2025 20:43]CR: He has taken only NPH 2U
[28-05-2025 20:43] PPM 1: Yes just to be on the safer side
[28-05-2025 20:44] CR: Without adding actrapid?
[28-05-2025 20:45] PPM 1: Yes actrapid is only for his dinner and may not be required now. Let's check after his dinner
[28-05-2025 20:46] CR: Okay, he understood better than me😊
PPM 1: 👍
[29-05-2025 07.56] PA: 102mg/dl
[29-05-2025 08.39] PA: Actrapid 6U and NPH 4U
[29-05-2025 08.57] PPM 1: 👍
[29-05-2025 10.45] PA: 161mg/dl
[29-05-2025 12.03] PA: Actrapid 4U NPH 4U
[29-05-2025 14.02] PA: 157mg/dl
[29-05-2025 19.47] PA: NPH 4U
[29-05-2025 22.09] PA: 300mg/dl
[30-05-2025 07.05] PA: Blood sugar 111mg/dl
[30-05-2025 08.04] PA: Actrapid 5U and NPH 4U
[30-05-2025 08:51] PPM 1: 👍@CR yes he appears to have understood and learned very well and his outcomes are improving.
@PPM15 @PPM16 @PPM14 this is the true goal of all our PaJR work, which is to demonstrate a positive correlation between our learning outcomes with the patient's illness outcomes and we are grateful to many of our patients (including this one) for enabling us to demonstrate that.
[30-05-2025 10.17] PA: 246mg/dl
[30-05-2025 11:07] PPM 1: @CR +1 increment in plain watery insulin to be done. NPH need not be increased.
[30-05-2025 12:35] PA: Actrapid 4U+4U NPH
[30-05-2025 19:34] PA: NPH 4U
[30-05-2025 19:37] PPM 1: Can take 4U Plain actrapid insulin also before dinner today because yesterday post dinner was 300.
[30-05-2025 20:51] CR: Tried calling him in the morning many times but couldn't reach. He has taken only 4U NPH as he felt uneasy and said that yesterday dinner he had rice and also ragi and hence blood sugar was 300.
[30-05-2025 21.27] PPM 1: Alright.
[30-05-2025 21.43] PA: Post dinner blood sugar 257mg/dl.
[31-05-2025 07.54] PA: Fasting blod sugar 106mg/dl
[31-05-2025 08.43] PA: Actrapid 5U NPH 5U
[31-05-2025 08:59] PPM 1: From tomorrow he can reduce his NPH before breakfast by 1
So tomorrow Plain 4, NPH 4
[31-05-2025 11.03] PA: Post breakfast blood sugar 108mg/dl
[31-05-2025 11:21] PPM 1: Too well controlled. 4+4 would be safer
[31-05-2025 12:15] PA: Actrapid u 3.5+3.5nph
[31-05-2025 12:24] PPM 1: Why NPH again before lunch?😳
[31-05-2025 12:27] PPM 1: If he's taking NPH before breakfast and lunch he needs to skip his night NPH tonight @CR
[31-05-2025 12:34] CR: Informed him.
[31-05-2025 18:35] CR: Post lunch is 195mg/dl. Should he take only Actrapid or both 4U?
[31-05-2025 19.15] PA: Actrapid 4U only
[31-05-2025 21.10] PA: Post dinner 204mg/dl
[01-06-2025 07.17] PA: Fasting sugar 122mg/dl
[01-06-2025 08:22] PA: Now before breakfast, can you please kindly let me know if I have to take both Actrapid 5 units and NPH 5 units? Or any change?
[01-06-2025 09:45] PPM 1: NPH can only be taken twice a day max and because of his renal failure we can even restrict it to once in this patient
[01-06-2025 09:46] PPM 1: Why NPH 10U? Please don't take NPH again today for the whole day
[01-06-2025 09:47] PPM 1: Oh it's added 5+5 I guess. Should be okay
[01-06-2025 09:54] PA: Yes, it includes Actrapid 5 units + NPH 5 units.
[01-06-2025 10.42] PA: 247mg/dl
[01-06-2025 10:45] PPM 1: This patient's NPH can remain at 5U and only the actrapid insulin can be titrated at +/- 1
[01-06-2025 19.12] PA: Actrapid 5U, dinner rai dosa with chutney
[01-06-2025 20:44] PPM 1: 👍
[02-06-2025 07.04] PA: Fasting blood sugar 111mg/dl. Actrapid 5U NPH 5U
[02-06-2025 07:47] PPM 1: 👍
[02-06-2025 09.40] PA: 268mg/dl
[02-06-2025 12.13] PA: Actrapid 5U NPH 4U, lunch rice with curry
[02-06-2025 14.16] PA: 154mg/dl
[02-06-2025 18.50] PA: Actrapid 5U, dinner ragi with chutney.
[02-06-2025 20.52] PA: 209mg/dl
[03-06-2025 07.17] PA: Fasting blood sugar 134mg/dl
[03-06-2025 08.04] PA: Actrapid 6U NPH 5U
[03-06-2025 08.52] PPM 1: 👍
[03-06-2025 15.11] PA: 235mg/dl
[03-06-2025 16:47] PPM 1: Insulin dose before lunch?
[03-06-2025 19.54] PA: Actrapid 5U
[04-06-2025 07.44] PA: 118mg/dl, Actrapid 6U NPH 6U, breakfast ragi dosa
[04-06-2025 10.01] PA: 209mg/dl
[04-06-2025 10:31] PPM 1: @CR his NPH need not be increased. Can keep at 5 as he also has CKD. He can increase his plain actrapid insulin
[04-06-2025 10:31] PPM 1: 👆this is largely the effect of 6U of actrapid and yesterday's NPH
[04-06-2025 12.14] PA: Actrapid 4U NPH 4U, linch rice with curry.
[04-06-2025 12:24] CR: How much Actrapid to be increased?
[04-06-2025 14.12] PA: 140mg/dl
[04-06-2025 16:30] PPM 1: Never more than +1 as discussed earlier that too only if the previous day's sugars at the same time were above 200
[04-06-2025 19.43] PA: Actrapid 4U only, dinner ragi dosa with curry
[04-06-2025 21.56] PA: 181mg/dl
[05-06-2025 07.35] PA: 133mg/dl, actrapid 6U NPH 6U, ragi breakfast.
[05-06-2025 09.57] PA: 205mg/dl.
[05-06-2025 10:45] PPM 1: @CR he should not be increasing the NPH any further. He can only increase actrapid by 0.5U if necessary. Currently no further increase is necessary
[05-06-2025 12.03] PA: Actrapid 4+4nph
[05-06-2025 12:07] PPM 1: Oh again why NPH before lunch!?
[05-06-2025 12.20] PA: LEVETIRACETAM TABLETS 500
[05-06-2025 12:26] CR: Spoke to him about NPH. The above medicine was given for imbalance when he was recently admitted in our hospital. He is asking whether to continue or stop. Taking since one month.
[05-06-2025 13:07] PPM 1: That is generally given for seizure! Unable to recall if he ever had seizures and if it was really necessary! It's also an expensive medicine that becomes even more problematic especially if it's unnecessary!
How many times a day is he taking it? It needs to be stopped gradually by stopping one if taking twice a day and then taking that one for a few days and then again on alternate days for a few days before stopping altogether
[05-06-2025 13:11] CR: Informed
[05-06-2025 19.58] PA: Actrapid 5U only, Ragi dosa with chutney for dinner.
[06-06-2025 06.56] PA: 111mg/dl
[06-06-2025 08.17] PA: Actrapid 6U NPH 5U, Ragi with chutney for breakfast.
[06-06-2025 09:42] PPM 1: 👍
[06-06-2025 09:43] 30F PA: May I know, What is this? In the left side?
[06-06-2025 09:47] PPM 1: Ragi java
A mixture of grounded ragi although originally they may have mixed barley too as java in Sanskrit stands for barley which is one of the most ancient grains consumed by mankind
[06-06-2025 09:51] 30F PA: And it seems like kheer... Grounded ragi boiled in water or milk?
[06-06-2025 11:20] PPM 1: Yes without sugar
[06-06-2025 11:21] 30F PA: Okay Thank you
[06-06-2025 12:01] PA: Actrapid 4u+4 u nph
[06-06-2025 12:35] PPM 1: 👍
[06-06-2025 12:40] CR: Is it okay doctor, NPH before lunch? @PPM1Sir
[06-06-2025 12:45] PPM 1: He was kind of doing that previously with his mixtard as well and his outcomes appeared to be okay so as @PPM2 and @PPM15 and @PPM4 would appreciate, from a patient outcomes data driven perspective he's leading us on the right track perhaps
[06-06-2025 12:56 PPM 4: Based on your description, *caution is warranted* when interpreting past outcomes with Mixtard insulin as evidence for current decisions. Here's a data-driven perspective:
### Key Concerns:
1. *"Appeared okay" ≠ Robust Evidence*
Subjective impressions or short-term stability ≠ long-term safety/outcomes. Diabetes management requires objective metrics (HbA1c trends, hypoglycemia rates, complications).
2. *Mixtard's Limitations*
- Fixed-ratio insulin (e.g., 70/30) offers *limited flexibility* vs. basal-bolus regimens.
- Higher risk of *hypoglycemia* (especially afternoon/evening) and suboptimal postprandial control.
- Modern guidelines favor *basal insulin + tailored mealtime dosing* for most T2DM patients needing intensification.
3. *Survivorship Bias*
Past "okay" outcomes may reflect patient-specific factors (e.g., residual beta-cell function, lifestyle) — not generalizable safety/efficacy.
---
### Data-Driven Recommendations:
- *Audit Outcomes:*
Compare *current vs. past clinical metrics*: HbA1c, hypoglycemia events, weight, variability (CGM data if available).
- *Risk Assessment:*
Evaluate if Mixtard increases hypoglycemia risk (especially if erratic schedules/comorbidities exist).
- *Guideline Alignment:*
Refer to ADA/EASD 2025: Basal insulin first → add GLP-1 RA → *only consider premixed if other options fail* (due to safety/titration challenges).
- *Patient-Centered Goals:*
Discuss flexibility, injection burden, and safety preferences with the patient.
---
### Bottom Line:
While past stability is reassuring, *transitioning to modern regimens often optimizes outcomes*. If insisting on premixed insulin:
✅ *Demand structured data* (not anecdotes).
✅ *Document shared decision-making* acknowledging risks.
✅ *Monitor rigorously* for hypoglycemia.
— but current evidence strongly favors more flexible approaches.
[06-06-2025 16.22] PPM 1: The LLM didn't get the entire context of this patient.
It's unfortunately in a very long drawn TLDR archived in his case report link.
[06-06-2025 16.49] PPM 2: I agree yes.
[06-06-2025 19.37] PA: Actrapid 4U only, dinner ragi dosa with chutney.
[07096-2025 07.51] PA: Fasting blood sugar 109mg/dl, actrapid 5U NPH 5U. breakfast ragi with chutney.
[07-06-2025 12.13] PA: Actrapid 5U only., lunch rice with dal
[07-06-2025 14.36] PA: Post lunch blood sugar 163mg/dl
[07-06-2025 18.56] PA: Actrapid 3.5U 3.5U NPH, breakfast ragi with chutney.
[08-06-2025 07.06] PA: 117mg/dl, Actrapid 5U NPH 5U, breakfast ragi.
[08-06-2025 10.17] PPM 1: 👍
[08-06-2025 12.01] PA: Actrapid 4U, lunch rice with curry.
[08-06-2025 18.50] PA: Actrapid 4u and 4 nph, dinner ragi with chutney
[08-06-2025 21.03] PA: 157mg/dl
PPM 1: 👍
[09-06-2025 06.53] PA: Fasting blood sugar 124mg/dl, Actrapid 5U NPH 5U, ragi for breakfast.
[09-06-2025 12.06] CR: Doctor he wants to eat goat meat and mango. Was asking whether he can eat?
[09-06-2025 12.23] PA: Actrapid 5U only, lunch rice with curry
[09-06-2025 19.05] PA: Actrapid 4U NPH 4U, dinner ragi with chutney
[10-06-2025 07.14] PA: 103mg/dl, actrapid 5U NPH 5U, breakfast ragi.
[10-06-2025 09.21] PPM 1: 👍
[10-06-2025 11.58] PA: Actrapid 5U, lunch rice with curry.
[10-06-2025 16:50] PPM1: 👍
[10-06-2025 18.52] PA: Actrapid 4U NPH 4U, dinner ragi with chutney
[11-06-2025 06.56] PA: Fasting sugar 106mg/dl
[11-06-2025 07:01] Rakesh Biswas Sir: 👍
[11-06-2025 07.52] PA: Actrapid 5U NPH 5U, breakfast ragi with curry👍
[11-06-2025 12.34] PA: Actrapid 5U only, lunch rice with curry
[11-06-2025 20.15] PA: Actrapid 4U NPH 4U, dinner ragi with curry
[11-06-2025 21:12] PPM 1: 👍
[12-06-2025 07.24] PA: Actrapid 4u and 4 nph, breakfast ragi with curry
[12-06-2025 12.01] PA: Actrapid 4u only, Lunch rice with coccinia
[12-06-2025 14:49] PPM 1: 👍
[12-06-2025 18.59] PA: Actrapid 4u and 4 nph, Dinner ragi with curry
[13-06-2025 06.46] PA: Fasting sugar 109mg/dl
[13-06-2025 07.23] PA: Actrapid 4U NPH 4U, breakfast ragi
[13-06-2025 09.18] PPM 1: 👍
[13-06-2025 10.22] PPM 17: Ragi?
[13-06-2025 12.14] PA: Actrapid 4U only, lunch rice with dal.
[13-06-2025 18.56] PA: Actrapid 4U and 4U NPH, Dinner ragi with chutney
[13-06-2025 19.36] PPM 1: 👍
[14-06-2025 06.46] PA: 106mg/dl
[14-06-2025 06.58] PA: Actrapid 4U NPH 4U, breakfast ragi with pickle.
[14-06-2025 10.07] PPM 1: 👍
[14-06-2025 11.51] PA: Actrapid 4U only, lunch rice with curry
[14-06-2025 17.09] PPM 1: 👍
[14-06-2025 19.14] PA: Actrapid 4U NPH 4U, dinner ragi with gravy curry
[15-06-2025 06.57] PA: 100mg/dl.
[15-06-2025 07.29] PA: Actrapid 4U NPH 4U, breakfast ragi and chutney
[15-06-2025 10.39] PPM 1: 👍
[15-06-2025 12.16] PA: Actrapid 2U, lunch rice with curry
[15-06-2025 19.00] PA: Actrapid 4U and NPH 4U, dinner rice with curry.
[16-06-2025 06.29] PA: Fasting blood sugar 85mg/dl
[16-06-2025 06.59] PA: Actrapid 3.5U NPH 3.5U, breakfast ragi with chutney.
[16-06-2025 11.46] PA: Rice with curry
[16-06-2025 19.25] PA: Sorghum paste with curry for dinner
[16-06-2025 22.03] PA: Actrapid 4u only
[17-06-2025 10.45] PA: Actrapid 2U NPH 2U
[17-06-2025 12.21] PA: Actrapid 2U, lunch rice with curry
[17-06-2025 12:58] CR: @PPM1 Doctor, this patient is having giddiness and feeling uneasy since 3 -4 days. As the blood sugar levels dropped, he is reducing the insulin dosage. He wants to meet you for consultation.
[17-06-2025 14:40] PPM 1: Alright.
It would have been nice if he had started seeing his blood sugars as soon as he started feeling giddy and then we could have optimised the dose here
[17-06-2025 19:34] PPM 1: Share the blood sugar after 2 hours and fasting tomorrow
[17-06-2025 20:02] PA: The strips used for testing sugar levels are completed sir.. And these are not available in my Village.. I'll try get them from Nalgonda tomorrow and share you.
[17-06-2025 20:05] PA: I remember when sugar levels is around 70 I'm feeling giddiness.... Kindly let me know if any medicine for this giddiness problem? Or do I need to come to hospital to meet you?
[17-06-2025 20:48] PPM 1: Unless you check his sugars and confirm that his giddiness is indeed due to sugar levels of 70 it would be difficult to draw any inferences based on these subjective thoughts.
However if it's just giddiness due to any other reason such as cerebral vasculopathy which was the reason for his last hospital admission with us, then he can take tablet promethazine theoclate 25 mg thrice daily for 2 days.
Please share what are the other medicines he's currently taking regularly for his stroke
[18-06-2025 08.31] PA: Actrapid 3U NPH 3U breakfast curd rice
[18-06-2025 15.34] PA: Actrapid 3U and lunch rice with cabbage curry.
[19-06-2025 06.59] PA: 108mg/dl
[19-06-2025 07.54] PA: Actrapid 3U NPH 3U, breakfast sorghum paste and chutney.
[19-06-2025 11.24] PA: Actrapid 3U, lunch rice with curry.
[19-06-2025 13.46] PPM 1: 👍
[19-06-2025 15.48] PPM 18: @PPM1 sir Patient has come to OPD sir
Follow up
With complaints of giddiness since 1month sir
No h/o tinnitus / decreased hearing
No nystagmus
No cerebellar signs
Has taken tab cinnarizine 25mg bd for 2days
And has taken promethazine 20mg tablet today morning
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