80M DIABETES, HYPERTENSION 30YRS, CKD 13YRS.TELANGANA.PAJR
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
10-11-2024
11-11-2024
13-11-2024 
20-11-2024
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