59F DIABETES 10YRS, RENAL FAILURE 10 MONTHS, UNCONTROLLED BLOOD SUGARS 10 DAYS. TELANGANA PAJR.
04-11-2024
This is an online E Log book to discuss our patient's de-identified health data shared after taking her signed informed consent.
Here we discuss our patient's 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.
In this case the patient is 59 Yr old female with Diabetes since 10yrs. She is also suffering with Renal failure since 10 months. Since 10 days her blood sugars are uncontrolled and was advised to be admitted in the hospital.
PPM 3 - Did you check the morning sugars?
PA - No madam. Will check in the evening.
06-11-2024
PPM 1 - What is the current treatment for her diabetes that she's on?
PPM 3 - 6U actrapid TID sir.
PPM 1 - Let's make it 8U TID from today. What's her Serum Creatinine?
PPM 3 - Creatinine 2 sir.
PA - Sugar value is 405
PPM 1 - Thrice and ask them to share the blood sugars 2hrs after every meal today thrice.
PPM 3 - @PA please give the patient 8U and share the sugar values 2 hrs of taking food.
PA - Okay madam.
PPM 1 - 👍
PA
PPM 1 - After 8U @PPM3?
PPM 3 - Yes sir
07-11-2024
PA - Fasting sugar
PPM 3 - What was the sugar value yesterday afternoon and night?
PA - 400 madam
PPM 3 - How much Insulin did you give?
PA - 8U
PPM 3 - 👍. Give 10U.
PA - Okay
PPM 3 - Did you check sugar levels 2 hrs after food?
08-11-2024
PA - 368
PPM 3 - Give 12U actrapid.
PA - Okay madam
PPM 1 - Please share her entire Insulin dose regime provided yesterday.
PPM 3 - 10U TID sir.
PPM 1 - Serum Creatinine? So 12U TID today?
PPM 3 - Creatinine 2 sir.
They are able to monitor GRBS only in the morning sir.
PPM 1 - While we are attempting to change the regular insulin dose in +2 increments isn't it mandatory for them to monitor it atleast 2hrs after every input?
Can they afford a CGM device?
PPM 3 - PA is not available all the time to check the sugars as he has to go for work.
So only Fasting sugars are checked.
PPM 1 - Who else is there in her house? @PPM4 current system challenges for you to talk about on 28th! Perhaps @PPM3 may also like to attend and share her PaJR experience and other patients there?
09-11-2024
PA -
PPM 1 - Fasting?
@PPM3 he needs to check her 3 am blood sugar to rule out Somogyi!
PPM 3 - OK Sir, but now shall we continue with 12U or increase to 14U sir?
PPM 2 - Somogyi has been reliably discredit and disproved. Only learnt it recently myself. It's always Dawn's apparently.
PPM 1 - The fasting is high either because she had nocturnal hypoglycemia or she needs additional NPH at night!
For deciding the pre breakfast Insulin you need to look at yesterday's two hours post breakfast values assuming the other variables like diet and exercise are constant. Till then it may be safer to continue 12U.
PPM 2 - Can they afford analog Insulin Sir? Lantus or Semglee?
PPM 1 - @Meta AI share one paper that suggests nocturnal hypoglycemia is not a major reason for fasting hyperglycemia citing valid searchable references and sharing their data in PICO format taking care to share only the absolute values.
Meta AI- Here's a paper that suggests "Nocturnal Hypoglycemia is not a major reason for fasting Hyperglycemia paper"
Nocturnal hypoglycemia does not predict fasting hyperglycemia in type I Diabetes by Danne. et.al. (2013), Reference- Danne.,T.,Kordonouri, O & Holder, M(2013).
Nocturnal hypoglycemia does not predict fasting hyperglycemia in type I Diabetes.
Journal of Clinical Endocrinology and Metabolism, 98(11), 4336-4342.doi 10.1210Ijc 2013-2341.
PICO FORMAT:
P (Population): 127 patient's with type I Diabetes.
I (Intervention): Continuous glucose monitoring (CGM) for 14 days.
C (Comparison): None
O (Outcome): Incidence of nocturnal hypoglycemia (<70mg/dl) and fasting hyperglycemia (>130mg/dl).
DATA:
•27% of patients experience nocturnal hypoglycemia.
•55% of patients had fasting hyperglycemia.
•No significant correlation between nocturnal hypoglycemia and fasting hyperglycemia (r=0.12, p=0.17).
This study suggests that nocturnal hypoglycemia is not a major predictor of fasting hyperglycemia in patients with type I Diabetes.
PPM 1 - @Meta AI The study design isn't too inspiring to make such a claim in the title.
Meta AI- You are right , the study design and results may not entirely support the titles conclusive claim. Here's why.
1. OBSERVATION STUDY:
The study is observational which makes it difficult to establish causality.
2. Small sample size:127 patients is a relatively small sample size for making broad conclusions.
3. Short Duration: 14 day CGM monitoring may not capture long term patterns.
4. Correlation vs causation: The lack of significant correlation(r=0.12) doesn't necessarily rule out nocturnal hypoglycemia's impact on fasting hyperglycemia.
Definitions: The thresholds for nocturnal hypoglycemia (<70mg/dl) and fasting hyperglycemia (>130mg/dl) might be debated.
A more nuanced title might reflect the study's limitations and findings, e.g.
"Nocturnal Hypoglycemia Not Strongly Associated with Fasting Hyperglycemia in Type I Diabetes A 14 Day CGM Study".
PA - Sir the patient is having fever. She is feeling very weak and no relief with Dolo 650.
PPM 3 - How much is the GRBS?
PA - Not checked.
PPM 1 - Ask the PA to check her temperature every 4hrs and share here.
PA - At this hour in the night no RMP is available as it is village.
PPM 1 - Every pharmacy has a digital thermometer that the PA can purchase.
10-11-2024
PA - Fasting sugar is 590.
PPM 3 - Please give the patient 14U now before breakfast.
PA - OK madam.
PPM 1 - Please ask him to share the sugars 2hrs after the 14U.
PA - 👍
PA - Isophane
PPM 3 - Explained to them sir.
PPM 1 - 👍
PPM 3 - Did you check the sugars @PA?
PA -
Sugar level. Post lunch.
She is having fever. Tomorrow should we bring her to the hospital?
PPM 3 - 👍
PPM 1 - When was this NPH and repeat actrapid given?
PPM 3 - 10.45am
PPM 1 - Sugars not checked at 1.45pm? How much Insulin given before lunch? What time was lunch?
PPM 3 - Before lunch what was the dose of Insulin?
11-11-2024
PA -
Fasting sugar level.
PPM 1 - What was the Insulin dose before breakfast, before lunch, before dinner?
Insulin actrapid 10U +Insulin isophane NPH 6U after giving please share blood sugars after 2hrs.
PA - 14U sir. We are coming to the hospital. The patient is having temperature.
PPM 3 - Please give 6U isophane Insulin also.
PA - 👍
PPM 1 - @PPM3 she needs admission in AMC and fever charting 4hrly alongwith hemogram, urine CUE and blood and urine culture sensitivity.
PPM 1 - @PPM3 she needs admission in AMC and fever charting 4hrly alongwith hemogram, urine CUE and blood and urine culture sensitivity.
PPM 3 - OK Sir.
PA - We are at the hospital. Where should the patient be admitted?
PPM 4 - Please take the OP slip and go to room 76.
PPM 1 - 👍 who is our PG in the OPD currently? Anyone in this group?
PPM 4 - PPM 3 sir.
PPM 1 - 👍
Reviewing the patient here now.
BP - 90/60
Temperature - Febrile low grade.
Plan - Admit
Sugar profile to adjust Basal bolus.
Temperature charting 4 hrly.
Start Amoxicillin as per previous urine culture sensitivity on October 24 during last admission.
PA - Sugar value 490 sir.
PPM 3 - Have to check after 2hrs of food.
PA - Yes madam.
PPM 1 - How much Insulin was given this morning?
PA - 14U sir.
PPM 1 - At what time? What about NPH?
PA - Now it is 527.
PPM 3 - Morning 14 HAI and at lunch 14 HAI sir.
PPM 1 - Yes she was also supposed to add NPH 6U in the morning. It's supposed to be twice daily.
PPM 3 - Yes sir we will add. Shall we give 6U HAI now sir?
PPM 1 - 👍
In such situations when the patient's sugar evaluations are being done without any fixed interval period, at least one can just give some 4-6U of subcutaneous Insulin actrapid to stem the tide till the actual dose and monitoring schedule regularised.
PA - Sir what should we give her for eating?
PPM 5 - Today hemogram report sir.
PPM 3 - Pre dinner GRBS 209 sir.
PPM 1 - 👍 Can add NPH 4U at dinner alongwith the pre dinner actrapid Insulin dose like yesterday.
PPM 3 - Post dinner GRBS 357 sir.
12-11-2024
PPM 3 - 2 am GRBS 287
7 am GRBS 302
PPM 6 -
PPM 3 - Post breakfast GRBS 570
PPM 1 - Pre breakfast Insulin?
PPM 3 - it is 302, given 14 HAI and 6 NPH.
PPM 1 - 👍. Can start her on IV Insulin hourly with monitoring to control immediately if there's any anxiety due to the slower communication over this platform. She actually may have needed 20U HAI although we can even increase the NPH now by +2 for longer term benefits. @PPM6 what antibiotic has been started? Amoxyclav? Or IV Monocef?
PPM 3 - Amoxyclav sir.
PPM 1 - Oral?
PPM 3 - Yes sir.
PPM 1 - Today's counts?
PPM 3 - 15,500, yesterday count was 14000
PPM 1 - Start her on hourly subcutaneous 4-6U with hrly blood sugar monitoring.
PPM 3 - @PPM6 inform the sister and post hrly GRBS.
PPM 6 - OK madam.
PPM 1 - Will the sister listen to him unless one of the interns tell them?
PPM 3 - 12pm GRBS is 343.
PPM 7 - Can the patient be put on DAPA or Acarbose or both?
PPM 1 - They are weak drugs with not much efficacy to reduce blood sugars. What are the Insulin dosages and further values obtained since post breakfast GRBS 570.
PPM 1 - They are weak drugs with not much efficacy to reduce blood sugars. What are the Insulin dosages and further values obtained since post breakfast GRBS 570.
PPM 3 - 6U actrapid given at 11am when the GRBS was 570. At 12pm 4U actrapid given when GRBS is 343.
PPM 1 - 👍. 1 pm would be pre lunch so we need to factor in the lunch calorie input. How much Insulin did she take before yesterday's lunch?
PPM 3 - 14U sir.
PPM 1 - What was the value after 2hrs yesterday? No NPH given yesterday morning I guess?
PPM 3 - Post lunch sugar value is 527 sir.
Yes sir yesterday NPH was not given.
PPM 7 - OK Sir My mom is a chronic diabetic (>27yrs). She has just lost vision in her right eye due to diabetic retinopathy. Was on both Lantus and Actrapid, taking a total of 60U/day alongwith OHAS. Since last 4 months she has been put on DAPA, gliptin and metformin. Her Insulin dosage has come down to just 26U of Lantus. These days her FBS is around 85-90 and RBS hovers around the 125-130 mark. Was just thinking if DAPA would work in our patient as well as it can be used in CKD.
PPM 1 - Because we have given 6U NPH today we can expect some post lunch help from that. So instead of giving 14U should we use 10U to be on the safe side?
If we had a better data about your patient we could possibly correlate that the current control is more due to Renal failure than DAPA. Either way if it doesn't help, the post lunch a lot we can still continue the hourly 4U to bring down the sugars?
PPM 2 - I wouldn't worry that much about in hospital hypoglycemias. There is a huge safety net and she requires high doses of insulin anyway?
PPM 1 - 👍
PPM 7 - OK Sir thank you.
PPM 1 - I am more worried about the safety net! @PPM7 what was her Serum Creatinine? While in your patient the strategy to support insulin therapy with the drugs that you mention could be alright, in this particular patient we also have a current transient situation due to her sepsis and hence we need to focus more on insulin driven control in this crisis phase.
PPM 7 - Serum Creatinine 1 and EGFR 61.
PPM 1 - 👍
PPM 5 - Sugar value 281mg/dl
PPM 1 - After how much time after lunch?
PPM 3 - Pre meal sir. Given 12U actrapid.
PPM 1 - 👍
PPM 3 - 3 pm GRBS is 319 sir. Giving 4U actrapid.
PPM 5 -
PPM 3 - 4 pm GRBS 269 sir.
PPM 1 - 👍
PPM 6 - 7 pm GRBS 195mg/dl
PPM 1 - Pre dinner insulin plan?
How much NPH yesterday night?
Can keep the same dose or +2.
Pre dinner actrapid depending on her dinner.
PPM 3 - Yesterday 4 NPH sir.
PPM 1 - 👍
13-11-2024
PA - Fever 101.
PPM 3 - Morning GRBS 151 sir.
PPM 1 - 👍
PPM 5 - Giving 12U HAI and 6U NPH sir.
PPM 1 - 👍. Keep sharing the glucose values. Share the updated fever chart @PPM3.
PPM 6 -
PPM 1 - @PPM3 Amoxyclav oral appears to be working in vivo? How's she feeling subjectively?
PPM 3 - No Sir she has 2 fever spikes 100F.
PPM 1 - Yes but the amplitude is less isn't it? How's her subjective improvement?
PPM 5 - GRBS at 7pm 71mg/dl.
GRBS at 9.30pm is 121mg/dl
PPM 1 - 👍
PPM 5 - GRBS at 10pm 156, 2am 147, 7am 171.
PPM 1 - Today's chart update @ PPM3.
PPM 6
How's the patient feeling subjectively now? Can you meet me now in the ICU?
PPM 5 -
15-11-2024
PPM 5 -
15-11-2024
PPM 5 - 2 fever spikes since yesterday sir. Subjectively she is better sir. Sugars are also under control.
PPM 1 - Please share the fever chart. Just checking the file right now: No temperature records in the file after this point! @PPM3 @PPM5? Is it because the patient improved subjectively? So sisters stopped recording? Also no urine culture in the file?
PPM 5 -
PPM 3 - No Sir after sending cultures she was started on Amoxyclav.
PPM 1 - 👍
16-11-2024
16-11-2024
PPM 5 - It's in the sister's hand over book sir.
PPM 1 - 👍
PPM 6
PPM 5 - Yes sir sweating, sir.
PPM 1 - 👍 Looks good.
19-11-2024
PPM 1- What's the 2 hours post breakfast today?
So she's currently on NPH twice a day?
PPM 3 - 275 sir post breakfast'
PPM 1 - Pre lunch?
Let's increase all by +2
PPM 3 - Okay sir. Pre lunch 140 sir.
PPM 3 - How much insulin did you give yesteday night?
PA - 10 HAI 4 N.
PPM 1 - Too well controlled! Can reduce N by 2U.
PPM 3 - @PA please give the patient 10 HAI and 2 NPH.
21-11-2024
21-11-2024
PA -
23-11-2024
PA - Fasting sugar value.
28-11-2024
PA -
PPM 1 - How much insulin is she currently on?
PA - 12 at 4 am
Afternoon 10
Evening HAI 10 NPH 4
PPM 1- 258 is fasting?
PPM 3 - Yes sir.
PPM 1 - The NPH at night can be increased by +2
28-11-2024
PA - The patient is complaining of burning sensation in the soles. Please advice a medicine.
PA Translator - The patient has burning sensation in her soles.
PPM 1 - Thanks
We will need to know since when?
29-11-2024
PA Translator - Since when is she facing the burning sensation problem? Earlier did she experience this problem, if at all what medication did she use?
15-12-2024
PPM 1 - We need to have this patient's EMR summary.
Can you pm her IP number?
What is her current update?
EMR Summary
Age/Gender : 59 Years/Female
Address :
Discharge Type: Relieved
Admission Date: 11/11/2024 11:39 AM
Diagnosis
UTI ( RESOLVING ) UNCONTROLLED SUGARS
?CHRD WITH SEVERE MS
Case History and Clinical Findings
Chief COMPLAINTS :
C/O FEVER SINCE 2 DAYS
C/O BURNING MICTURITION SINCE 2 DAYS HISTORY OF PRESENTING ILLNESS:
PATIENT WAS APPARENTLY ALRIGHT 2 DAYS BACK THEN SHE HAS FEVER , WHICH WS HIGH GRADE ASSOCIATED WITH CHILLS AND RIGORS, Relieved BY TAKING MEDICATION BURNING MICTURITION SINCE 2 DAYS
NO COUGH , COLD POLYURIA + , NoCTuRiA +
NO ABDOMINAL PAIN , VOMITINGS , NAUSEA PAST HISTORY :
K/C/O DM 2 SINCE 10 YEARS ON HUMAN ACTRAPID 14 U TID N/K/C/O HTN , CVA , CAD , ASTHMA ,C EPILEPSY
H/O HOSPITAL ADMISSION 1 MONTH BACK I/V/O UROSEPSIS GENERAL EXAMINATION :
PATIENT IS C/C/C NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA
BP: 110/70 MMHG
PR: 76 BPM
RR: 18 CPM
SPO2: 98%
SYSTEMIC EXAMINATION :
CVS: S1S2 + RS: BLAE +
P/A: SOFT NON TENDER CNS: NO FND
COURSE IN HOSPITAL :PATIENT HAD PRESENTED TO OPD WITH COMPLAINTS OF FEVER AND Burning MICTURITION SINCE 2 DAYS .AND HIGH SUGARS APPROPRIATE INVESTIGATIONS WAS SENT AND DIAGNOSED WITH UTI . PATIENT WAS CONSERVATIVELY MANAGED WITH IV INSULIN ,IV ANTIBIOTICS ,IV FLUIDS, ANTACIDS AND NOW FEVER SPIKES ARE ABSENT BACTERIAL AND CULTURE SENSITIVITY SHOWED NO BACTERIA AND RESISTANCE TO ANY ANTIBIOTIC .2DECHO SHOWED CRHD AND ADVICED WITH CARDIOLOGIST OPINION .PATIENT IS HEMODYNAMICALLY STABLE AND PLANNED FOR DISCHARGE.
Investigation
HBsAg-RAPID 11-11-2024 03:17:PM Negative Anti HCV Antibodies - RAPID 11-11-2024 03:17:PM Non Reactive BLOOD UREA 11-11-2024 03:17:PM 51 mg/dl 42-12 mg/dl SERUM CREATININE 11-
11-2024 03:17:PM 2.8 mg/dl 1.1-0.6 mg/dl SERUM ELECTROLYTES (Na, K, C l) 11-11-2024
03:17:PMSODIUM 130 mmol/L 145-136 mmol/LPOTASSIUM 3.1 mmol/L 5.1-3.5 mmol/LCHLORIDE
98 mmol/L 98-107 mmol/LLIVER FUNCTION TEST (LFT) 11-11-2024 03:17:PMTotal Bilurubin 0.84
mg/dl 1-0 mg/dl Direct Bilurubin 0.19 mg/dl 0.2-0.0 mg/dl SGOT(AST) 16 IU/L 31-0 IU/LSGPT(ALT) 14
IU/L 34-0 IU/LALKALINE PHOSPHATASE 330 IU/L 98-42 IU/LTOTAL PROTEINS 6.7 gm/dl 8.3-6.4 gm/dl ALBUMIN 2.5 gm/dl 5.2-3.5 gm/dlA/G RATIO 0.59COMPLETE URINE EXAMINATION (CUE) 11-11-2024 03:17:PMCOLOUR Pale yellow APPEARANCE Clear REACTION Acidic SP.GRAVITY
1.010ALBUMIN +++SUGAR ++++BILE SALTS Nil BILE PIGMENTS Nil PUS CELLS 4-5EPITHELIAL CELLS 2-3RED BLOOD CELLS Nil CRYSTALS Nil CASTS Nil AMORPHOUS DEPOSITS Absent OTHERS Nil RFT 11-11-2024 04:40:PMUREA 51 mg/dl 42-12 mg/dl CREATININE 2.8 mg/dl
1.1-0.6 mg/dl URIC ACID 4.1 mmol/L 6-2.6 mmol/LCALCIUM 9.4 mg/dl 10.2-8.6
mg/dl PHOSPHOROUS 2.7 mg/dl 4.5-2.5 mg/dl SODIUM 130 mmol/L 145-136 mmol/LPOTASSIUM
3.1 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 98 mmol/L 98-107 mmol/LBLOOD UREA 12-11-2024
06:48:PM 59 mg/dl 42-12 mg/dl SERUM CREATININE 12-11-2024 06:48:PM 2.4 mg/dl 1.1-0.6 mg/serum ELECTROLYTES (Na, K, C l) 12-11-2024 06:48:PM SODIUM 135 mmol/L 145-136
mmol/LPOTASSIUM 3.1 mmol/L 5.1-3.5 mmol/LCHLORIDE 105 mmol/L 98-107 mmol/LBLOOD
UREA 14-11-2024 06:35:AM 64 mg/dl 42-12 mg/dl SERUM CREATININE 14-11-2024 06:35:AM 2.1 mg/dl 1.1-0.6 mg/dl SERUM ELECTROLYTES (Na, K, C l) 14-11-2024 06:35:AM SODIUM 136
mmol/L 145-136 mmol/LPOTASSIUM 3.2 mmol/L 5.1-3.5 mmol/LCHLORIDE 104 mmol/L 98-107 mmol/LLIVER FUNCTION TEST (LFT) 16-11-2024 08:44: AM Total Bilurubin 0.54 mg/dl 1-0 mg/direct Bilurubin 0.18 mg/dl 0.2-0.0 mg/dl SGOT(AST) 10 IU/L 31-0 IU/LSGPT(ALT) 10 IU/L 34-0
IU/LALKALINE PHOSPHATASE 334 IU/L 98-42 IU/LTOTAL PROTEINS 6.8 gm/dl 8.3-6.4 gm/d l AL
BUMIN 2.2 gm/dl 5.2-3.5 gm/dl A/G RATIO 0.49BLOOD UREA 16-11-2024 09:20:AM 62 mg/dl 42-12 mg/serum ELECTROLYTES (Na, K, C l) 16-11-2024 09:20: AMSODIUM 136 mmol/L 145-136
mmol/LPOTASSIUM 3.8 mmol/L 5.1-3.5 mmol/LCHLORIDE 101 mmol/L 98-107 mmol/LSERUM
CREATININE 16-11-2024 09:20:AM 2.2 mg/dl
Treatment Given(Enter only Generic Name)
1. INJ . HAI S/C TID
2. INJ NPH S/C BD
3. INJ MONOCEF 1 GM IV/BD
4, TAB NITROFURANTOIN 100 MG PO/OD
5. TAB PAN 40 MG PO/OD
6. TAB PCM 650 MG PO /SOS
Advice at Discharge
1. INJ . HAI S/C TID
10u-10U-10U
2. INJ NPH S/C BD
4U-0-4U
3, TAB NITROFURANTOIN 100 MG PO/OD X 2 DAYS
4. TAB PAN 40 MG PO/SOS
5. TAB PCM 650 MG PO /SOS
5. TAB DYTOR10 PO/OD X 1MONTH
6. TAB MET -XL12.5 X 1MONTH
7. TAB. ECOSPRIN AV 75/10 PO/OD X 1 MONTH
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, DO NOT 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: 18/11/24 Ward: FMW Unit:I
16-12-2024
PPM 1 - @PPM3 @PPM4 can you share the echocardiography video of her severe Mitral stenosis that we appear to have never discussed here?
19-12-2024
PPM 1 - Reviewing this PaJR patient right now in our OPD and particularly interestedin a peculiar discharge diagnosis of?CHRD with severe MS! Whatever data we have now is all against that!
OPD 59F Diabetes 15 yrs also labelled as CRHD with severe MS @PPM5 to ensure the repeat echo video today.
20-12-2024
PPM 1 - We were trying to understand yesterday as to why this peculiar diagnosis of CRHD with severe MS was added to her EMR summary that one can access in full here 👇
https://pajrcasereporter.blogspot.com/2024/11/59f-diabetes-10yrs-renal-failure-10.html?m=1
@PPM4 please ask intern who captured her echocardiography yesterday to share the video here if possible.
I talked to another intern and she said in her report there's no mention of it!
@caretaker please share a deidentified image of her echo report @PA please guide him as to how to deidentify it
@PPM5 and @PPM2 our PaJR participatory medicine data is growing fantastically with lots of workflow systems insights that are otherwise lost to the world and can make good impactful and meaningful content for the "journal of participatory medicine" especially as Amy Price is it's current editor in chief. Only we need some good writers like you but who have more time in their hands.
PA - Spoke to the caretaker and explained how to deidentify it.
PPM 1 - 👍
PPM 2 - Absolutely. Very happy to see.
Caretaker - 
PPM 1 - How is her fever and how much insulin is she taking are the questions we are still struggling with.
08-01-2025
PPM 1 - Do you have any previous echocardiography report of the patient?
Very high random blood sugar yesterday!
@PA please ask him to share her FBS and two hours ppbs after every meal along with the insulin dose she's getting currently
He needs to remove the qr codes from the images as they contain full identifiers.
21-12-2024
Caretaker - 
Caretaker - The patient is suffering with fever.
23-12-2024
Caretaker - Fasting sugar value of the patient is 315.
PPM 3 - How much insulin did the patient take?
PPM 1 - 👍
Caretaker - 12+4
06-01-2025
PPM 1 - Reviewed her in the OPD
Complains of fever
Osmotic symptoms
No informational continuity from relatives
Adviced admission.
PPM 3 -
PPM 1 - Thanks for sharing
Started Norflox and sent urine culture?
PPM 3 - Yes sir.
PPM 1 - Could have caught her at the urine culture counter to show to @PPM4.
Caretaker - Sugar value at 8.25am is 227mg/dl
17-01-2025
PPM 4 - 
Pain abdomen thesis addition!
PPM 1 - 👍
This neglected PaJR patient @PA has been getting admitted recurrently with UTI and today she got admitted again and this time she is showing emphysematous pyelonephritis on ultrasound.
PPM 4 - She is not complaining of pain abdomen sir
Only burning micturition as of now.
PPM 5 - Sir what is the treatment we should keep
As of now she is complaining of fever with chills and burning micturition since 5days.
PPM 5 - Today's report sir.
PPM 1 - Iv meropenem to begin on an escalatory path and then we can deescalate after two days
Send urine and blood culture first.
Or can begin with a lower antibiotic such as iv ceftriaxone and then escalate after two days
Either way the urine and blood culture can guide if we send them today and obtain the report in two days.
PPM 4 - Okay sir.
We sent cultures and started her on meropenem.
PPM 1 - 👍
18-01-2025
PPM 1 - Today's update.
21-01-2025
PPM 5 -
PPM 1 - Thanks for sharing.
Was unable to see her previous urine culture except one that showed insignificant growth but she was given nitrofurantoin at that time and currently she's showing nitrofurantoin resistant.
22-01-2025
PPM 5 -
PPM 1 - 
Yesterday's plan executed today. Will need to repeat X-ray kub to visualise the DJ stents.
Nice images of the left emphysematous pyelonephritis.
ECG shows left axis with poor progression of R wave suggestive of CAD.
Current sugar control.
PPM 5 - 
PPM 1 - Thanks.
Any data trends in this admission shared through the fever chart as previously archived for her here 👇
03-02-2025
Caretaker - At 18.09 the sugar level of the patient is 444mg/dl, and temperature is 101.9 F.
07-02-2025
PA - 
PPM 1- @PA to calculate how much cotrimoxazole dose can be given one would need to know her e GFR and then prescribe the dose accordingly 👇
PPM 3 - 25 sir
PPM 1 - Spot on!
So tablet Septran DS for 3 days followed by Septran SS?
PPM 3 - 
21-02-2025
PPM 1 - 👆this dosing needs to be explained to the relative advocate in Telugu and I've already asked him to regularly share her four hourly temperature along with other things like diet plates and activities, which till now they have been defaulting.
PA - Will come to the hospital alongwith the patient.
08-02-2025
PA - Fasting sugar is 133mg/dl
Breakfast with 3 Idlies and chutney
PPM 1 - How much insulin was given to the patient yesterday and today?
PA - 6+6
PPM 1 - Yesterday or today?
6+6 what? Share the images of the vial and loaded syringes.
PA - 3 times daily sir.
PPM 1 - Share the images of the vial and loaded syringes for us to check the dose 3 times daily before taking.
PA - Okay sir.
PPM 1 - We are admitting her for IV antibiotics now @PPM4. The advocate has gone to meet you in room 78.
👆 appears to be sensitive to piptaz
Can start on iv piptaz @PPM5.
PPM 5 - Okay sir.
09-02-2025
PA - The patient has bloating stomach.
PPM 1 - @PPM5 who's on duty who can clinically review this vapu and share here?
PPM 6 - She is complaining of pain abdomen left hypochondrium region sir
P/a-palpable mass in left hypochondrium
PPM 1 - Put the ultrasound probe there and see what is showing below that palpable mass.
It's more likely to be pyonephrosis if not a displaced DJ stent!
Also get an official emergency ultrasound by radiology and a consult from urology.
10-02-2025
PA -
PPM 1 - @PPM5 let's plan a drainage of that collection along with the urosurgeons.
PPM 5 - Urology opinion has been taken they said that they would discuss regard this with their HOD and if necessary plan for nephrostomy sir.
PPM 1 - 👍
PPM 5 - Update - yesterday afternoon nephrostomy was done
No fever spikes
Patient feels symptomatically well .
Pus collected -750ml till now
PPM 1 - 👏👏
PPM 1 - 👆👆the initial credit goes to the patient advocate user to point it out here? @PPM2
PPM 1 - @PPM5 any update?
PA - Hi sir.
The patient is in our hospital since 12 days. The patient is suffering from sugar and kidney problems. Nobody is caring about the patient today sir. No treatment today. They said they will discharge her today. If you ask about kidney problems again, they will say that it is because of the disease. What next sir?
PPM 1 - @PPM5 are you in campus? Can you find out from someone there to check out her file to find out the answers to the questions posed here?
PPM 5 - I am on leave sir
PPM 6 - Sir urology sirs told me that we can discharge the patient and review to urology opd sir.
I'll ask @PPM6 to update on it.
PPM 6 - I already informed their attenders everything sir
That the urology people told to do dtpa scan
And if needed they will do nephrectomy also.
I told the attenders who is staying with the patient sir.
PPM 1 - Let's answer them here point by point:
My mother has been in our hospital for 12 days now.
The patient is suffering from sugar and kidney problems.
Next enti sir, who is taking care of the patient today?
Answer: @PPM6 and PPM7 and they have already explained everything verbally to you and it's possible that we can help explain further here
They did not do any treatment.
I'm sure @PPM6 and @PPM7 are continuing all the necessary treatment.
They say that she will be discharged today.
Is that right @PPM6?
If you ask about kidney problems again, they will say that it is because of the disease.
Yes it's because of her diabetes which wasn't controlled properly because she never shared her sugars properly here when she was at home so we could never help to adjust her insulin doses properly as no one from her home informed us about her sugars here
Next enti sir
The Surgeons want to remove the kidney which is filled with pus but before that they want to get a DTPA scan of the kidneys
That’s why I mentioned about discharge sir.
పాయింట్ 1: నా రోగి 12 రోజులుగా మా ఆసుపత్రిలో ఉన్నాడు. రోగి షుగర్ మరియు కిడ్నీ సమస్యలతో బాధపడుతున్నాడు.
తదుపరి సార్, ఈ రోజు రోగిని ఎవరు చూసుకుంటున్నారు?
సమాధానం: డాక్టర్ తుషార మరియు డాక్టర్ రాంజీ మరియు వారు ఇప్పటికే మీకు మాటలతో ప్రతిదీ వివరించారు మరియు మేము ఇక్కడ మరింత వివరించడంలో సహాయపడే అవకాశం ఉంది
పాయింట్ 2: వారు ఎటువంటి చికిత్స చేయలేదు.
డాక్టర్ తుషార మరియు డాక్టర్ రాంజీ అవసరమైన అన్ని చికిత్సలను కొనసాగిస్తున్నారని నేను ఖచ్చితంగా అనుకుంటున్నాను.
పాయింట్ 3: ఆమెను ఈరోజు డిశ్చార్జ్ చేస్తారని వారు అంటున్నారు.
సమాధానం: ఆమెను వారి వైపు నుండి డిశ్చార్జ్ చేయవచ్చని యూరాలజిస్టులు చెప్పారు మరియు డాక్టర్ తుషార ఆమె రక్తంలో చక్కెరలు బాగా నియంత్రించబడి మా వైపు నుండి డిశ్చార్జ్ అయ్యేలా చేస్తారా అని మాకు చెబుతారు.
పాయింట్ 4: మీరు మళ్ళీ కిడ్నీ సమస్యల గురించి అడిగితే, అది వ్యాధి వల్లనే అని వారు చెబుతారు.
సమాధానం: అవును ఆమె డయాబెటిస్ సరిగ్గా నియంత్రించబడలేదు ఎందుకంటే ఆమె ఇంట్లో ఉన్నప్పుడు ఆమె ఇక్కడ తన చక్కెరలను సరిగ్గా పంచుకోలేదు కాబట్టి ఆమె ఇన్సులిన్ మోతాదులను సరిగ్గా సర్దుబాటు చేయడంలో మేము ఎప్పుడూ సహాయం చేయలేకపోయాము ఎందుకంటే ఆమె ఇంటి నుండి ఎవరూ ఆమె చక్కెరల గురించి ఇక్కడ మాకు తెలియజేయలేదు
పాయింట్ 5: తదుపరి సార్
సర్జన్లు చీముతో నిండిన కిడ్నీని తొలగించాలనుకుంటున్నారు, కానీ అంతకు ముందు వారు కిడ్నీల DTPA స్కాన్ చేయించుకోవాలనుకుంటున్నారు
Mī pāyiṇṭlaku pāyiṇṭla vārīgā samādhānaṁ ivvaḍāniki nēnu ikkaḍa prayatnin̄cānu:
Pāyiṇṭ 1: Nā rōgi 12 rōjulugā mā āsupatrilō unnāḍu. Rōgi ṣugar mariyu kiḍnī samasyalatō bādhapaḍutunnāḍu.
Tadupari sār, ī rōju rōgini evaru cūsukuṇṭunnāru?
Samādhānaṁ: Ḍākṭar tuṣāra mariyu ḍākṭar rān̄jī mariyu vāru ippaṭikē mīku māṭalatō pratidī vivarin̄cāru mariyu mēmu ikkaḍa marinta vivarin̄caḍanlō sahāyapaḍē avakāśaṁ undi
pāyiṇṭ 2: Vāru eṭuvaṇṭi cikitsa cēyalēdu.
Ḍākṭar tuṣāra mariyu ḍākṭar rān̄jī avasaramaina anni cikitsalanu konasāgistunnārani nēnu khaccitaṅgā anukuṇṭunnānu.
Pāyiṇṭ 3: Āmenu īrōju ḍiścārj cēstārani vāru aṇṭunnāru.
Samādhānaṁ: Āmenu vāri vaipu nuṇḍi ḍiścārj cēyavaccani yūrālajisṭulu ceppāru mariyu ḍākṭar tuṣāra āme raktanlō cakkeralu bāgā niyantrin̄cabaḍi mā vaipu nuṇḍi ḍiścārj ayyēlā cēstārā ani māku cebutāru.
Pāyiṇṭ 4: Mīru maḷḷī kiḍnī samasyala gurin̄ci aḍigitē, adi vyādhi vallanē ani vāru cebutāru.
Samādhānaṁ: Avunu āme ḍayābeṭis sariggā niyantrin̄cabaḍalēdu endukaṇṭē āme iṇṭlō unnappuḍu āme ikkaḍa tana cakkeralanu sariggā pan̄cukōlēdu kābaṭṭi āme insulin mōtādulanu sariggā sardubāṭu cēyaḍanlō mēmu eppuḍū sahāyaṁ cēyalēkapōyāmu endukaṇṭē āme iṇṭi nuṇḍi evarū āme cakkerala gurin̄ci ikkaḍa māku teliyajēyalēdu
pāyiṇṭ 5: Tadupari sār
sarjanlu cīmutō niṇḍina kiḍnīni tolagin̄cālanukuṇṭunnāru, kānī antaku mundu vāru kiḍnīla DTPA skān cēyin̄cukōvālanukuṇṭunnāru
I have tried to answer your points here point by point:
Point 1: My patient has been in our hospital for 12 days now. The patient is suffering from sugar and kidney problems.
Next enti sir, who is taking care of the patient today?
Answer: Dr Tushara and Dr Ramji and they have already explained everything verbally to you and it's possible that we can help explain further here
Point 2: They did not do any treatment.
I'm sure @PPM6 and @PPM7 are continuing all the necessary treatment.
Point 3: They say that she will be discharged today.
Answer: The urologists have said that she can be discharged from their side and Dr Tushara will tell us if her blood sugars are controlled well enough to be discharged from our side.
Point 4: If you ask about kidney problems again, they will say that it is because of the disease.
Answer: Yes it's because of her diabetes which wasn't controlled properly because she never shared her sugars properly here when she was at home so we could never help to adjust her insulin doses properly as no one from her home informed us about her sugars here
Point 5: Next enti sir
The Surgeons want to remove the kidney which is filled with pus but before that they want to get a DTPA scan of the kidneys.
25-02-2025
PA - Fasting sugar value is 96mg/dl.
How much insulin to be given to the patient?
PPM 1 - Currently take same as mentioned in the discharge summary.
Continue sharing the sugars two hours after every meal and we shall see if we need to change the dose.
PA - Okay sir.
26-02-2025
PA - Fasting sugar value of the patient 91mg/dl.
PPM 1 - Yesterday 2 hrs post meal for 3 times was not shared.
PA - No sir.
PPM 1 - Why?
PA - The patient had vomitings yesterday.
PPM 1 - Didn't you give her insulin yesterday?
PA - Given sir. But did not check her sugar levels. Daily 3 times 6+6 dose is being given.
PPM 1 - The patient needs to check her sugar levels otherwise how can we decide the dosage.
PA - Post lunch sugar value is 56mg/dl
PPM 1 - We are supposed to see it two hours after breakfast, two hours after lunch and two hours after dinner
Please mention the doses of insulin she has been taking.
Ask the patient to take dinner and check the sugar after two hours of dinner.
@PA2 can we add him to 80M's group and ask him to guide him how to share his insulin and sugar values?
PA 2 - Added
PPM 1 -Off course this will take a few weeks for him to learn from but he could even talk to that patient to understand how best to share his data?
Hopefully he should only teach him how to share his data and not teach him how to manage diabetes.
27-02-2025
PA - Fasting sugar 103mg/dl
PPM 1 - Please share the insulin dose before breakfast
A picture of the breakfast
The sugars 2 hours after breakfast.
Similarly for lunch and dinner.
PA - How much insulin to be given to the patient?
PPM 1 - We can't change the dosage if he's not providing us any proper clue.
He just needs to continue the same dosages he is taking everyday and keep informing us what dose he's taking. For example can he tell us how much insulin she took yesterday?
PA - 6+6
PA 2 - @PA meeru regular ga yentha insulin isthunnaro theliyadu, daily share chesthe doctor gari ki thelusthundi appudu values batti dosage cheptharu. Ninna yentha iccharo anthe ivvandi.
PA - Medam dicharji lo 6+6 continue cheyamanaru
PA 2 - Alage cheyyandi
Post breakfast sugar value and insulin dosage pic share cheyyandi.
PA - Ok madam
PPM 1 - This is 12U
Alright so at 2:48 we'll know the post lunch.
Can they share the food images also
They are taking
6U plain+6U NPH before breakfast
Same before lunch
What is she taking before dinner? Same? Perhaps that's why she's going into hypoglycemia now @PPM2.
PPM 1 - Below is her current last EMR summary during her last recent discharge:
Age/Gender : 59 Years/Female
Address :
Discharge Type: Relieved
Admission Date: 08/02/2025 03:59 PM
Name of Treating Faculty
DR RAMJI (AP) DR HARIKA PGY2
DR TUSHARA PGY1
Diagnosis
RECURRENT UTI SECONDARY(E COLI SENSITIVE TO FOSFOMYCIN, GENTAMICIN, PIPTAZ, MEROPENAM) SECONDARY TO UNCONTROLLED SUGARS
LEFT EMPHYSEMATOUS PYELONEPRITIS B/L DJ STENTING DONE [22/1/25]
RIGHT EXPANDING PERINEPHRIC ABSCESS S/P 1ST NEPHROSTOMY DONE (11/2/25) ,S/P 2ND NEPHROSTOMY DONE (20/2/25)
ANEMIA SECONDERY TO CHRONIC KIDNEY DISEASE S/P 1 PRBC TRANSFUSION DONE CHRONIC KIDNEY DISEASE STAGE 4 ? DIAETIC NEPHROPATHY
TYPE 2 DIABETES MELLITUS SINCE 15 YEARS (HBA1C 7.8) ON INJECTABLES
Case History and Clinical Findings
C/O FEVER SINCE 4 DAYS
C/O GENERALIZED WEAKNESS SINCE 4 DAYS
HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 4 DAYS BACK, THEN DEVELOPED FEVER WITH CHILLS AND RIGOR, HIGH GRADE
RELIEVED WITH MEDICATION - NOT ASSOCIATED WITH VOMITNGS/LOOSE STOOLS N/C/O BURNING MICTURITION/INCREASED FREQUENCY OF MICTURITION/HESITATION NO C/O DECREASED URINE OUTPUT
NO C/O CHEST PAIN, PALPITATIONS/SOB PAST HISTORY:-
K/C/O DIABETES MELLITUS SINCE 15 YEARS, IS ON HUMAN ACTRAPID INJECTABLES. INJ INSULIN - 6 UNITS, INJ NPH - 6 UNITS
H/O EMPHYSEMATOUS PYELONEPHRITIS 1 MONTH BACK, B/L DJ-STENTING DONE (22/1/2025)
GENERAL EXAMINATION:- PATIENT IS C/C/C
NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, PEDAL EDEMA TEMP: 98.2F
PR: 88BPM RR: 20CPM
BP: 130/70MMHG GRBS: 89MG/DL APPETITE NORMAL BOWELS REGULAR MICTURITION NORMAL NO ALLERGIES
NO ADDICTIONS MENOPAUSE ATTAINED SYSTEMIC EXAMINATION:- CVS: S1, S2+, NO MURMURS RS: BAE+, NVBS HEARD P/A: SOFT, NON-TENDER CNS: NFND
OPHTHALMOLOGY REFFERAL DONE ON : 11 /2/25 I/V/O DIABETIC RETINOPATHY CHANGES UROLOGY REFERRAL DONE ON 8/2/2025:-
K/C/O EMPHYSEMATOUS PYELONEPHRITIS LEFT + B/L RENAL CALCULI OPERATED B/L DJS STENT 22/2/24. NOW FEBRILE, PATIENT WAS NOT TAKING MEDICATION AND SWELLING AND TENDERNESS AT THE RENAL ANGLE. US SHOWS RENAL CALCULUS
ADVISED CBP, CUE, SC, SE, CT-KUB, RBS, URINE C/S
1ST NEPHROSTOMY WAS DONE ON 11/2/2025
2ND NEPHROSTOMY WAS DONE ON 20/2/2025
UROLOGY OPINION ON 13/2/25:- SYMPTOMATICALLY BETTER, NO FEVER SPIKES
ADVISED CUE, USG KUB, X RAY KUB, SERUM CREATININE AND NEPHROLOGY OPINION
UROLOGY OPINION CASE REVIEWED ON 14/2/25:
UROLOGY REVIEW REFERRAL DONE ON 18/2/2025:- ADV: REPEAT NCCT KUB
UROLOGY REFERAL ON 20/2/25:
UNDER LOCAL ANAESTHESIA WITH ASP PATIENT POSITION IN RIGHT LATERAL POSITIONED UNDER GUIDENCE OF USG AND IP INSERTION DONE WITH HELP OF GUIDE WIRE SERIAL DILATIONS DONE AND MALECOT CATHTER PASSED AND OBSERVED . PUS COMING FROM THE DRAIN ,DRAIN SECURED WITH 2-0 ,IMMEDIATE POSTOP UNEVENTFUL.
Investigation
08-02-2025
POST LUNCH BLOOD SUGAR 168 mg/dl HbA1c 7.8%
BLOOD UREA 65 mg/dl LFT
Total Bilurubin 0.55 mg/dlDirect Bilurubin 0.16 mg/dlSGOT(AST) 10 IU/LSGPT(ALT) 12 IU/LALKALINEPHOSPHATASE403 IU/L TOTAL PROTEINS 5.9 gm/dlALBUMIN 1.6 gm/dl A/G RATIO 0.36
Serum Creatinine 2.2 mg/dl SERUM ELECTROLYTES
SODIUM 133 mmol/LPOTASSIUM 3.3 mmol/L CHLORIDE 98 mmol/L ElectrodeCALCIUM IONIZED
1.20 mmol/L
09-02-2025
FBS 237MG/DL LIPID PROFILE
09-02-2025 Total Cholesterol 144 mg/dlChild :Desirable:<170Borderline high:170-199High :
>199Adult :Desirable:<200Borderline high:200-239High : >239 CHOD/PODTriglycerides 344 mg/dlHDL Cholesterol 38 mg/dlLDL Cholesterol 80 mg/dlVLDL * 68 mg/dl
08-02-2025
PERIPHERAL SMEAR RBC : Normocytic normochromic WBC : Increased in countPLATELET : AdequateImp ; Normocytic Normochromic Anemia with Leukocytosis
T3, T4, TSH 08-02-2025 11:15:PMT3 0.27 ng/ml 1.87-0.87 ng/mlT4 9.38 micro g/dl 12.23-6.32 micro
g/dlTSH 2.46 micro Iu/ml 5.36-0.34 micro Iu/ml
08-02-2025
URINE PROTEIN / CRETININE RATIO Test Result UnitsSPOT URINEPROTEIN120 mg/dl.SPOTURINECREATININE19.6 mg/dl.RATIO 6.12
08-02-2025
Anti HCV Antibodies - RAPID Non ReactiveHBsAg-RAPID 08-02-2025 NegativeHIV NEGATIVE 10-02-2025 12:30:PM
COMPLETE BLOOD PICTURE (CBP) 10-02-2025 12:30:PMHAEMOGLOBIN 5.9 gm/dl 15.0-12.0
gm/dlTOTAL COUNT 20600 cells/cumm 10000-4000 cells/cummNEUTROPHILS 80 % 80-40
%LYMPHOCYTES 13 % 40-20 %EOSINOPHILS 01 % 6-1 %MONOCYTES 06 % 10-2
%BASOPHILS 00 % 2-0 %PLATELET COUNT 4.60 10-02-2025SERUM CREATININE 2.3 mg/dl
10-02-2025
SERUM ELECTROLYTES (Na, K, C l)SODIUM 132 mmol/L 145-136 mmol/LPOTASSIUM 4.7
mmol/L 5.1-3.5 mmol/LCHLORIDE 102 mmol/L 98-107 mmol/L
URINE PROTEIN / CRETININE RATIO 09/02/2025 08:03 AM-SPOT URINE PROTEIN 120 mg/dl.SPOTURINE CREATININE 19.6 mg/dl.RATIO 6.12
SEROLOGY NEGATIVE RBS 10-2-2025: 112MG/DL
SERUM CREATININE 10-2-2025: 2.3MG/DL
SERUM ELECTROLYTES 10-2-2025:-SODIUM 132 mmol/LPOTASSIUM 4.7 mmol/LCHLORIDE 102
mmol/LCALCIUM IONIZED 1.26 13/02/2025
24H URINE PROTEIN/CREATININE RATIO 13/02/2025 24 HOURS URINE PROTEIN 570 mg/day.24 HOURS URINE CREATININE 0.9 g/day RATIO 0.63 URINE VOLUME 1,900 ml 12/2/2025:-
HEMOGRAM 12/2/2025:-HAEMOGLOBIN 5.2 gm/dl TOTAL COUNT 10,100 cells/cumm eNEUTROPHILS 72 % LYMPHOCYTES 23 % EOSINOPHILS 00 % MONOCYTES 05 % BASOPHILS 00 % PCV 17.4 vol % M C V 86.1 fl M C H 25.7 pg M C H C 29.9 % RDW-CV 18.6 %
RDW-SD 58.6 fl RBC COUNT 2.02 millions/cumm PLATELET COUNT 3.74 lakhs/cu.mm SMEARRBC Normocytic normochromic Light MicroscopyWBC With in normal limits Light MicroscopyPLATELETS Adequate in number and distribution Light MicroscopyHEMOPARASITES No hemoparasites seen Light MicroscopyIMPRESSION Normocytic normochromic Anemia
HEMOGRAM 13/2/2025:-HAEMOGLOBIN 5.4 gm/dl TOTAL COUNT 6,800 cells/cumm NEUTROPHILS 55 % LYMPHOCYTES 31 % EOSINOPHILS 04 % MONOCYTES 10 % BASOPHILS 00 % PCV 18.1 vol % M C V 87.9 fl M C H 26.2 pg M C H C 29.8 % RDW-CV 19.1 % RDW-SD 61.2
fl RBC COUNT 5.06 millions/cumm PLATELET COUNT 3.88 lakhs/cu.mm SMEAR
RBC Normocytic normochromic Light Microscopy
WBC With in normal limits Light Microscopy
PLATELETS Adequate in number and distribution Light MicroscopyHEMOPARASITES No hemoparasites seen Light MicroscopyIMPRESSION Normocytic normochromic Anemia
13/2/2025:-
COMPLETE URINE EXAMINATION (CUE)
COLOUR Pale yellow APPEARANCE ClearExaminationREACTION Acidic 5.0-9.0 SP.GRAVITY
1.010 ALBUMIN +++ NegativeSUGAR + NegativeBILE SALTS Nil Negative BILE PIGMENTS Nil Negative PUS CELLS 5-6 0-5/HPF EPITHELIALCELLS3-4 0-5/HPF RED BLOODCELLSNil 0-2/HPF
CRYSTALS Nil Nil CASTS Nil Nil AMORPHOUSDEPOSITSAbsent Nil OTHERS Nil Nil 13/2/2025:-
SERUM CREATININESerum Creatinine 2.4 mg/dl 13/2/2025:-
SODIUM 137 mmol/L 136 - 145 Ion SelectiveElectrodePOTASSIUM 5.2 mmol/L 3.5 - 5.1 Ion
SelectiveElectrodeCHLORIDE 106 mmol/L 98 - 107 Ion SelectiveElectrodeCALCIUM IONIZED 1.26 mmol/L
Blood Urea 66 mg/dl 13/2/2025:
HAEMOGLOBIN 5.7 gm/dl TOTAL COUNT 4,400 cells/cumm NEUTROPHILS 43 %LYMPHOCYTES 43 % EOSINOPHILS 04 % MONOCYTES 10 % BASOPHILS 00 %PCV 18.4 vol % M C V 83.6 fl M C H 25.9 pg M C H C 31.0 % RDW-CV 19.0 % RDW-SD 27.8 fl RBC COUNT 2.20 millions/cumm
PLATELET COUNT 3.96 lakhs/cu.mm SMEARRBC Normocytic normochromic Light MicroscopyWBC With in normal limits Light MicroscopyPLATELETS Adequate in number and distribution Light MicroscopyHEMOPARASITES No hemoparasites seen Light MicroscopyIMPRESSION Normocytic normochromic Anemia
14/2/2025:-HAEMOGLOBIN 6.3 gm/dl TOTAL COUNT 6,600 cells/cumm NEUTROPHILS 50 % 40 -
80 Light MicroscopyLYMPHOCYTES 38 % 20 - 40 Light MicroscopyEOSINOPHILS 02 % 01 - 06
Light MicroscopyMONOCYTES 10 % 02 - 10 Light MicroscopyBASOPHILS 00 % 0 - 2 Light
MicroscopyPCV 20.2 vol % 36 - 46 CalculationM C V 83.1 fl 83 - 101 CalculationM C H 25.9 pg 27 -
32 CalculationM C H C 31.2 % 31.5 - 34.5 CalculationRDW-CV 18.8 % 11.6 - 14.0 HistogramRDW-
SD 57.0 fl 39.0-46.0 HistogramRBC COUNT 2.43 millions/cumm 3.8 - 4.8 ImpedencePLATELET COUNT 4.50 lakhs/cu.mm 1.5-4.1 ImpedenceSMEARRBC Normocytic normochromic Light MicroscopyWBC With in normal limits Light MicroscopyPLATELETS Adequate in number and distribution Light MicroscopyHEMOPARASITES No hemoparasites seen Light MicroscopyIMPRESSION Normocytic normochromic Anemia16-2-2025:
HAEMOGLOBIN 5.7 gm/dl 12.0 - 15.0 Colorimetric LOX -PAPTOTAL COUNT 4,400 cells/cumm
4000 - 10000 ImpedenceNEUTROPHILS 43 % 40 - 80 Light MicroscopyLYMPHOCYTES 43 % 20 -
40 Light MicroscopyEOSINOPHILS 04 % 01 - 06 Light MicroscopyMONOCYTES 10 % 02 - 10 Light
MicroscopyBASOPHILS 00 % 0 - 2 Light MicroscopyPCV 18.4 vol % 36 - 46 CalculationM C V 83.6 fl
83 - 101 CalculationM C H 25.9 pg 27 - 32 CalculationM C H C 31.0 % 31.5 - 34.5 CalculationRDW-
CV 19.0 % 11.6 - 14.0 HistogramRDW-SD 27.8 fl 39.0-46.0 HistogramRBC COUNT 2.20
millions/cumm 3.8 - 4.8 ImpedencePLATELET COUNT 3.96 lakhs/cu.mm 1.5-4.1 ImpedenceSMEARRBC Normocytic normochromic Light MicroscopyWBC With in normal limits Light MicroscopyPLATELETS Adequate in number and distribution Light MicroscopyHEMOPARASITES No hemoparasites seen Light MicroscopyIMPRESSION Normocytic normochromic Anemia
HEMOGRAM 16/2/2025:-
HAEMOGLOBIN 7.8gm/dl TOTAL COUNT 4800 cells/cumm NEUTROPHILS 48 % LYMPHOCYTES 39 % EOSINOPHILS 03% MONOCYTES 10 % BASOPHILS 00 % PCV 18.1 vol % M C V 87.9 fl M C H 26.2 pg M C H C 29.8 % RDW-CV 19.1 % RDW-SD 61.2 fl RBC COUNT 2.83millions/cumm
PLATELET COUNT 3.65 lakhs/cu.mm SMEARRBC Normocytic normochromic Light MicroscopyWBC With in normal limits Light MicroscopyPLATELETS Adequate in number and distribution Light MicroscopyHEMOPARASITES No hemoparasites seen Light Microscopy
Test ResultBLOOD GROUP : ARH TYPING : POSITIVE (+VE) SERUM CREATININE 16-2-2025: 2.0MG/DL
SERUM ELECTROLYTES 16-2-2025:-SODIUM 136 mmol/LPOTASSIUM 6.3 mmol/LCHLORIDE 106mmol/LCALCIUM IONIZED 1.12
18-02-2025
BLOOD UREA 45 MG/DL
HEMOGRAM ON 18/2/25
HAEMOGLOBIN 8.6 gm/dl PAPTOTAL COUNT 5,500 cells/cumm NEUTROPHILS 50 % LYMPHOCYTES 38 % EOSINOPHILS 02 % MONOCYTES 10 % BASOPHILS 00 % 0 - 2 Light
MicroscopyPCV 27.2 vol % 36 - 46 CalculationM C V 87.2 fl 83 - 101 CalculationM C H 27.6 pg 27 -
32 CalculationM C H C 31.6 % 31.5 - 34.5 CalculationRDW-CV 18.4 % 11.6 - 14.0 HistogramRDW-
SD 56.6 fl 39.0-46.0 HistogramRBC COUNT 3.12 millions/cumm 3.8 - 4.8 ImpedencePLATELET COUNT 3.43 lakhs/cu.mm 1.5-4.1 ImpedenceSMEARRBC Normocytic normochromic Light MicroscopyWBC With in normal limits Light MicroscopyPLATELETS Adeqaute Light MicroscopyHEMOPARASITES No hemoparasites seen Light MicroscopyIMPRESSION Normocytic normochromic anemia
SERUM CREATININE 18-2-2025: 1.8MG/DL
SERUM ELECTROLYTES 18-2-2025:-SODIUM 139 mmol/LPOTASSIUM 5.0 mmol/LCHLORIDE 107mmol/LCALCIUM IONIZED 1.12
BLOOD UREA 18-02-2025 45 MG/DL
20-02-2025
HAEMOGLOBIN 8.2 gm/dlTOTAL COUNT 5,400 cells/cumm 4000 - 10000
ImpedenceNEUTROPHILS 56 % 40 - 80 Light MicroscopyLYMPHOCYTES 34 % 20 - 40 Light
MicroscopyEOSINOPHILS 02 % 01 - 06 Light MicroscopyMONOCYTES 08 % 02 - 10 Light
MicroscopyBASOPHILS 00 % 0 - 2 Light MicroscopyPCV 24.1 vol % 36 - 46 CalculationM C V 83.1 fl
83 - 101 CalculationM C H 28.3 pg 27 - 32 CalculationM C H C 34.0 % 31.5 - 34.5 CalculationRDW-
CV 18.0 % 11.6 - 14.0 HistogramRDW-SD 53.5 fl 39.0-46.0 HistogramRBC COUNT 2.90
millions/cumm 3.8 - 4.8 ImpedencePLATELET COUNT 3.20 lakhs/cu.mm 1.5-4.1 ImpedenceSMEARRBC Normocytic normochromic Light MicroscopyWBC With in normal limits Light MicroscopyPLATELETS Adequate in number and distribution Light MicroscopyHEMOPARASITES No hemoparasites seen Light MicroscopyIMPRESSION Normocytic normochromic anemiaBlood Urea 39 mg/dl 12 - 42 Urease-GLDHSerum Creatinine 1.8 mg/dl 0.6 - 1.1 Modified Jaffe's
SODIUM 139 mmol/L 136 - 145 Ion SelectiveElectrodePOTASSIUM 4.4 mmol/L 3.5 - 5.1 Ion
SelectiveElectrodeCHLORIDE 104 mmol/L 98 - 107 Ion SelectiveElectrodeCALCIUM IONIZED 1.14 mmol/L Cord Blood : 1.30 - 1.60
USG OF ABDOMEN WAS DONE ON 8/2/2025:-
RIGHT KIDNEY: 9.2 X 3.5CM NS/E, CMD+, PCS NORMAL LEFT KIDNEY OUTLINE NOT VISUALISED
IMPRESSION :RIGHT RENAL CALCULI REVIEW USG DONE ON 9/2/25
ALL THE FINDINGS ARE CONSISTENT WITH PREVIOUS SCAN COLLECTION : 11X5CM
USG UKB DONE ON 14/2/2025:-
RIGHT KIDNEY: 10.8 X 4.9CMS - NORMAL SIZE INCREASED ECHOGENECITY, CMD+, PCS NORMAL
LEFT KIDNEY: 10.2 X 4.1CMS - NORMAL SIZE ALTERED ECHOTEXTURE WITH FEW ECHOGENIC FOCI IN THE PARENCHYMA. CMD PARTIALLY MAINTAINED, PCS NORMAL B/L DJ STENT IN SITU
POST HYSTERECTOMY STATUS FINDINGS:-
-E/O FEW CALCULI NOTED IN BOTH KIDNEYS, LARGEST MEASURING 10-11MM IN RIGHT KIDNEY UPPER POLE AND 7-8MM IN THE MIDPOLE OF LEFT KIDNEY
-E/O 38 X 22MM, ILL-DEFINED COLLECTION NOTED IN THE LEFT RETROPERITONEUM BETWEEN SPLEEN AND LEFT KIDNEY UPPER POLE.
IMPRESSION:-
-LEFT EMPHYSEMATOUS PYELONEPHRITIS
-B/L RENAL CALCULI
-B/L DJ STENT IN SITU
-ILL-DEFINED COLLECTION IN LEFT RETROPERITONEUM (DECREASED)
-RIGHT RAISED ECHOGENECITY OF KIDNEY, CORRELATE WITH RFT REVIEW USG UKB DONE ON 14/2/2025
I/V/O DRAINAGE COLLECTION AND COLLECTION RESIDUAL CONSISTENCY LEFT:- E/O 7.5X7.3CM ILL-DEFINED COLLECTION NOTED IN LEFT SPLENORENAL SPACE. REVIEW USG DONE ON 21/2/25 :
E/O 7.8X3.9CM ILL-DEFINED COLLECTION NOTED IN THE PERINEPHRIC REGION . 10/2/25:-
CT-KUB(PLAIN) DONE ON 10/2/25:-
-LARGE COLLECTION CONTAINING AIR FLUID LEVEL IN LEFT RETROPERITONEUM MEASURING 15.5 X 12.8 X 8.6CM (CCXAPXT) CAUSING COMPRESSION OF LEFT RENAL PARENCHYMA.
-SUPERIORLY COLLECTION CAUSING COMPRESSION AND UPWARD DISPLACEMENT AND SPLEEN. INFERIORLY COLLECTION IS EXTENDING UPTO LEVEL OF PELVIC BRIM.
-URINARY BLADDER - LARGE AIR POCKET INSIDE URINARY BLADDER. NO CALCULI. NO WALL THICKNESS.
IMPRESSION:-
-BILATERAL RENAL CALCULI.
-BILATERAL DJ STENTS.
-LEFT SIDED EMPHYSEMATOUS PYELONEPHRITIS.
-LARGE COLLECTION CONTAINING AIR FLUID LEVEL IN LEFT RETROPERITONEUM MEASURING 15.5 X 12.8 X 8.6CM (CCXAPXT) CAUSING COMPRESSION OF LEFT RENAL PARENCHYMA.
18/2/2025:-
CT KUB PLAIN DONE ON 18/2/2025:-
-B/L DJ STENT
RIGHT KIDNEY: 10.85 X 4.6CMS - 15MM CALCULUS IN MID POLE WITH HU 1500-1600, , PCS NOT DILATED
LEFT KIDNEY: 10.9 X 4.7CMS -PCS NOT DILATED, FEW CALCULI NOTED MEASURING 6-7MM, MULTIPLE GAS CONTAINING FOCI IN RENAL PARENCHYMA AND PCS
IMPRESSION:-
-B/L RENAL CALCULI
-B/L DJ STENTS.
-LEFT SIDED EMPHYSEMATOUS PYELONEPHRITIS
-LARGE COLLECTIONCONTAINING AIR FLUID LEVEL IN LEFT RETROPERITONEUM MEASURING12X11X7.5 CM ( CCXAPXT) CAUSING CIOMPRESSION OF LEFT RENAL PARENCHYMA.
PERCUTANEOUS CATHETER NOTED WITH ITS TIP TERMINATING IN SUBUTANEOUS PLANE OF POSTERIOR ABDOMINAL WALL
(PCN)PUS FOR C/S ON 13/2/2025:-
GRAM STAIN: PLENTY OF PUS CELLS, FEW GRAM POSITIVE COCCI AND OCCASIONAL GRAM NEGATIVE BACILLI SEEN.
CULTURE REPORT: ESCHERICHIA COLI ISOLATED (PLENTY GROWTH)
SENSITIVE TO GENTAMICIN, COTRIMOXAZOLE, PIPERACILLIN/TAZOBACTUM, MEROPENEM INTERMEDIATELY SENSITIVE TO AMOXYCLAV
RESISTANT TO CEFUROXIME, CIPROFLOXACIN, CEFTRIAXONE, AMIKACIN BLOOD CULTURE AND SENSITIVITY REPORT 11/2/25 REPORT:CONTAMINENTS GROWN
URINE FOR C/S ON 12/2/2025:-
WET MOUNT: 2-4 PUS CELLS SEEN.
CULTURE REPORT: ESCHERICHIA COLI >10^5 CFU/ML OF URINE ISOLATED SENSITIVE TO GENTAMICIN, FOSFOMYCIN, AMIKACIN, PIPERACILLIN/TAZOBACTUM, MEROPENEM
RESISTANT TO AMOXYCLAV, NITROFURANTOIN, NORFLOXACIN, CEFUROXIME, OFLOXACIN, CEFTRIAXONE.
20-02-2025
SERUM ELECTROLYTES (Na, K, C l) 20-02-2025SODIUM 139mmol/L 145-136
mmol/LPOTASSIUM 4.4mmol/L 5.1-3.5 mmol/LCHLORIDE 104 mmol/L 98-107 mmol/L SERUM CREATINE 1.8 MG/DL
HEMOGRAM 20/2/2025:-
HAEMOGLOBIN 8.2 gm/dl PAPTOTAL COUNT 5,400 cells/cumm NEUTROPHILS 56
%LYMPHOCYTES 34 % EOSINOPHILS 02 % MONOCYTES 8% BASOPHILS 00 %PCV 24.1vol % M C V 83.1 fl M C H 28.3 pg M C H C 34.0 % RDW-CV 18.0 % RDW-SD 53.5.8 fl RBC COUNT 2.90
millions/cumm PLATELET COUNT 3.20 lakhs/cu.mm SMEARRBC Normocytic normochromic Light MicroscopyWBC With in normal limits Light MicroscopyPLATELETS Adequate in number and distribution Light MicroscopyHEMOPARASITES No hemoparasites seen Light MicroscopyIMPRESSION Normocytic normochromic Anemia
20/2/25Blood Urea 39 mg/dl
Test Result Units Normal Range MethodBlood Urea 34 mg/dl 12 - 42 Urease-GLDH. Assay results should
Test Result Units Normal Range MethodHAEMOGLOBIN 7.9 gm/dl 12.0 - 15.0 Colorimetric LOX - PAPTOTAL COUNT 6,600 cells/cumm 4000 - 10000 ImpedenceNEUTROPHILS 64 % 40 - 80 Light
MicroscopyLYMPHOCYTES 28 % 20 - 40 Light MicroscopyEOSINOPHILS 01 % 01 - 06 Light
MicroscopyMONOCYTES 07 % 02 - 10 Light MicroscopyBASOPHILS 00 % 0 - 2 Light
MicroscopyPCV 23.2 vol % 36 - 46 CalculationM C V 83.8 fl 83 - 101 CalculationM C H 28.5 pg 27 -
32 CalculationM C H C 34.1 % 31.5 - 34.5 CalculationRDW-CV 18.3 % 11.6 - 14.0 HistogramRDW-
SD 55.4 fl 39.0-46.0 HistogramRBC COUNT 2.77 millions/cumm 3.8 - 4.8 ImpedencePLATELET COUNT 3.1 lakhs/cu.mm 1.5-4.1 ImpedenceSMEARRBC Normocytic normochromic Light MicroscopyWBC counts with in normal limits Light MicroscopyPLATELETS Adequate in number and distribution Light MicroscopyHEMOPARASITES No hemoparasites seen Light MicroscopyIMPRESSION Normocytic normochromic anemia
Serum Creatinine 1.7 mg/dl 0.6 - 1.1 Modified Jaffe's
SODIUM 136 mmol/L 136 - 145 Ion SelectiveElectrodePOTASSIUM 4.5 mmol/L 3.5 - 5.1 Ion
SelectiveElectrodeCHLORIDE 103 mmol/L 98 - 107 Ion SelectiveElectrodeCALCIUM IONIZED 1.23 mmol/L Cord Blood : 1.30 - 1.60
21/2/25
HAEMOGLOBIN 7.9 gm/dl PAPTOTAL COUNT 6,600 cells/cumm NEUTROPHILS 64%LYMPHOCYTES 28 % EOSINOPHILS 01 % MONOCYTES 7% BASOPHILS 00 %PCV 23.2vol
% M C V 8381 fl M C H 28.5 pg M C H C 34.1 % RDW-CV 18.3 % RDW-SD 55.4 fl RBC COUNT
2.77 millions/cumm PLATELET COUNT 3.10 lakhs/cu.mm SMEARRBC Normocytic normochromic Light MicroscopyWBC With in normal limits Light MicroscopyPLATELETS Adequate in number and distribution Light MicroscopyHEMOPARASITES No hemoparasites seen Light MicroscopyIMPRESSION Normocytic normochromic Anemia
21/2/25Blood Urea 34 mg/dl SERUM CREAT -1.7
PUS FOR CULTURE AND SENSITIVITY ON 20/2/25
GRAM STAIN : PLENTY OF PUS CELLS , FEW GRAM NEGATIVE BACILLI SEEN REPORT : ESCERICHIA COLI (SCANTY GROWTH) ISOLATED
SENSITIVE TO GENTAMICIN, COTRIMAXAZOLE, AMIKACIN, PIPERACILLIN/TAZOBACTUM, MEROPENEM
RESISTANT TO AMOXYCLAV,CIPROFLOXACIN, CEFUROXIME
Treatment Given(Enter only Generic Name)
INJ EPO 4000IU SC/ WEEKLYONCE
INJ HAI SC /TID 20 MIN BEFORE LUNCH INJ NPH SC/BD 45 MIN BEFORE LUNCH
INJ MEROPENEM 1GM IV/BD GIVEN FOR 7 DAYS INJ.TRAMADOL 1 AMP I 100ML NS IV/SOS
TAB PAN 40MG PO/OD TAB OROFER XT PO/OD
TAB NODOSIS 500MG PO/BD TAB SHELCAL-CT PO/OD TAB VIT B COMPLEX PO/OD SYP ASCORIL D 10ML PO/TID T.DOLO650MG QID
TAB ULTRACET PO/BD
GRBS PRE BREAKFAST PRE LUNCH PRE DINNER BEFORE BED MONITOR VITALS
Advice at Discharge
INJ EPO 4000 IU SC/WEEKLY ONCE INJ HAI 6-6-6 UNITS SC/TID
INJ NPH 6UNITS 6UNITS SC/BD
TAB PAN 40MG PO/OD X5DAYS
TAB OROFER XT PO/OD TO CONITNUE
TAB NODOSIS 500MG PO/BD TO CONTINUE TAB SHELCAL-CT PO/OD TO CONTINUE TAB VIT B CAPSULE PO/OD 2PM X 7 DAYS SYP ASCORIL D 10ML PO/TID X 7DAYS
Follow Up
REVIEW TO UROLOGY OPD AFTER 1 WEEK /SOS
REVIEW TO GM OPD 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:24/2/2025 Ward: FMW Unit: IV
27-02-2025
PA - Insulin at 19.06
PPM 1 - As i suspected he's giving 6+6 thrice!
He needs to be spelt out that the dose before lunch needs to be simply neel laga plain insulin 6 units.
PA 2 - @PA meeru overdose isthunnaru. Lunch mundara 6U plain insulin (Neel laga) ivvali
PA - Ok madam
28-02-2025
PA - Fasting sugar 103mg/dl.
Breakfast 2 dosa.
PPM 1 - 👍
PA - Post breakfast sugar 46mg/dl.
PPM 1 - Was this seen at 10:55 AM or 12:55 PM?
PA 2 - According to PA it is post breakfast.
PPM1 - Reduce plain insulin before breakfast to 2U.
PA - Okay sir
PPM 1 - What insulin was taken before lunch?
What insulin is planned today before dinner?
PA - At 20.17 the sugar value of the patient is 185mg/dl
Insulin 6U.
PPM 1 - @PA2 Has he has again taken the mixed preparation thrice today? What did he give before lunch today?
PA - 6U
PPM 1 - Plain insulin? Neel laga?
PA - Neellalaga.(Like water) In the afternoon.
PPM 1 - 👍
Need to know the time. Looks like pre lunch at 12:55PM
01-03-2025
PA 2 - Dosage time, sugar values time also should be shared. Sugar value should be checked exactly after 2 hrs.
PA - Okay madam.
PA - Fasting sugar is 94mg/dl.
PPM 1 - 👍
PA - Post breakfast 178mg/dl.
Post lunch sugar 255mg/dl.
PPM 1 - But this doesn't look like neel laga plain insulin! @PA2
👆 Doesn't look transparent like water. Looks more opaque and milky?
PA - 200 percent plain insulin sir.
Human Actrapid morning and evening 6+6 dose.
Afternoon 6U plain insulin.
PPM 1 - Please share the vial from which the insulin was taken.
PA - Okay sir
PPM 1 - This is plain insulin 👆
Dinner
02-03-2025
PA - Fasting sugar 67mg/dl
PPM 1 - Didn't you check post dinner sugar level?
From now on pre dinner 6U plain insulin and 2U isophane insulin to be administered to the patient.
PA - Okay sir.
Sugar level at 7 pm is 267mg/dl
PPM 1 - 6U plain insulin and 2U isophane?
03-03-2025
PA - The patient's fasting sugar value is 119mg/dl.
Insulin 6U.
Breakfast Idly with chutney.
PPM 1 - 👍
6U plain insulin.
Lunch with rice and egg curry.
PPM 1 - He appears to be checking pre meal sugars only.
He needs to check them two hours after every meal @PA2.
PA - Today hospital sir. Urology check up sir.
PPM 1 - 👍
04-03-2025
PA - Fasting sugar value is 80mg/dl
PPM 1 - 👍
PA - 6U Mixtard.
Breakfast ragi
[04-03-2025 08:51] PPM 1: @PA2 did he take mixtard thrice yesterday?
[04-03-2025 08:53] PPM 1: Is this plain?
I guess his plain insulin vial may have become contaminated with NPH as he may not have followed the proper sequence of loading from the vial
[04-03-2025 09:27] PA 2: @PA Ninna Mixtard dose yenni sarlu icharu?
[04-03-2025 09:34] PA: Morning evening
[04-03-2025 09:46] PA 2: Sugar values correct ga thinna 2hrs tharuvatha share cheyyandi.
[04-03-2025 09:56] PA: Ok madam.
PA - Post breakfast sugar 108mg/dl
At 18.05 sugar level of the patient is 42mg/dl
05-03-2025
PA - Fasting sugar is 183mg/dl
6U Mixtard
Breakfast idly.
PPM 1 - 👍
PA - Sugar level at 12.54pm is 97mg/dl
06-03-2025
PA - Fasting sugar is 129mg/dl
PPM 1 - 👍
PA - Pre brekfast insulin 6U mixtard.
Breakfast dosa with chutney
PPM 1 - 👍
Yesterday's lunch and dinner insulin dose? @PA
PA - Lunch actrapid 6
Dinner 6+2
PA - 129mg/dl at 10.57am.
[06-03-2025 13.56] PA: Insulin
[06-03-2025 19.13] PA: Pre dinner Sugar value.
[06-03-2025 19.16] PA: Insulin
[06-03-2025 19.17] PA:
[06-03-2025 19.20] PA: Dinner
[07-03-2025 07.08] PA: Fasting sugar value 155mg/dl
[07-03-2025 07.09] PPM 1: 👍
[07-03-2025 07.44] PA: 6U insulin. At 08.09 breakfast ragi.
PPM 1 - 👍
[07-03-2025 12.53] PA: 6U insulin.
[07-03-2025 19.17] PA: 259mg/dl
[07-03-2025 19:55] PPM 1: They appear to be checking the sugars just before meals and not two hours
after meals.
[07-03-2025 20:07] PA 2: Told him several times, not understanding.
[07-03-2025 20:12] PPM 3: Sir, is it two hours after Bfast, lunch and dinner? Il try and put a message
here in telugu for @PA
[07-03-2025 20:19] PPM 3 @PA
గోగుల రాజు గారు,
మీరు ప్రతి రోజు,
పొద్దున, మధ్యాహ్నం మరియు రాత్రి భోజనం అయిన
రెండు గంటల తర్వాత
షుగర్ రీడింగ్స్ తీసి ఇక్కడ ఫోటో పెట్టండి.
ప్రతి ఫోటో కింద ఆ షుగర్ రీడింగ్:
breakfast తర్వాత లేదా
lunch తర్వాత లేదా
dinner తర్వాత అని రాయండి.
[07-03-2025 21:33] PA: Ok sir
[08-03-2025 06:56] PA: Fasting 114mg/dl
Pre breakfast insulin at 7.54am
Breakfast at 7.55am
[08-03-2025 07.55] PA: Ragi for breakfast.
[08-03-2025 10.10] PA: 200mg/dl, post breakfast.
Pre lunch Insulin at 13.18
Lunch at 13.20
PPM 1 - 👍
09-03-2025
Fasting sugar at 6.50am
Pre lunch sugar at 13.29
Pre lunch insulin at 13.32
[09-03-2025 13:32] PPM 3: PA గారు. ముందే ఛేప్పినట్టు, ప్రతి పూట, తిన్న రెండు గంటల తర్వాత
మీరు బ్లడ్ షుగర్ రీడింగ్ తీసి ఇక్కడ ఫోటో పెట్టాలి. ఆ ఫోటో కింద బ్రేక్ఫాస్ట్ తర్వాత లేదా లంచ్
తరవాతా లేదా డిన్నర్ తరవాతా అని రాయాలి.
[09-03-2025 13:33] PPM 3: Thinna tharuvatha 200, ఇలాగా. ఇది కరెక్ట్ గా పెట్టారు.
[10-03-2025 08:18] PA: Fasting 110mg/dl
[10-03-2025 08:18] PA: Kallu tiruguthunai sir injection ivala vodda
[10-03-2025 08:26] PPM 1: Tinaka mundu tisukowali.
Fasting normal vochindi kada.
[10-03-2025 08:28] PA: Entha ivvali sir
[10-03-2025 08:29] PA: Insulin
[10-03-2025 08:35] PPM 1: 👆ninna entha iccharu?
[10-03-2025 08:37] PA: 6+6
[10-03-2025 08:49] PPM 1: Same iyyandi
[10-03-2025 09.01] PA: 
[10-03-2025 12.54] PA: 129mg/dl.
[10-03-2025 12.55] PPM 1: 6U plain insulin.
[10-03-2025 12.55] PA: Giving 6U plain insulin.
[10-03-2025 19.42] PA: Sugar value
[11-03-2025 19.32] PA: Pre dinner sugar value is 181mg/dl.
[22-03-2025 07.17] PA: Fasting sugar 121mg/dl, Breakfast ragi
[10-03-2025 19.47] PA: Insulin
[10-03-2025 19.52] PA: Dinner
[11-03-2025 07.58] PA:
[11-03-2025 08.01] PA: 6+2 Insulin
Breakfast at 08.03am
[11-03-2025 08:03] PPM 1: 👆ninna 6+6?
Ee roju enduku takkuwa?
Ninna 6+6 icchinapudu rondu ghantala taruwata sugar chuda leda
[11-03-2025 08:18] PA: Ok sir
[11-03-2025 19.53] PA: Insulin.
PPM 1 - 👍
[12-03-2025 07.38] PA: Fasting sugar
Insulin at 07.39am
Ragi at 07.40am
PPM 1 - 👍
[12-03-2025 19.20] PA: Pre dinner sugar is 129mg/dl, Insulin 6U
PPM 1 - 👍
[13-03-2025 06.45] PA: Fasting sugar is 71mg/dl
[13-03-2025 07.50] PA: 6U insulin, Dosa for breakfast.
[13-03-2025 19.18] PA: 153mg/dl. 6U Insulin.
[14-03-2025 07.05] PA: Fasting sugar value 90mg/dl
[14-03-2025 07.44] PA: 6U insulin, Breakfast Dosa at 7.46am.
[14-03[2025 08.36] PPM 1: 👍
[14-03-2025 19.55] PA: Sugar value is 99mg/dl
PPM 1 - 👍
[15-03-2025 07.36] PA: Fasting sugar 110mg/dl. Ragi breakfast.
PPM 1 - 👍
[15-03-2025 09.33] PA: 
PPM 1 - 👍
[16-03-2025 07.22] PA: Fasting sugar 93mg/dl, Insulin 6U, Breakfast ragi
[16-03-2025 14.17] PA: Post lunch sugar 227mg/dl, Insulin 6U
[17-03-2025 06.59] PA: Fasting sugar 272mg/dl
[17-03-2025 08.41] PPM 1: What was her pre dinner insulin dose?
[17-03-2025 12.57] PA: Pre lunch sugar value 83mg/dl
[17-03-2025 16.53] PPM 1: Pre lunch?
[17-03-2025 17.11] CR: Yes doctor. I spoke to him and explained, about what is fasting sugar and post
lunch. Hope he understood 🙏.
[19-03-2025 08.06] PA: Fasting sugar 119mg/dl
[19-03-2025 08.06] PA: Insulin 6U Breakfast mini dosa with chutney.
[19-03-2025 19.38] PA: Insulin 6U, Dinner rice with curry
[20-03-2025 06.41] PA: Fasting sugar 157mg/dl
PPM 1 - 👍
[21-03-2025 06.43] PA: Fasting sugar 90mg/dl
PPM 1 - 👍
[22-03-2025 19.25] PA: 6U Insulin.
[23-03-2025 06.49] PA: Fasting sugar 184mg/dl
PPM 1 - 👍
[24-03-2025 06.36] PA: Fasting sugar 117mg/dl
[24-03-2025 08.19] PA: 6U Insulin, breakfast Idly.
PPM 1 - 👍
[24-03-2025 13.14] 6U Insulin, Lunch rice with curry.
[04-04-2025 07.18] PA: Sugar value 110mg/dl
[07-04-2025 06.53] PA: Sugar 87mg/dl
PPM 1: 👍
[08-04-2025 06.36] PA: Sugar level 149mg/dl
[09-04-2025 06.36] PA: Fasting sugar 72mg/dl
PPM 1: 👍
[09-04-2025 13.47] PA: Post lunch sugar 121mg/dl
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