This is an Online E Log Book to discuss our patient's de-identified health data shared after taking her signed informed consent. Here e discuss our patient's problems through series of inpus fromavailable global online community experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.
In this case the patient is a 19yr old female with denovo type 1 diabetes mellitus. She is pursuing her Dental course. She is a normal healthy person with no history of any health issues. Until one day when there was a regular check up in their institution, she was diagnosed with high random blood sugar of 440mg/dl value. According to the patient there was no history of diabetes in their family. She was admitted in the hospital for 4 days and given treatment.
PA - GRBS at 8.47pm.
PPM 3 -Ask the patient to eat a bit more in the breakfast.
Let her take 4 units of actrapid. Bedtime at 10pm continue 20 units (reduce from 22)
PA - Ok sir.
PPM 1 - 20U of?
Can someone share the current insulin plan @PA's patient is actually getting that is took yesterday.
PPM 3 - 20U og glargine at bedtime sir.
Yesterday's bedtime glargine, patient was told to take 22U.... Bringing the sugar to low normal range.. Felt 20 is more appropriate leaving a margin for fluctuations in calorie changes to avoid hypoglycemia.
PPM 1 - 👍
What were the short acting doses she took yesterday?
PPM 3 - 6,10,8 actrapid not appropriately taken (hindrance from our side) half an hour before food sir which we highlighted yesterday sir.
PPM 1 - That's fine
What were her two hour post meal sugars after every meal yesterday and what was her fasting?
@Software Engineer may be able to represent it graphically similar to her own patients.
Software Engineer - 👍
PPM 2 - I think targets of FBS 80 to 130 and PPBS of 130 to 180 are acceptable. Although these are usual Type 2 targets.
Also @PPM1 sir what happened to the actual journey record sir?
Daily activities, diets and input output of calories?
What she does? Body morphology?
PPM 3 - She's bit lean, BDS student sir.
PPM 2 -Looks like these have not been relayed in the group?
PPM 1 - This is a new group not made by our regular PaJR reporters. So this group will need some hand holding on all these from you.
PPM 3 - With due respect sir, 7 point sugar monitoring profile is outdated practice sir, I have confirmed it with our endocrinologist, who got offended when I asked about it's practice going on here...
This is one of the change I wanted to propose in our diabetes management, I have not yet discussed with my fellow SR's..
PPM 2 - Any reason why it is outdated?
PPM 2 - A parallel to something being outdated - While NPH in Type 1 is outdated because it is the only intermediate/long acting which has a peak and thus not the best outcomes, the reason above is perfectly valid in constrained settings.
However that should be driving us to introduce these better insulins at lower costs but the apathy at higher levels of management can drain our energy out sometimes!
Thank you. Ideally an image would help as that would give more detail on muscle mass, height, other morphological characteristics etc.
PPM 3 - It can be done only when we are requiring intense monitoring, but not as a routine...
Patients convenience, post prandial raise can be assessed by the next before meal reading, or once 3 or 6 months FBS, PPBS sugar values...
PPM 2 - I understand but this doesn't make it outdated? Maybe a different method of practice but not outdated.
And a 7 point profile for a few days does help as Dawn's is something which needs to be anticipated in Type 1 isn't it?
PPM 3 -FBS high value raises the suspicion, then guides us to particularly look for 3:00 am sugars sir, then can be managed accordingly....
PPM 2 - Reasonable. And what FBS values should raise concern?
PPM 3 - Any early morning hyperglycemia even after predicted insulin requirement, adjustments raises the suspicion sir...
For example today morning the sugar was 75,but instead if it was 270,300,350 prompts me to check 3:00 am sugars to look for whether it's a rebound hyper or hyper due to inadequate dosing...
PPM 2 - 👍
PPM 1 - Yes even we discourage 7 points here and resort to 4 points largely
While fasting is a good indicator of the basal insulin outcomes of one is unable to assess the two hour post meal sugars one may not be able to adjust the short acting doses
PPM 2 - Which is why she must be educated on carb counting
See if she can take a DAFNE course? @PPM1 sir @PPM3
PPM 3 - 👍
PPM 1 - You should attach many of the current gen endocrinologists to our PaJR and let them learn from the hyperlocal data there. @PPM2 is one such current gen endocrinologist
PPM 3 - @PPM2 sir is an endocrinologist😮
PPM 2 - Haha not yet. Going to be.
PPM 1 - 👆@PPM2 following a normal diet as here and adjusting the doses accordingly gives us stable control of all 4 points in weeks
PPM 2 - Yes but please switch her to Aspart sir.
PPM 1 - Off course again depending on her affordability.
PPM 2 - Apidra vs Novorapid (best and most reliable yet) vs Humalog vs Trurapi any of these can help.
PPM 1 - 👍
PPM 3 - 👍
PPM 1 - Our 3F in the other group is on aspart and glargine.
PPM 2 - Indeed.
PPM 3 - 2 hr post breakfast sugar correlates with before lunch reading sir, so there's no need for the extra prick, this is my interpretation sir..
There could be any importance of that extra prick, which I discussed with endocrinologist, but there's no added benefit..
Endocrinologists also practice 4 pricks routine at the initiation of treatment for longtime, this is what our faculty said sir...
PPM 1 - Yes it's also what we always try to tell
Just 4 pricks in the beginning toward optimization and after that only once a week
PPM 3 - 👍
PPM 1 - We prefer the two hour post meal 3 pricks as it's a better indication of the intervention outcomes.
PPM 2 - 👍
PA - Before lunch , sugar value is 158mg/dl
PPM 1 - Two hour Post breakfast not done I guess?
How much insulin actrapid was given yesterday before lunch and what was the two hour post lunch yesterday?
PA - 10U sir.
Roti sir.
PPM 1- No 2 hour post lunch blood sugars done yesterday?
PA - Done sir
Are you taking the same dose also now today before lunch?
PA - Yes sir
PPM 3 - How it's a better indicator sir??
I cannot reason out how it's a better indicator sir..
PA - No sir , checking sugar levels just before meals.
PPM 1 - When we evaluate an intervention after a fixed time interval there is likely to be less confounders than if the time interval is variable. For example if we are simply seeing all the pre meals it means we are looking at the insulin outcomes of the meal prior to that so checking before lunch would mean the insulin taken before breakfast and here the problem is the pre meal checking time before the next meal can become variable and introduce other confounders in the evaluation.
On the other hand when we are assessing the intervention two hours after the insulin and meal that time interval is not varying much and likely to have less confounders.
PPM 3 - With all due respect Sir..
I always ask my Pg's to fix the time of food intake sir.
So the problem is not with checking sugar pre meal, but with, not fixing the meal intake time...
Same as long acting insulin effect is reflected in FBS, before breakfast insulin effect is reflected in the before lunch blood sugar reading and so we can adjust accordingly, having fixed the breakfast, lunch, dinner timings.
I find this method of checking 2hr post meal and adjusting insulins can have more confounding factors, reason being the effect of insulin can vary from person to person both in time and duration, and the sugar levels may become stable after sufficiently acted upon by insulin, the values of which are shown in next pre-meal provided the meal timings are fixed.
Pre meal sugar levels check, gives us opportunity to cautiously adjust insulin levels earlier, without the low sugar levels getting masked by next meal raise in blood sugar.
Also this method of check---> dose---> eat consumes less of the patient's time and doesn't become an impediment in the daily tasks of the patient. Taking insulin before meal - - - > meal - - - > sugar levels 2hr after meal looks like disjunction to me...
Above all this is how guidelines are recommending, practiced by endocrinologists sir, so I vouch for pre meal blood sugar checks.. During my 3 yrs of MD this is how I was trained by endocrinologist, and also I have taken sufficient time to gain understanding and deny 7 point profile sir.
hoping my disagreement is not taken as arrogance sir🙏
PPM 1 - 👍
Agree!
Well fixing the meal timing and getting the sugar pre meal does seem to be a good time tested idea to even evaluate the effect of the insulin taken before the previous meal.
Our contention probably arose from the fact that post prandial sugars have often been a common evaluation parameter but then it need not make it the only parameter and even pre prandial should be a good strategy.
PPM 3 - Thank you sir, wish I will be as considerative as you are and, be with a mind with openness to interpret new information and incorporate in practice of medicine as well as life sir🙏🙏.
PPM 1 - 👍
PA - Before dinner sugar value 242mg/dl.
PPM 1 - 👍
PPM 3 - Tell your patient to take 8 units as already advised.
Plz ask your patient to do the charting, before breakfast, before lunch, before dinner, bedtime(10:00pm), and also is your patient taking food more or less at the sametime??
Hope your patient is already doing it..
Reminder for your patient to take 20 units only at bedtime.
PPM 1 - 👍
PA - 👍
Sir daily as insulin has to taken 30mim before food the timings are:
Morning:7:30am afternoon:1:30pm night:7:30pm bedtime:10pm
Food taking at morning:8am afternoon:2pm night:8pm
PPM 1 - Your patient is lucky to have such a good sincere patient advocate. 👏👏
I'm sure she will do very well in this illness journey and soon everything will become much easier for her to handle and this experience will also help her a lot in her own profession.
PPM 3 - When this 3 times insulin is about to finish let us know we will change it to another one, then your patient need not wait for half an hour to eat food.
With new insulin your patient can just take insulin and eat, take insulin and eat...
PPM 1 - 👍
PA - Thank you sir.
PPM 2- What is the patient having for dinner? Please share her food plate.
PA -
24-12-2024
PA - Yes sir.
Software engineer - Okay doctor.
PA - Before breakfast. 73mg/dl
Regarding this my patient getting shivering hands and foot sir.
PPM 3 - Tell your patient to eat well immediately.
Reduce bedtime insulin to 18 units....
PPM 1 - 👍
PA - Okay sir.
PPM 3 - Give some sugar water immediately..
Your patient can buy glucan - D and keep it at home...
A small packet in patient's bag too...
PA - Okay sir.
PPM 3 - Reduce to 16U.
PPM 1 -
Yes hypoglycemia is a very common occurrence at the same time potentially harmful.
Check out how some of our patients have self recorded these events in their deidentified case reports here 👇
https://patientnewhealthreport2024.blogspot.com/2024/12/patientnewhalthreport2024.html?m=1
@PA2 can help to prepare one for your patient too.
PA - Before lunch 186mg/dl
PPM 1 - 👍
PA - The patient wanted to have boost with milk and sugar. But advised only plain milk.
PPM 1 - 👍
PA - Before dinner sugar value is 268mg/dl. She had carrots and some nuts at 6pm. Also milk without sugar at 5pm.
PPM 1 - Yesterday's was 242 at this time? How much pre dinner actrapid insulin did the patient take yesterday?
PA - 8units.
PPM 1 - Alright
Can take the same
Reduce lantus to 16U as decided today morning
@PPM3 we may not know what's the real efficacy of 8U on the 2 hours post dinner with our current strategy but i agree that not knowing just one value is trivial.
25-12-2024
PA - 82mg/dl. Pre breakfast.
PPM 1 - 👍
8U Actrapid and 16U lantus at night? Also please clarify the exact time these were injected into your patient.
PA - 8u at 8pm,16u at 10 sir.
PPM 1 - 👍
PA - Yesterday timings delayed sir.
PPM 1 - Well at least her dinner time wasn't delayed? I guess she eats everday at 8:00PM?
PPM 1 - 👍
PA - 192mg/dl. Pre lunch.
PPM 1 - 👍
This is a result of the morning insulin before breakfast other than yesterday's lantus
How much actrapid insulin did she take before breakfast today?
How much time do you think elapsed between the pre breakfast insulin and this blood sugar value?
PA - 4 u.
4hours 30 min sir.
PPM 1 - @Software engineer we'll need to later plot all these graphically similar to how it's been plotted in your other PaJR patient here 👇
PA - Pre dinner sugar value is 307mg/dl.
PPM 3 - What is your patient taking now?
PA - 10U sir.
PPM 3 - All four doses please.
PA - At 7:30am =4u at1:30pm=10u at7:30pm=8u at 10:00=16u
PPM 3 - Make it 14 units bedtime
6 UNITS before breakfast
12 units before lunch
8units(same) before dinner. .
PA - Ok sir my patient will change it to this.
26-12-2024
PA - Pre breakfast 127mg/dl.
PPM 1 - Do keep mentioning these timings.
@PPM2 while most studies of hyperglycemia intervention outcomes look at two hour post prandials are their studies that look at pre meals or fixed 4 hour post prandials as in this current common scenario?
If not then @Software engieer's graphs for this patient will be particularly very valuable.
PA - Ok sir
Today at7:40 6u has taken sir.
PPM 1 - 👍
Always mention the type of insulin
Such as: 6U actrapid.
PA - Okay sir.
Pre lunch 238mg/dl.
Taking 12U actrapid.
PPM 3 - Tell your patient to gently tap over the insulin site after taking insulin...
PA - Ok sir.
PPM 3 - And when injecting insulin make sure all the insulin taken into syringe is given completely...
PPM 1 - 👍
This is the effect of 6U of actrapid taken before breakfast. @SE assessed after nearly 7 hours? Please check the time interval between yesterday's breakfast insulin and the pre lunch.
👆 please share all these from 21/12 to today 26/12 listed with time in one text if possible.
PA - Ok sir
On 21st at 8:30pm(117mg/dl). On22nd at 7:30am(129mg/dl). at1:30pm(177mg/dl). At 7:30pm(238mg/dl on 23rd at 7:30am(75mg/dl) at1:30pm(158mg/dl) at 7:30pm(242mg/dl on 24th at 7:30am(73mg/dl) at 1:30pm(186mg/dl) at 7:30pm(268mg/dl) on25th at 7:30am(82mg/dl) at 1:30pm(192mg/dl) at 8:00pm(307mg/dl) on 26th at 7:40(127mg/dl) at1:30pm(238mg/dl).
PPM 1- Thanks
Also mention the insulin doses and their times within this timeline.
PA -
On 22nd at 7:30 a.m. 6 units of accrapid taken. At 1:30 p.m. 10 units of accrapid taken. At 7:30 p.m. 8 units of accrapid. Taken at 10:00 p.m. 22 units of glargin taken. On 23rd at 7:30 a.m. 4 u of accrapid taken. At 1:30 p.m. 10 units of acropid, at 7:30 p.m. 8 units of accrapid ,at 10:00 p.m. 20 units of glargin taken. On 24th at 7:30 a.m. 4 units of accrapid taken, at 1:30 p.m. 10 units of accrapid taken, at 7:30 p.m. 8 units of accrapid ,at 10:00 p.m. 20 units of glargine taken. On 25th at 7:30 a.m. 4 units of accrapid taken, at 1:30pm 10 units of accrapid taken, at 7:30 p.m. 8 units of accrapid, at 10:00 p.m. 16 units of glargin. On 26 th at 7:30 a.m. 6 units of acropid taken, at 1:30 p.m. 12 units of accrapid taken.PPM 1 - @Meta AI please arrange the following data as per date and time of taking the insulin as well as blood sugar value to make it conducive for a line graph representation:
On 22nd at 7:30 a.m. 6 units of accrapid taken. At 1:30 p.m. 10 units of accrapid taken. At 7:30 p.m. 8 units of accrapid. Taken at 10:00 p.m. 22 units of glargin taken. On 23rd at 7:30 a.m. 4 u of accrapid taken. At 1:30 p.m. 10 units of acropid, at 7:30 p.m. 8 units of accrapid ,at 10:00 p.m. 20 units of glargin taken. On 24th at 7:30 a.m. 4 units of accrapid taken, at 1:30 p.m. 10 units of accrapid taken, at 7:30 p.m. 8 units of accrapid ,at 10:00 p.m. 20 units of glargine taken. On 25th at 7:30 a.m. 4 units of accrapid taken, at 1:30pm 10 units of accrapid taken, at 7:30 p.m. 8 units of accrapid, at 10:00 p.m. 16 units of glargin. On 26 th at 7:30 a.m. 6 units of acropid taken, at 1:30 p.m. 12 units of accrapid taken.
Meta AI -Here is the arranged data:
# Insulin Intake and Blood Sugar Levels
22nd
| Time | Insulin Type | Units | Blood Sugar Value |
| -----|---------------|-------|---------------------|
| 7:30 a.m. | Accrapid | 6 | - |
| 1:30 p.m. | Accrapid | 10 | - |
| 7:30 p.m. | Accrapid | 8 | - |
| 10:00 p.m. | Glargin | 22 | - |
23rd
| Time | Insulin Type | Units | Blood Sugar Value |
| -----|---------------|-------|---------------------|
| 7:30 a.m. | Accrapid | 4 | - |
| 1:30 p.m. | Accrapid | 10 | - |
| 7:30 p.m. | Accrapid | 8 | - |
| 10:00 p.m. | Glargin | 20 | - |
24th
| Time | Insulin Type | Units | Blood Sugar Value |
| -----|---------------|-------|---------------------|
| 7:30 a.m. | Accrapid | 4 | - |
| 1:30 p.m. | Accrapid | 10 | - |
| 7:30 p.m. | Accrapid | 8 | - |
| 10:00 p.m. | Glargine | 20 | - |
25th
| Time | Insulin Type | Units | Blood Sugar Value |
| -----|---------------|-------|---------------------|
| 7:30 a.m. | Accrapid | 4 | - |
| 1:30 p.m. | Accrapid | 10 | - |
| 7:30 p.m. | Accrapid | 8 | - |
| 10:00 p.m. | Glargin | 16 | - |
26th
| Time | Insulin Type | Units | Blood Sugar Value |
| -----|---------------|-------|---------------------|
| 7:30 a.m. | Accrapid | 6 | - |
| 1:30 p.m. | Accrapid | 12 | - |
Note: Blood sugar values are missing from the original data. Please provide the blood sugar values to complete the table.
PPM 1 - @Meta AI please add these blood sugar values to the previous insulin timeline:
On 21st at 8:30pm(117mg/dl). On22nd at 7:30am(129mg/dl). at1:30pm(177mg/dl). At 7:30pm(238mg/dl on 23rd at 7:30am(75mg/dl) at1:30pm(158mg/dl) at 7:30pm(242mg/dl on 24th at 7:30am(73mg/dl) at 1:30pm(186mg/dl) at 7:30pm(268mg/dl) on25th at 7:30am(82mg/dl) at 1:30pm(192mg/dl) at 8:00pm(307mg/dl) on 26th at 7:40(127mg/dl) at1:30pm(238mg/dl).
Meta AI - Here is the updated table with the added blood sugar values:
# Insulin Intake and Blood Sugar Levels
21st
| Time | Blood Sugar Value |
| -----|---------------------|
| 8:30 p.m. | 117 mg/dl |
22nd
| Time | Insulin Type | Units | Blood Sugar Value |
| -----|---------------|-------|---------------------|
| 7:30 a.m. | Accrapid | 6 | 129 mg/dl |
| 1:30 p.m. | Accrapid | 10 | 177 mg/dl |
| 7:30 p.m. | Accrapid | 8 | 238 mg/dl |
| 10:00 p.m. | Glargin | 22 | - |
23rd
| Time | Insulin Type | Units | Blood Sugar Value |
| -----|---------------|-------|---------------------|
| 7:30 a.m. | Accrapid | 4 | 75 mg/dl |
| 1:30 p.m. | Accrapid | 10 | 158 mg/dl |
| 7:30 p.m. | Accrapid | 8 | 242 mg/dl |
| 10:00 p.m. | Glargin | 20 | - |
24th
| Time | Insulin Type | Units | Blood Sugar Value |
| -----|---------------|-------|---------------------|
| 7:30 a.m. | Accrapid | 4 | 73 mg/dl |
| 1:30 p.m. | Accrapid | 10 | 186 mg/dl |
| 7:30 p.m. | Accrapid | 8 | 268 mg/dl |
| 10:00 p.m. | Glargine | 20 | - |
25th
| Time | Insulin Type | Units | Blood Sugar Value |
| -----|---------------|-------|---------------------|
| 7:30 a.m. | Accrapid | 4 | 82 mg/dl |
| 1:30 p.m. | Accrapid | 10 | 192 mg/dl |
| 7:30 p.m. | Accrapid | 8 | - |
| 8:00 p.m. | | | 307 mg/dl |
| 10:00 p.m. | Glargin | 16 | - |
26th
| Time | Insulin Type | Units | Blood Sugar Value |
| -----|---------------|-------|---------------------|
| 7:40 a.m. | Accrapid | 6 | 127 mg/dl |
| 1:30 p.m. | Accrapid | 12 | 238 mg/dl |
PPM 3 - @Meta AI can you arrange them in four columns 7:30 am, 1:30pm,7:30 or 8:00 pm, 10:00 pm along a row of dates starting from 21st to 26th.
Meta AI - Here is the rearranged table:
| Date | 7:30 a.m. | 1:30 p.m. | 7:30/8:00 p.m. | 10:00 p.m. |
| -----|-------------|-------------|------------------|--------------|
| 21st | - | - | 117 mg/dl | - |
| 22nd | 129 mg/dl (6u) | 177 mg/dl (10u) | 238 mg/dl (8u) | 22u Glargin |
| 23rd | 75 mg/dl (4u) | 158 mg/dl (10u) | 242 mg/dl (8u) | 20u Glargin |
| 24th | 73 mg/dl (4u) | 186 mg/dl (10u) | 268 mg/dl (8u) | 20u Glargine |
| 25th | 82 mg/dl (4u) | 192 mg/dl (10u) | 307 mg/dl | 16u Glargin |
| 26th | 127 mg/dl (6u) | 238 mg/dl (12u) | - | - |
Note: "u" represents units of insulin, and insulin types are in parentheses.
PPM 3 - @PA your patient has taken 14 units glargine at bedtime yesterday I suppose ( not 16u).
PA - Here it is mentioned sir.
PPM 3 - @PA No problem give confirmation what your patient received yesterday at 10:00 pm.
PPM 1 - 👍
Yes even 16U the fasting appeared to be good.
PPM 3 - So it was 16units glargine?
PA - Sir how much glargine should my patient take at bedtime today?
16 or 14?
PPM 3 - Take same as yesterday.
Let us know when your patient gets rapid acting humalog insulin...
PA - Mostly by Saturday sir.
PPM 3 - @Meta AI separate each day bit spaciously.
Meta AI -
Here is the rearranged table with added spacing between each day:
| Date | 7:30 a.m. | 1:30 p.m. | 7:30/8:00 p.m. | 10:00 p.m. |
| -----|-------------|-------------|------------------|--------------|
| 21st | - | - | 117 mg/dl | - |
| Date | 7:30 a.m. | 1:30 p.m. | 7:30/8:00 p.m. | 10:00 p.m. |
| -----|-------------|-------------|------------------|--------------|
| 22nd | 129 mg/dl (6u) | 177 mg/dl (10u) | 238 mg/dl (8u) | 22u Glargin |
| Date | 7:30 a.m. | 1:30 p.m. | 7:30/8:00 p.m. | 10:00 p.m. |
| -----|-------------|-------------|------------------|--------------|
| 23rd | 75 mg/dl (4u) | 158 mg/dl (10u) | 242 mg/dl (8u) | 20u Glargin |
| Date | 7:30 a.m. | 1:30 p.m. | 7:30/8:00 p.m. | 10:00 p.m. |
| -----|-------------|-------------|------------------|--------------|
| 24th | 73 mg/dl (4u) | 186 mg/dl (10u) | 268 mg/dl (8u) | 20u Glargine |
| Date | 7:30 a.m. | 1:30 p.m. | 7:30/8:00 p.m. | 10:00 p.m. |
| -----|-------------|-------------|------------------|--------------|
| 25th | 82 mg/dl (4u) | 192 mg/dl (10u) | 307 mg/dl | 16u Glargin |
| Date | 7:30 a.m. | 1:30 p.m. | 7:30/8:00 p.m. | 10:00 p.m. |
| -----|-------------|-------------|------------------|--------------|
| 26th | 127 mg/dl (6u) | 238 mg/dl (12u) | - | - |
PPM 3 - 307mg/dl
@Meta AI- can you read this value?
Meta AI - It seems like you're asking if I can read a specific value, but you haven't provided the value yet. Please go ahead and share it, and I'll do my best to assist you!
PPM 1 - @Meta AI can you see images or you are only able to see text here?
Meta AI - For information on data use and privacy, please refer to Meta’s Privacy Center: https://www.facebook.com/privacy/center/
PPM 1 - @Meta AI this answer doesn't appear relevant to the question:
Can you see images posted here or are only able to see text here?
Meta AI - To answer your question, I'm a text-based AI assistant and do not have the capability to see images. I can only process and respond to text-based input.
PPM 1 - 👍
PA - 319mg/dl
26th at 8.09pm actrapid 8U.
PPM 1 - This is the effect of 12U taken at 1.30pm.
PPM 1 - Just sharing another of our PaJR patient's Insulin doses and glucose outcomes today.
EMR SUMMARY
Age/Gender : 19 Years/Female
Address :
Discharge Type: Relieved
Admission Date: 17/12/2024 01:08 PM
Diagnosis
DIABETIC KETOACIDOSIS (RESOLVED)
DENOVO TYPE 1 DIABETES MELLITUS (HBA1C-7%)
Case History and Clinical Findings
C/0 CAME FOR REGULAR CHECKUP WITH RBS-442 H/O POLYPHAGIA PRESENT
NO H/O POLYURIA,BREATHLESSNESS,FEVER ,COLD,COUGH,CHEST PAIN NO H/O PALPITATIONS, ORTHOPNOEA, PND
NO H/O PEDAL EDEMA, PROFUSE SWEATING, GIDDINESS, DECREASED URINE OUTPUT NO H/O PAIN ABDOMEN, Vomiting, LOOSE STOOLS
PAST ILLNESS:
N/K/C/O DM, HTN, THYROID DISORDERS, EPILEPSY, CAD, CVA
PERSONAL HISTORY:
APPETITE: NORMAL
BOWEL AND BLADDER: REGULAR ALLERGIES: NONE
ADDICTIONS: NO
FAMILY HISTORY: INSIGNIFICANT
GENERAL EXAMINATION PT IS C/C/C
BP: 100/80 MMHG PR: 72 BPM
RR: 17CPM TEMP: AFEBRILE SPO2: 98% AT RA GRBS: 442 MG/DL
NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY CVS: S1S2+ NO MURMURS
RS: BAE+
P/A: SOFT, NT, BS+ CNS: NFND
COURSE: A FEMALE PT OF AGE 19 YEAR OLD CAME FOR REGULAR CHECKUP VITALS: BP: 100/80MMHG, PR: 82 BPM, RR: 17 CPM, SPO2: 98% AT RA, GRBS: 442 MG/DL. ON FURTHER EVALUATION WAS DIAGNOSED AS DENOVO DIABETES TYPE 1 AND DIABETES KETOACIDOSIS PT WAS TREATED WITH IV FLUIDS AND WAS STARTED ON LONG ACTING AND SHORT ACTING INSULINS, ADEQUATE GLYCEMIC CONTROL WAS ACHIEVED. PT WAS DISCHARGED IN HEMODYNAMICALLY STABLE CONDITION
Investigation
HAEMOGLOBIN 11.6 gm/dl TOTAL COUNT 8300 cells/cumm NEUTROPHILS 59 %LYMPHOCYTES
36 %EOSINOPHILS 01 %MONOCYTES 04 %BASOPHILS 00 %PLATELET COUNT 3.7 HBA1C-7%
HBsAg-RAPID 17-12-2024 04:37:PM Negative
Anti HCV Antibodies - RAPID 17-12-2024 04:37:PM Non Reactive RFT 17-12-2024 04:39:PMUREA 22 mg/dl CREATININE 0.8 mg/dl URIC ACID 1.5 mmol/LCALCIUM 9.6 mg/d lPHOSPHOROUS 3.0
mg/dlSODIUM 135 mmol/LPOTASSIUM 4.0 mmol/L.CHLORIDE 98 mmol/L
LIVER FUNCTION TEST (LFT) 17-12-2024 04:39:PM Total Bilurubin 2.01 mg/dl 1-0 mg/dl Direct Bilurubin 0.27 mg/dl SGOT(AST) 12 IU/LSGPT(ALT) 18 IU/LALKALINE PHOSPHATASE 116 IU/LTOTAL PROTEINS 7.7 gm/dl ALBUMIN 4.3 gm/d A/G RATIO 1.32ABG 17-12-2024 06:40:PMPH
7.33PCO2 33.6PO2 91.8HCO3 17.5 St.HCO3 18.6BEB -7.1BEecf -7.3TCO2 36.5O2 Sat 97.0O2
Count 14.4
SERUM ELECTROLYTES (Na, K, C l) 18-12-2024 12:05:AM SODIUM 135 mmol/L 145-136
mmol/LPOTASSIUM 3.9 mmol/L 5.1-3.5 mmol/LCHLORIDE 104 mmol/L 98-107 mmol/L
ABG 18-12- 2024 12:05:AMPH 7.36PCO2 30.5PO2 137HCO3 17.1St.HCO3 18.7BEB -7.0BEecf -7.3TCO2
36.0O2 Sat 99.3O2 Count 13.1
COMPLETE URINE EXAMINATION (CUE) 18-12-2024 12:05:AM
COLOUR Pale yellow
APPEARANCE Clear REACTION Acidic SP.GRAVITY 1.010ALBUMIN Nil SUGAR +BILE SALTS Nil BILE PIGMENTS Nil PUS CELLS 3-4EPITHELIAL CELLS 2-4RED BLOOD CELLS Nil CRYSTALS Nil CASTS Nil AMORPHOUS DEPOSITS Absent OTHERS Nil
USG ABDOMEN DONE ON 17/12/24 IMPRESSION NOTES:
NO ABNORMALITY DETECTED
URINE FOR KETONE BODIES: POSITIVE
Treatment Given (Enter only Generic Name)
IV FLUIDS NS @100 ML/HR
INJ HUMAN ACTRAPID INSULIN S/C TID ACC TO GRBS BEFORE MEAL INJ GLARGINE 10U S/C HS
Advice at Discharge
INJ HUMAN ACTRAPID INSULIN S/C TID ACC TO GRBS BEFORE MEAL TO CONTINUE INJ GLARGINE 10U S/C AT BEDTIME TO CONTINUE
Follow Up
REVIEW TO GM OPD WITH FBS,PLBS AFTER 15DAYS
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:20/12/24 Ward: AMC Unit:II
27-12-2024
PA - Fasting sugar value is 123mg/dl.
PPM 1 - 👍
PPM 3 - 👍
PA - Sugar value at 12.30pm is 231mg/dl. Actrapid 12U
PPM 1 - How much insulin did the patient take at 6am?
231mg/dl value is the effect of that actrapid insulin taken at 6:00AM along with the basal lantus insulin taken yesterday at 10 PM.
How much lantus taken yesterday? (123mg/dl)
PA - 6 U actrapid at 6 am.
Yesterday 16U.
At 7.37pm , sugar value is 277mg/dl, 8U actrapid.
PPM 3 - Give your patient 18 units of glargine at bedtime.
PA - 👍
10.11pm sugar value 224mg/dl, glargine 18U.
28-12-2024
PA - 6 am fasting sugar value is 84mg/dl, actrapid 6U.
PPM 1 - 👍
The idea is to gradually increase glargine dose keeping the fasting as a prime guide until it's influence on all overall blood sugars is such that just a single dose of lantus would become enough for this patient to achieve good control similar to as demonstrated in our other diabetes type 1 PaJR group.
PPM 4 - 👍
PA - Sir shall I get it today?? The rapid acting humalog insulin.
PPM 3 - Please.
PPM 4 - Good evening sir
Now patient has brought
Insulin lispro injection @PPM3 @PPM1 sir.
PPM 1 - 👍
PPM 2 - What was the cost?
How many units? 100 or 300?
PPM 4 - She has brought the cartridge sir
100iu/ml and costed around Rs.900 sir.
PPM 2 - 👍
PPM 2 - Oh this is a vial. She couldn't get a pen?
Can we teach her carb counting at all?
This should be a very good starter.
PPM 4 - This is the cartridge sir
So if she buys a pen
She can change the cartridge after it gets over.
PPM 2 - Oh yes I completely missed seeing the right side. Yes indeed. Can she a get a pen then?
PPM 4 - Yes sir.
PPM 2 - Awesome. Can you take ownership of her carb counting teaching from the above PDF? Shouldn't take too long just a primer on what a CP is (carbohydrate portion) and how she can start with 1 unit of Lispro for every 9 or 10g of carbs.
PPM 1 - 👍
PPM 2 - That way she can adjust the dose herself and become more autonomous and self governing.
PPM 4 - Okay sir.
PPM 2 - As suggested her every 1unit of Lispro will correct her sugars this way. Can bookmark.
Ideally she shouldn't be taking any correctional doses but should she occasionally require any - she can dose it appropriately.
PPM 3 - Harika find out from the indo Asian group,any conventional foods patient is taking....
PPM 4 - Okay sir.
PA - 8.30pm 94mg/dl, actrapid 8U.
PPM 3 - Your patient must eat something, don't give glargine if sugar is such low...
PA - Ok sir.
PPM 3 - Yesterday before dinner 277 mg/dl
Today before dinner 94 mg/dl very big difference
Such difference shouldn't occur....
PPM 2 - That may not be a good idea I think. 94 is normal isn't it?
Ideally no patient should ever skip long acting insulin. Ever.
PPM 3- Yesterday's
before dinner it was 277 sir patient received 8 units actrapid and 18 units at bedtime
Today morning before breakfast 6:00 am value is 84mg/dl
Patient may go into hypoglycemia with the current before dinner reading sir... That's my primary concern, my concern of developing DKA due to omitting bedtime insulin is not concerning me right now sir..
I advised patient to have something, infact patient has to eat well, and glargine dose can be decided / confirmed in due time sir..Right now I don't have other solution in mind sir..
You can please guide sir🙏
Tell your patient to eat well...
PA - Sure sir.
PPM 2 - Two very good questions and clinical conundrums
Ideally the best way to begin would be apply the Gold questionnaire and check her hypoglycemia awareness, given she is 19 I would assume it would be 1.
Next, she also does not have any documented hypoglycemia yet. Just lowish but nothing below 70.
Next, I would check if she can recognize hypoglycemia symptoms (similar to gold questionnaire) and how to alleviate an impending hypo.
Next, for her age I would say 2 to 3 Hypos per week are acceptable.
I also would never, categorically never, stop any long acting insulin even if hypoglycemic. If more than 3 Hypos per week perhaps I would reduce the dose of Lantus by 10 to 20%.
I also think it would be prudent to be more worried about a DKA than a slight hypo, especially given her age and educational background.
My 2 cents.
To add to this I'm also noticing that we are micromanaging patient's long acting doses. Which is why most patient's morning sugars are yo yoing.
Fix a dose and do not be too worried unless less than 70 on 3 occasions per week.
PPM 1 - For the 3F it's uncertain uncharted territory that comes into view with hyperlocal micromanaged PaJR follow up.
PPM 2 - Understand. But may not be the best case here.
29-12-2024
PA - Good morning sir. Today at 6.30am 195mg/dl, actrapid 6U
PPM 3 - Plz give +4u subcutaneous actrapid...
Did your patient start humalog??
PA - No sir.
PPM 3 - Ok... Plz give + 4u
PA - Ok sir thank you.
PPM 1 - How much glargine was taken yesterday night?
PA - 12.30pm 137mg/dl, actrapid 12U.
PPM 1 - 👍
👆@PA How much lantus taken by your patient yesterday?
PPM 3 - She omitted glargine yesterday bedtime sir.
PPM 1 - Alright.
PPM 3 - 
PPM 3 - @PPM1 @PPM2 sir patient's pre meal glucose target can be around 100mg/dl, plz share your opinions...
PPM 1 - I would be happy with 100-130.
PPM 3 - 👍
PPM 2 - Is this specifically for Type 1?
PPM 3 - No sir for both type -1, type - 2
PPM 2 - Well then those are the targets aren't they. 80 to 130. I have no problem with occasional mid 70s too.
PA - 7.45pm, 225mg/dl, actrapid 8U.
30-12-2024
PA - Good morning sir. 6.04am 141mg/dl, actrapid 6U.
PPM 1 - 👍
How much glargine taken yesterday night?
PA - 18U sir.
PPM 1 - 👍
PA - At 12.45pm, 133mg/dl, actrapid 12U.
At 7.26pm, 102mg/dl, actrapid 8U.
PPM 2 - Hasn't the patient gotten Lispro already? Does she not have the pen yet?
PPM 3 - No sir, She did not get pen.
PA - At 10.06pm 18U glargine taken sir.
PPM 3 - Bedtime sugar?
PA - 128mg/dl
PPM 3 - Your patient need to eat something...
For such value you have to reduce bedtime insulin glargine for your patient...
PA - But my patient already has taken sir.
18u sir
Had papaya sir.
31-12-2024
PA - At 6.18am 138mg/dl, actrapid 6U.
PPM 1 - 👍
PPM 3 - Plz let us know your patient's bedtime sugar before glargine dose.
PA - Ok sir.
At 1.00pm 126mg/dl, actrapid 10U.
At 7.41pm, 172mg/dl, actrapid 8U
PPM 3 - Yesterday evening your patient's blood sugar before dinner is 102
Today it's 172mg/dl...
There is much difference, plz try to maintain around 100mg/dl..
If your patient can do that, we can fix doses and daily sugar checking can be stopped and occasional sugar checks can be done...
PA - Ok sir.
Sir should the patient take 4 u more now?
2U.
PPM 3 - I will tell you..
1 unit for every 30mg/dl give 3 units extra here..
PA - Ok sir.
Bedtime sugar value is 149mg/dl, 16U glargine.
01-01-2025
PA - Good morning sir, at 6.00am 160mg/dl, actrapid 6U.
PPM 3 - What doses is your patient is currently on??
PA - Sir yesterday at 6:00am |6u actrapid ,1:00pm|10u actrapid , 8:00pm|8u accrapid, 11:pm|14u glargine.
PPM 3 - Increase all by 2 units, if your patient is starting new insulin (HUMOLOG) then take this dose or let us know before starting.. Have a good day..
PA - Sure will let you know before my patient starts HUMOLOG sir, thank you.
PPM 1 - @SE @PA2 we may need to plot the values graphically with time in x axis and the blood sugar values in y axis as demonstrated in the other groups.
SE - Sir can patient Advocate write the blood sugar values along with the doses till this date at one place. It will be easier to read the data properly to plot the graph.
With respect to time as well.
PPM 1 - @PA please help @SE with this.
PA - Sure sir.
At 12.40pm 156mg/dl, actrapid 12U.
At 8.21pm 117mg/dl, actrapid 8U.
PPM 1 - 👍
PPM 3 - Is it first time?
PA - Yes sir not happened before.
PPM 3 - It can subside by tomorrow..
Remember that we have to do some tests as part of diabetes management which are not yet done..
PPM 1 - 👍
PPM 3 - 👍
PA - At 11.0pm 134mg/dl, glargine 14U.
02-01-2025
PA - At 7.33am 123mg/dl, actrapid 6U.
PPM 1 - 👍
PA - At 1.00pm 224mg/dl, actrapid 12U.
PA - Good evening sir, the patient bought pen and glargine insulin.
PPM 2 - Brilliant 👍.
PPM 3 - Before starting to use this pen for your patient, plz gain an understanding how it works. Any leaflet provided with the pen??
Or from ppt shared to you or you can directly contact us in the OPD for initial instructions.
PA - The patient will contact you in the OPD sir.
Leaflet also provided sir.
PPM 3 - Ok until consultation can continue actrapid.
@PPM4 when is endocrine OP?
PPM 4 - Every Friday sir.
PPM 3 - 👍
@PA tomorrow would be good time for your patient, try to make it...
PA - Ok sir, what are the timings to consult the endocrinologist sir?
PPM 5 - 9 am-12pm.
PA - 👍
At 8 pm 213, actrapid 8U.
At 10.30pm 147mg/dl, glargine 14U.
03-01-2025
PA - At 6 am 172mg/dl, actrapid 6U.
PPM 3 - 8 Units.
PPM 1 - @SE @PA2 will be looking forward to the graphical display of these counterintuitive intervention outcomes non linearity as in 16U producing fasting of 160 while as the dose is being slowly reduced over the next few days the fasting instead of increasing further is increasing. There are off course x factors to explain that but we probably need a good mechanism to extract x from the available data.
SE - 👍
PPM 1 - The swelling of feet of the patient needs to be investigated incase the patient appears today.
PPM 3 - 👍
PPM 1 - 14U glargine at night and fasting is 123 here as opposed to previous days 160 on 16U of glargine @SE this is the mild trough of the yo yo and there's a milder crest ahead the next day that I shall tag below.
SE - 👍
PPM 1 - Today's the yo yo crest again on glargine 14U @SE.
The x factors influencing this is off course diet and exercise the information around which is not much available in this patient's PaJR. Perhaps the patient advocate may be able to throw more light on the x factors. Again it's a very mild yo yo and @PPM2 people may not have meticulously studied the effect of these on long term target organ changes although there are certain text book references to these fluctuations and their effect on long term outcomes but I daresay the data in those studies may not be as hyperlocal as we aim to extract?
SE - 👍
PPM 2 - Perhaps can start with appraisal of that literature and then see if any patterns can emerge which can be extrapolated.
PPM 1 - 👍
04-01-2025
PA - Good morning sir, today at 5.52am sugar value is 222mg/dl, actrapid 6U.
PPM 3 - How much glargine given yesterday night?
PPM 1 - 👍
PA - 14U sir.
PPM 3 - Ok from today night it will be 16 units.
PA - Ok sir. May I start HUMOLG from night?
PPM 3 - New pen purchased and confirmed about the compatibility of pen and vial??
Not need to hurry take your time, about the pen and vial.
PPM 1 - 👍
PA - At 7.46pm 87mg/dl, actrapid 6U.
Patient taking 6U instead of 8U.
PPM 3 - Ok 👍
PA - At 9.20am 109mg/dl, HUMALOG 4U.
PPM 1 - First time humalog?
PA - Yes sir.
PPM 1 - 👍
PA - At 2 pm 86mg/dl, humalog 10U.
Sir can u please advise my patient that after refilling the cartridge in pen should it keep outside or in refrigerator ?
PPM 2 - Refrigerator.
PPM 3 - This is simple thing, read instructions about temperature.
Check the leaflet..
PPM 2 - Can you share a video of her taking Humalog? Just want to check technique.
How do you plan on disposing needles?
PPM 3 -
Question 1- with cartridge or without cartridge
U have 2 types of insulins
2 different temperatures
Check for the leaflets...
PPM 2 - What is the pen on the left and on the right?
PA - On left it is HUMALOG, on right it is glargine sir.
PPM 2 - Okay. I believe both should be refrigerated.
What is the suggested storage temperature for both?
PA - 
PPM 2 - Will ask one of our DSNs tomorrow for full clarity. It will be learning for me too.
Follow the instructions as is for now and I will get back on this tomorrow.
Just spoke to our DSN here.
Pen with Cartridge can stay at room temperature. The cartridge needs to be replaced after a maximum of 28 days.
The extra cartridges need to be refrigerated.
PPM 1 - 👍
PPM 2 - This is for both Humalog and Glargine.
PENTAMED Blue Sharps Containers | Glass Waste and Metallic Implants | Bio-hazard | Bio-Medical Sharps Container Puncture Proof Box | (1.5 | 3.5 | 5.5 Liters) (1.5 Ltr)
https://amzn.in/d/0T2aeRh
We also recommend a sharps bin for patients on Insulin. To dispose needles safely.
PPM 1 - But both your DSN as well as the package insert didn't mean Telangana room temperature!
Currently it's 25 degree here but soon it won't be and so for all practical purposes we may keep everything in the refrigerator avoiding the freezer compartment.
PPM 2 - I agree with this. Although I did mention to her that the patient is in India.
06-01-2025
PA - Good morning sir, at 6 am 159mg/dl, humalog 4U.
PPM 3 - HUMALOG as sir said extra cartridges store in refrigerator, but not near deep freezer..
The one you started using has to be kept in less than 30 degree temperature...
PPM 1 - 👍
PPM 3 - Your patient has purchased
Allstar
Lilly brand pens
Allstar goes with Lantus cartridge (but your patient has basalog which needs a change - there's incompatibility), if I'm asked whether I can use with basalog? That becomes an experiment, which becomes clear only using it..
Lilly goes with HUMOLOG ( this is fine)
Best thing is to get pen and cartridges together....
PA - At 7:40pm| 175mg/dl| HUMALOG 8u.
PPM 1 - 👍
PPM 3 - Humalog doses reduced by 2 units each compared to regular sir, long acting continuing the same..
@PA how much current daily doses your patient is taking??
PA - Before breakfast:4u before lunch:10u before dinner:8u before sleep:14u glargine.
PPM 1 - 👍
PPM 3 - 👍
07-01-2025
PA - Good morning sir. At 6 am 210mg/dl, Humalog 4U.
Sir do my patient need 2 more extra units?
PPM 3 - Give just before taking breakfast.
PA - Only 4u, has taken sir.
PPM 2 - She has to share her food plate so we can at least have a visual assessment of how many carbs she will be having and then decide how much Humalog she needs.
PPM 1 - 👍
PA - Morning at 7:00am upma. At 11am pomegranate afternoon 1pm brown rice with beans curry, at 5pm| bread omlette, at 8pm chapathi with beans curry at 10pm milk without sugar.
PPM 2 - 👍
08-01-2025
PA - Good morning sir, 8/1/24 at 6am 175mg/dl HUMALOG 6u.
Breakfast at 6.28am Vermicelli upma.
PPM 1 - This is likely to be calorie dense as the vermicelli is likely to be the easily digested wheat endosperm (aka maida) and even if it's rice vermicelli it's likely to be ultra processed.
PPM 3 - Increase HUMALOG by 2 units each.
PPM 1 -
Try to see if this plate is balanced in the proportion of 25% cereals, 25% legumes, 25% fruits and 25% vegetables as illustrated here 👇
PA - 8/1/25. At 6am HUMALOG 6u.1pm HUMALOG 12u. 8pm HUMALOG 8u. 10:30pm glargine 13u.
Morning breakfast: vermicelli Upma. Lunch: brown rice with tomato chutney. 5pm :guava. dinner roti 3.
10-01-2025
PPM 1 - Sana Biotechnology has reported on a single patient with T1D who received a (sub therapeutic) dose of their proprietary hypoimmune islet cells (UP421). 6 months later, the patient has measurable C-peptide, both at baseline, and after a mixed meal. And all this, without any immunosuppression!
This is just from 1 patient and it is perhaps too early to celebrate.
*What are hypoimmune islet cells?*
Hypoimmune allogenic pancreatic islets represent a promising advancement in the treatment of type 1 diabetes mellitus (T1DM) by potentially eliminating the need for lifelong immunosuppression, which is a significant barrier in current transplantation therapies. This approach involves engineering pancreatic islets to evade immune detection, thus allowing for successful transplantation without the adverse effects associated with immunosuppressive drugs.
Mechanisms of Hypoimmune Islet Engineering
* Genetic Modifications: Hypoimmune pancreatic islets are engineered by knocking out the genes responsible for HLA class I and II expression and overexpressing CD47. This modification helps the islets evade immune detection and rejection by the host's immune system. The CD47 overexpression acts as a "don't eat me" signal to immune cells, further protecting the islets from immune-mediated destruction.
*
Efficacy in Preclinical Models
* Humanized Mouse Models: In studies involving humanized diabetic mice, hypoimmune islets have shown the ability to survive, engraft, and function effectively without the need for immunosuppression. These islets were able to normalize blood glucose levels and avoid both alloimmune and autoimmune responses.
* Non-Human Primate Models: In diabetic non-human primates, hypoimmune islets have demonstrated stable endocrine function and enabled insulin independence without inducing an immune response, maintaining normal blood glucose levels for extended periods.
Safety and Potential Clinical Applications
* Safety Mechanisms: A CD47-targeting antibody has been proposed as a safety switch to eliminate transplanted hypoimmune islets if necessary, providing a safeguard against potential adverse effects.
* Clinical Implications: The ability to transplant hypoimmune islets without immunosuppression could significantly broaden the applicability of islet transplantation, making it a viable option for a larger population of diabetes patients who currently face limitations due to the side effects of immunosuppressive therapy.
17-01-2025
PA - Good evening sir.
Sugar value at 6 am is 203mg/dl, 6U Humalog. The patient had milk in the morning.
At 1 pm Roti for lunch and 12U Humalog.
At 8.50 pm 185mg/dl, 8U Humalog. The patient had curd rice.
PPM 1 - 👍
PPM 3 - Is the patient on diet control? Did she check the weight before starting insulin?
PA - Yes she is on diet control. Also doing exercises but sugar levels are increasing after exercise at early morning. Did not check the weight.
PPM 3 - Please check the weight tomorrow.
Before exercise they are less and after exercise they are increasing?
PA - Just checking only after exercise sir.
PPM 3 - Patient's sugar levels might be more in the morning unrelated to exercise..
Let us know the readings...
Are they like this?
Bedtime Lantus how much patient is taking??
18-01-2025
PA - 14U sir
At 5.25 am before exercise 247mg/dl. At 6.37am after exercise 236mg/dl. Patient want to increase 6U to 8U. This increase of sugar level may be the reason for delayed lantus at bedtime sir.
PPM 3 - Is your patient changing needle every time??
Injection technique is proper??
PA - Changing after using twice. yes.
PPM 1 - "After moderate to intense exercise, blood glucose can remain high for one to two hours. At the beginning of exercise, insulin levels decrease to allow blood glucose to increase. As a result, there is a marked increase in glucose production (sometimes 7-fold) but only a small increase in glucose utilization (a 4-fold increase before exhaustion)."
Purdon, C., Brousson, M., Nyveen, S.L., Miles, P.D., Halter, J.B., Vranic, M., & Marliss, E.B. (1993) The roles of insulin and catecholamines in the glucoregulatory response during intense exercise and early recovery in insulin-dependent diabetic and control subjects. The Journal of Clinical Endocrinology & Metabolism, 76(3), 566–573.
Unquote
PPM 2 - 👍
PPM 3 - 👍
See whether your patient can reduce calories, maintain more or less same timings.
Before this you can try single needle usage because needle can get blocked after use and next time dose may not be delivered efficiently...
PPM 2 - Ideally she needs to be checking her 2 AM or 3 AM blood sugar for a couple of days to check for any Dawn's phenomenon
Dawn's is a complex pathology for morning hyperglycemia.
It is extremely hard managing Dawn's but a few interventions I would recommend are
1. Exercise in the evening before dinner, instead of in the morning. Only if possible.
2. Increase protein to carb ratio in evening meal. More eggs, chicken or even almonds and cashews in the evening meal would help.
What was the patient's last HbA1c and when is she planning to get her next HbA1c?
PA - At 7 am 236mg/dl, 8U. Had ragi java. At 11 am kiwi fruit. 1 pm brown rice with cucumber curry 10U. 8 pm 145mg/dl, 8U, roti with tomato chutney.
PPM 3 - Before lunch value?
PA - Not checked sir.
PPM 3 - Your patient can increase bedtime Lantus by 2 units...
PA - Okay sir.
19-01-2025
PA - Good morning sir. At 8.30am 185mg/dl, 6U Humalog.
PPM 1 - 👍
This reflects the 16U lantus your patient took yesterday.
PA - Breakfast with Idly and java. At 1.20pm 193mg/dl. 12U. Lunch Roti with chicken.
20-01-2025
PA - Good Morning sir. Bedtime glargine 16U. At 6am 216mg/dl 6U, breakfast upma.
PPM 1 - Even 16U didn't work adequately on her fasting sugar values.
PPM 3 - Patient is checking sugar levels at different timings sir..
PPM 1 - What time did she take dinner? Did she take lispro/humalog before that? If yes then at what dose?
PPM 3 - Yesterday at 8:30 am. Today at 6:00 am.
PPM 1 - As long as we are aware of the timings it should not be an issue @SE
8:30 pm dinner? Any humalog before that?
Knowing the time of her dinner would also be very important to guage the overall fasting duration from dinner time to pre breakfast as that would also influence her fasting blood sugars.
PA - Dinner completed at 9pm sir.
PPM 3 - HUMALOG before that?
PA - 8U sir.
PPM 1 - Keep sharing all the patient's insulin doses everday at least if not anything else.
And also just the time taken.
PA - Okay sir.
At 12pm Brown rice, 12U. 5pm milk with biscuit. 9pm 250mg/dl 8U Humalog, brown rice with egg fried. The patient's weight is 44kg now sir.
PPM 2 - 
PPM 2 - If you notice - none of the variants of rice has low glycemic index (less sugars). Unfortunately brown rice was marketed as a better alternative to white rice but that isn't the case and glycemic index is just as high.
PPM 1 - 👍
PA - Sir lantus has completed now, my patient took only 8u glargine at 10:30pm.
PPM 3 - Plz arrange vial before hand, there shouldn't be any lapse in insulin supply...
PPM 2 - Missed doses of Insulin can precipitate DKA and put the patient in ICU /Hospital again.
Please make sure insulin is adequately stocked.
PA - Ok sir
21-01-2025
PA - At 6am 216mg/dl, 6U Humalog. Breakfast java with green peas.
PPM 1 - 👍
PA - At 1pm Rice with dal, 12U Humalog.
In the evening one chocolate, at 8.15pm roti with curd, 118mg/dl.
PPM 1 - 👍
22-01-2025
PA - Bedtime glargine at 10.40pm yesterday, 14U.
Today at 6am 247mg/dl, java and green peas.
PPM 3- Bedtime we already increased to 16 units right?
PA - Yes sir but yesterday sugar level was 118 so my patient thought could take 14u.
PPM 1 - Pre dinner 118?
Well the glargine doesn't act on the dinner much. It acts overall and it's effect shows in the fasting so don't change glargine dose depending on pre dinner.
PA - Okay sir.
At 1 pm rice with egg fry.
At 5 pm Biscuit. 7.40pm pre dinner sugar is 224mg/dl
23-01-2025
PA - At 6.28am 237mg/dl, 6U Humalog. Vermicelli upma.
PPM 1 - Vermicelli is a processed food largely comprising of maida, which may have less nutrients and just empty calories
Processed food needs to be avoided when consuming any kind of meal
PA - Okay sir.
PPM 3 - Categorise your patient into sedentary or moderate or vigorous activity.
Calculate your patient 's calorie intake currently.
Categorise patient's activity and modify accordingly calorie (preferably carbohydrate) intake...
If all above things are appropriate and yet sugars are high, requires insulin dose increment...
PA - At 1 pm 12U Humalog. Brown rice with egg.
At 4 pm Samosa, 6 pm Guava. At 8pm pre dinner sugar level 229mg/dl, 8U Humalog, 2 Chapathi with bitter gourd.
PPM 3 - Increase short acting by 2 units each.
PA - Ok sir
Sir the patient was suffering with slight chest pain at left from afternoon itself.
PPM 3 - Such complaints needs direct consultation.
PA - Yes sir patient wants to consult tomorrow.
24-01-2025
PA - At 6.15am 187mg/dl, 8U Humalog.
PPM 1 - This is from 16U of glargine and what was the night dose of lispro?
PA - 10U sir
At 6.30am Upma, At 11am carrot, green peas. At 1pm 14U Humalog, brown rice with curd, At 8.20pm pre dinner sugar is 114mg/dl, 10U Humalog, Rice with sambar.
PPM 1 - 👍
23-01-2025
PA - Bedtime glargine at 10.40pm 16U.
At 6am 141mg/dl. 6.30am 10U Humalog, milk and java.
PPM 1 - 👍
PA - 1 pm Roti, 6pm one sweet, at 8.46pm 295mg/dl, 10U Humalog, rice with dal.
Taken 12U.
PPM 1 - 👍
26-01-2025
PA - Good morning sir, my patient forgot the bedtime glargine and missed it today at 7;12am fasting sugar level:165mg/dl.
PPM 1 - Amazing that the fasting is holding inspite of missing the dose!
This fasting sugar of 165 was after 11 hours of fasting since yesterday's dinner?
PPM 2 - Can we explore why she forgot the Glargine?
PPM 1 - Another angle to medical cognition as in memory driven cognition?
Just a hypothesis:
She may have slept off after dinner?
I wonder why do we advocate this unearthly hour of post dinner for the long acting?
PPM 2 - Ideally the patient should take the missed dose asap!
PPM 1 - Asap after waking up? Like once she woke up and saw her fasting 165 she may have taken the lantus?
PPM 2 - Yes sir.
PA - No sir didn't take.
Patient slept after dinner and forgot it sir and just to see how far it increased checked the glucose level sir.
Completely denied the lantus at yesterday night haven't taken till now.
PPM 2 - Can take now.
PPM 1 - I'm surprised by my guess!
PA - Can patient take it now after taking lispro sir?
PPM 2 - Yes.
Don't worry as Lantus does not have any peaks, so your night dose too can remain the same dose.
PA - At 10am 8U Humalog, Idly 4.
Sir Taken 16u glargine now itself.
PPM 1- 👍
PPM 2 - 👍
PA - At 3 pm pre meal sugar is 276mg/dl. 14U Humalog. Rice with chicken. At 8.16pm pre dinner sugar is 222mg/dl, 10U Humalog. Roti with chicken.
Here in this after breakfast with 4 idly, patient have eaten 2 chapathis at 12pm then checked glucose level at 2:30pm sir.
Glargine at 10.30pm 16U
27-01-2025
PA - At 6.20am 221mg/dl, 8U Humalog, 1 Chapati with beans curry.
PA - At 8pm 126mg/dl, 10U Humalog, rice with tomato sauce.
10.30pm 16U glargine.
28-01-2025
PPM 2 - She could consider taking the Lantus after the evening meal so that she won't forget the dose and also better with post evening meal dosing.
PPM 1 - You mean before? She's already taking it after?
PA - At 6.30am 206mg/dl, 4U Humalog, One chapati with tomato chutney.
PPM 2 - Meal at 8PM and Lantus at 10 30 PM.
Can take right after meal.
PPM 1 - 👍
PA - Sir parents bought lispro mix:50 can patient take this?
PPM 1 - Then lantus may have to be withheld.
It will unnecessarily complicate things.
PA - Sir, can patient take it right now?
PPM 2 - This has intermediate acting (10h to 12h acting insulin) and will complicate things.
PA - Sir patient need immediate response regarding this insulin like same doses or have to change as patient need to take it before dinner 🙏 right now.
PPM 1 - Don't take this today
Take lispro separately
Take lantus separately as before
We can discuss this later with more time in hand.
What was your planned lispro dose before dinner today?
Yesterday you took 10U of lispro before dinner.
PA - Yes sir but it has completed and bought new one that is lispro mix 50.
PPM 1 - 👆To take the same 10U of lispro with this mixture vial you will need to take 20U of this mixture and you will also get 10U of longer acting lispro, which won't allow you to take the lantus ever. Also you will need to repeat the lispro mix twice daily (before breakfast and dinner) with plain lispro before lunch.
All the above needs some time for all members of the team here to come to a consensus if you should start this new experiment at this juncture.
The upside is that it could mean 3 insulin pricks per day as opposed to 4 insulin pricks with the current lispro lantus regime.
How far is the shop? Can't it be changed to the plain lispro?
PA - Okay sir patient will try as possible.
Sir there is no availability as for now.
PPM 1 - Has the patient taken dinner?
PA - No sir. Before dinner Insulin have to be taken so didn't even had dinner sir.
PPM 1 - If there is no other option then she can take 20U of this lispro mix which will give her 10U of lispro and 10U of long acting lispro and she can't take lantus from today
Please check the two hour post dinner today and if possible at 2:00AM (ideally this patient should buy a CGM monitoring sensor soon)
I guess tomorrow before breakfast she will again have to take this same injection of lispro mix. We can decide that dose tomorrow looking at her fasting.
PA - Okay sir thank you.
29-01-2025
PA - Yesterday pre dinner sugar level at 8.30pm is 147mg/dl, at 9.40pm 20U lispro mix.50.
Today fasting sugar level is 169mg/dl.
What dose should the patient take now? Previously with plain lispro the doses are 8u,14u,10u.
PPM 3 - Take 20 units before breakfast. By afternoon arrange HUMALOG lispro.
PA - Sir already taken 8u.
PPM 3 - Here your patient got only 4 units short acting and 4 long acting very less...
PPM 1 - 👍
For 8U lispro you need to take 16U of lispro mix.
Can take another 8U now and take some food or wait till lunch.
Yesterday's two hour post dinner would have been desirable to know to decide how much more plain lispro could be added to the mix before dinner. Yesterday's protamine lispro that your patient took as 10U along with plain lispro in a single shot achieved fair control for her fasting at 169 so perhaps increasing the 2U lispro protamine at night would make it better.
At @PPM3 @PPM2 now that we have begun we can try this regime of
Lispro mix 20U before breakfast
Lispro plain 10-14U before lunch (adjust as per pre meals)
Lispro mix 20U before dinner
Stop lantus
Increments or decrements of+ or -2 can be made as we monitor her everyday
If she could buy a CGM sensor for 5000/- she would have a painless and more efficient monitoring.
In this context here's another interesting paper @PPM3 @PPM2 👇
PPM 3 - 👍
PPM 2 - Interesting. Will read.
PA - At 12.40pm Lispro mix 28U, Roti with curd.
At 5pm 1 Roti, at 9pm pre dinner sugar level 325mg/dl
PPM 3 - How much before dinner your patient is taking HUMALOG??
PA - Plain lispro 10u sir.
PPM 1 - 👍
Yes I guess she may currently be having no lispro with her? Only lispro mix? Lispro mix cannot be taken thrice.
PPM 3 - 10-14-12 this is how we increased last as I remember.
PA - Yes sir.
PPM 3 - Give before dinner 18 units... Lantus how much patient is on??
PA - 16u sir
PPM 3 - She purchased lispro I think sir...
PA - Sir now should take more 8u of Humolog.
PPM 3 - You purchased plain lispro??
PA - Yes sir.
PPM 3 - 10 given before dinner??
PA - Didn't have dinner taken insulin just now sir.
PPM 3 - Ok give 6 units more and tell your patient to have dinner.
PA - Ok sir thank you, and tomorrow before breakfast should take lispro plain or mix sir?
PPM 3 - Sugar is high, be careful next time with this experience....
Plain as usual 10-14-12.
PA - Okay sir.
30-01-2025
PPM 2 -Assumed so. In fact Humalog Mix 50 is Lispro plain + Lispro Protamine Hagedron (like NPH)
So did believe that Lispro would sit well with NPH.
PPM 1 - 👍
PA - Yesterday bedtime glargine at 11pm, 16U.
31-01-2025
PA - At 6am fasting sugar is 208mg/dl.
At 6.40am lispro mix 16U, Upma.
PPM 1 - Why lispro mix again?
Yesterday night it was decided plain lispro?
PA - Yes sir but if lispro mix is not used it will be wasted,so patient wants to continue lispro mix along with plain,like lispro mix morning and evening,and lispro plain at afternoon.
PPM 1- Hmmm that's a bit of an issue in the sense that if lispro mix is adequate twice daily then lantus is not required but I guess this patient is planning to have a unique innovative schedule of lispro mix once and lantus once till the pending lispro mix gets utilised. Will be good to follow up and document the results of this brief serendipitous experiment which no one may have documented before @PPM2
PPM 2 - 👍
I think the better suggestion would be that next time if the patient is unable to get plain Lispro, she can try for Novorapid or Trurapi, which are very similar to plain Lispro.
This would be better than buying a Lispro mix.
Also, the faster the patient enrolls herself in a diabetes education course, the better. Can she consider an online course, like DAFNE etc?
PPM 3 - @PA find time for this ...
PA - Sir I was eagerly waiting for knowing all about this diabetes.
PPM 3 - Can do that...
This course helps to control your diabetes management better, to prevent complications....
Confirm syringe and insulin compatibility too incase of non-availability and buying other brand ultra short or any form of insulin.. I think this problem occurred already once in the beginning... @PA.
PPM 3 - Sir parents purchased mix by mistake or lack of knowledge about the difference between the two..
Take mix morning and evening
Plain lispro before lunch..
PPM 1- 👍
PA - Sir afternoon at 1pm|14u plain HUMOLOG| at 8pm|pre dinner sugar level:113mg/dl|lispro mix 20u
PPM 2 - I understand. These are the alternatives she can take.
PA - Yes sir already I Bought lispro kwik pen so I should use only lispro Humolog instead of other brands.
Fasting sugar 183mg/dl.
PPM 2 - I think it is high time your patient should consider getting a continuous glucose monitor such as Abbott FSL2 or Dexcom One +
I also think "Time in Range" which can be tracked on these CGMs is becoming a reliable marker of glycemic control than HbA1c now.
PA - At 1pm Lispro plain 14U, At 8pm pre dinner sugar value is 182mg/dl, lispro mix 20U.
PPM 1 - 👍
01-02-2025
PA - At 6.27am fasting sugar level is 166mg/dl. At 7am 16U lispro mix.
PPM 1 - 👍
03-02-2025
PA - Fasting sugar 215mg/dl, 16U lispro mix.
PPM 1 - How much lispro mix or lantus taken at night yesterday? That determines the fasting value.
👆16U lispro mix at what time because your patient shared just once yesterday saying 16U at 7:00AM yesterday.
PPM 3 - To keep in simple understandable words
If the blood sugar is high
Ask yourself 2 questions
1.what am I eating?
2.how much am I eating?
100 grams of carbohydrate is not same as 100 grams of protein
The same 100 grams of a different macronutrient increases your blood sugar levels differently
So you have to learn to adjust, control your portions of meal to keep blood sugars in target range.
Yesterday morning it was 166
Today it's 215, so overall you ate some more carbohydrates, or grossly altered meal intake timing or timing of insulin dose.
So if you are eating something with more carbohydrates, you may have to eat 40grams of such recipe, and balance the rest 60grams otherwise to keep yourself full, blood sugar controlled.
Plz learn these things while you are measuring sugars.
PPM 1 - 👍Also she took 20U of lispro mix the night before and we don't know how much lispro mix she took yesterday night.
PPM 3 - Yes sir.. She might have taken 20 units like before sir...
PPM 1 - I can't assume that but will wait for the patient's advocate to confirm here.
PPM 3 - Certainly sir.
PPM 1 - 👍
PA - Yes sir yesterday patient taken more flaverourd sugars like cake icecream and also biryani that may be the reason.
Yesterday before breakfast at 10am 16u lispro mix,2 chapathis.at 2pm|14u lispro plain, biryani.8pm|20u lispro mix roti2, between 9to 10 some ice-cream and a piece of cake sir.
PPM 1 - 👍
A sweet solution to the puzzle!
PPM 3 - If your patient is planning for an ice-cream or something, can limit roti to just 1 or if it's an unplanned ice-cream or cake 2-3units plain lispro can be taken extra..
Again it's only occasionally, but not to be done as a habit...
PPM 1 - 👍
PA - Okay sir.
04-02-2025
PA - At 8.50pm pre dinner sugar level 133mg/dl.
At 6.30am 18U lispro mix.
At 1pm 16U lispro plain.
At 9pm lispro mix 20U.
05-02-2025
PA - Fasting sugar level 105mg/dl. Lispro mix 16U.
PPM 1 - 👍
Three times lispro seems to be giving ideal control 👏👏.
PPM 1 - Agreed. In fact this is a reasonably good strategy and is followed here as well.
Can @PA your patient consider getting a Freestyle Libre 2 continuous glucose monitor just once?
We can see the Target in range with this strategy and perhaps make it long term.
PA - Sorry sir, she cannot afford that cost it was around 5 thousand.
PPM 2 - Yes I understand. Let me see if I can help in any other way.
PA - At 6.10am fasting sugar is 209mg/dl. This may be due to less units of lispro 9U taken instead of 20U as it was finished. The patient will take plain and lantus from today sir.
PPM 1 - Does the patient want to switch back to 4 pricks as opposed to the good control obtained with the three pricks of lispro alone? @PPM2 @PPM3
PPM 3 - The total dose also needs to be taken into consideration sir, to say one is better over the other...
3 pricks is more convenient to the patient we can continue the same sir...
Currently she's on 18- 16- 20 units (total - 54 units).
PPM 1 - What was the previous total dose with 4 pricks that gave her the same ideal control?
PPM 3 - Earlier 10-14-12 (+ 16 Lantus) = 52 units
No much difference.
✅
PPM 1 - 👍
06-02-2025
PA - Pre dinner sugar level 161mg/dl
At 6.30am 10U lispro plain.
At 1 pm 14+2U lispro plain (increased because of potato curry)
At 8.30pm 12U lispro plain.
07-02-2025
PA - At 6.16am fasting sugar is 167mg/dl. 8U lispro plain
Night at 10.30pm 16U lantus.
PPM 1 - 👍
PA - At 1 pm 14U Humalog. Pre dinner sugar 187mg/dl, 12U Humalog.
At 10.20pm lantus 16U
PPM 1 - 👍
08-02-2025
PA - Fasting sugar level at 10am is 145mg/dl, 8U Humalog.
Lunch at 4pm, 14U Humalog
Pre dinner sugar value at 9.40pm 121mg/dl, 8U Humalog.
09-02-2025
PA - Yesterday bedtime lantus at 11pm 16U glargine
Today fasting sugar is 171mg/dl, 6U lispro plain at 8.40am.
At 2pm 12U lispro
At 8pm 10U lispro
At 10.30pm 16U lantus.
PPM 1 - 👍
PPM 3 - Try to fix timings without much variation..
PA - Okay sir only timings vary on Sunday.
10-02-2025
PA - At 6.30am fasting sugar 185mg/dl, 6U lispro
Finger millet java for breakfast.
PPM 1 - 👍
PA - Pre dinner sugar at 8.20pm is 157mg/dl, 8U lispro. Rice with fish curry and one boiled egg.
11-02-2025
PA Lantus at 10pm 16U.
Today fasting sugar at 6.20am 166mg/dl
PPM 1 - 👍
12-02-2025
PA - Fasting sugar at 6.25am 94mg/dl.
Yesterday at 8.30pm pre dinner sugar is 247mg/dl. Patient ate one chapati and taken 10U lispro.
At 10.30pm glargine 16U.
247mg/dl is due to intake of sweet sir.
PPM 1 - 👍
Which sweet?
PA - Bread halwa sir.
PPM 1 - @Meta AI how many calories in Hyderabadi bread halwa?
Meta AI - Hyderabadi bread halwa! That's a delicious dessert!
The calorie count of Hyderabadi bread halwa can vary depending on the recipe, portion size, and ingredients used. However, I can provide you with an approximate estimate.
A typical serving of Hyderabadi bread halwa (about 100-150 grams) can contain around 250-350 calories. Here's a breakdown of the approximate nutrition facts:
- Calories: 250-350 per serving
- Carbohydrates: 35-45 grams
- Sugar: 20-25 grams
- Fat: 10-12 grams
- Protein: 2-3 grams
Please note that these values are approximate and can vary based on the specific recipe, ingredients, and portion size.
If you're concerned about calorie intake, consider using healthier alternatives or adjusting the portion size. Would you like some suggestions for healthier variations of Hyderabadi bread halwa?
PPM 1 - @Meta AI patient took 10U of lispro before hyderabadi bread halwa and the blood sugars were 247. How much more lispro may have made her post meal sugar to 147 instead of 247 if she could have taken the Hyderabadi bread halwa into account before deciding her lispro dose?
Meta AI - To estimate the additional lispro needed, we'll use the patient's current data and make some calculations. Please note that this is a simplified analysis and not a substitute for professional medical advice.
# Assumptions
- The patient's current blood sugar is 247 mg/dL.
- The desired post-meal blood sugar is 147 mg/dL.
- The patient has already taken 10 units of lispro.
# Calculations
1. Blood sugar reduction needed: 247 mg/dL (current) - 147 mg/dL (desired) = 100 mg/dL
2. Insulin sensitivity factor: This varies from person to person, but a common estimate is 1 unit of rapid-acting insulin (like lispro) lowers blood sugar by 30-50 mg/dL. Let's assume an average sensitivity of 40 mg/dL per unit.
3. Additional lispro needed: To reduce blood sugar by 100 mg/dL, we'll divide the reduction needed by the insulin sensitivity factor: 100 mg/dL ÷ 40 mg/dL/unit ≈ 2.5 units
# Recommendation
Based on this calculation, the patient may have needed an additional 2-3 units of lispro (rounding up from 2.5 units) to achieve a post-meal blood sugar of 147 mg/dL, assuming the same insulin sensitivity and no other factors affecting blood sugar.
Please consult a healthcare professional for personalized guidance, as this is a simplified analysis and individual factors may vary.
PA - Taken halwa at 5pm and lispro 10u at 8:30pm sir.
PPM 1 - What was the insulin taken before 5PM yesterday?
PA - 14 u lispro at 1pm sir.
PPM 1 - Nothing before breakfast yesterday?
@Meta AI patient took no lispro before hyderabadi bread halwa at 5PM and the blood sugars were 247 at 8:30PM before dinner.
How much lispro at 5PM before taking the hyderabadi bread halwa may have made her pre dinner sugar at 8:30 PM to 147 instead of 247?
Meta AI - To estimate the lispro dose needed, we'll use the patient's current data and make some calculations. Please note that this is a simplified analysis and not a substitute for professional medical advice.
# Assumptions
- The patient's current blood sugar is 247 mg/dL at 8:30 PM.
- The desired pre-dinner blood sugar is 147 mg/dL.
- The patient consumed Hyderabadi bread halwa at 5 PM and took no lispro.
- The time interval between consuming the hyderabadi bread halwa and the blood sugar check is approximately 3.5 hours.
# Calculations
1. Blood sugar reduction needed: 247 mg/dL (current) - 147 mg/dL (desired) = 100 mg/dL
2. Insulin sensitivity factor: As before, let's assume an average sensitivity of 40 mg/dL per unit.
3. Total insulin needed: To reduce blood sugar by 100 mg/dL, we'll divide the reduction needed by the insulin sensitivity factor: 100 mg/dL ÷ 40 mg/dL/unit = 2.5 units
However, since the patient consumed the hyderabadi bread halwa 3.5 hours before the blood sugar check, we need to consider the duration of action of lispro. Lispro typically starts working within 15 minutes, peaks between 1-3 hours, and has a duration of action of approximately 4-5 hours.
# Adjustment for duration of action
Considering the 3.5-hour time interval, the lispro dose needed might be slightly higher to account for the waning effect of the insulin. A common approach is to add 10-20% to the calculated dose. Let's add 15% to the total insulin needed: 2.5 units x 1.15 ≈ 2.875 units
# Recommendation
Based on this calculation, the patient may have needed approximately 3 units of lispro (rounding up from 2.875 units) at 5 PM, before consuming the hyderabadi bread halwa, to achieve a pre-dinner blood sugar of 147 mg/dL at 8:30 PM.
Please consult a healthcare professional for personalized guidance, as this is a simplified analysis and individual factors may vary.
PA - 6u at 7am sir
6.30am fasting sugar is 94mg/dl.
PA - As Humalog cartridge was completed morning with one unit patient could not take theinsulin for morning and afternoon, skipped the dosage. Breakfast upma, Lunch one chapati.
At 7pm pre dinner sugar level is 135mg/dl.
PPM 1 - Upma chapati have done well without insulin!
PPM 2 - This is largely because quite often there is still some reserve of Insulin left. Perhaps a form of the honeymoon phase.
PPM 1 - 👍
13-02-2025
PA - Good morning sir yesterday 9pm dinner was curd rice and one egg. 11pm: glargine 16u.
6.30am fasting sugar is 197mg/dl, 6U Humalog.
PPM 1 - 👍
14-02-2025
PA - Yesterday at 1pm 14U Humalog, 9pm 164mg/dl, 10U, at 11pm 16U glargine.
^.30am fasting sugar 185mg/dl, 16U Humalog.
15-02-2025
PA - Fasting sugar is 149mg/dl, 6U Humalog.
PPM 1 - Please share yesterday's all doses of lispro and glargine with timings
PA - Yesterday at 1pm 14U Humalog.
At 8.30pm 10U Humalog
At10.30pm 16U glargine.
PPM 1 - 👍
PA - At 1pm 14U Humalog
8pm 10U Humalog.
At 10pm 16U glargine.
16-02-2025
PPM 1 - So essentially it's currently
6+14+10 and 16?
PA - Yes sir.
PPM 3 - Before breakfast supposed to be 8.
Before dinner 12.
PPM 2 - Isn't the patient informally carb counting and then taking her doses?
PPM 3 - I'm not sure about sir..
I remember the doses advised to her....
PA - Patient was not sure about carb count sir but she is taking less food in the breakfast and dinner she reduced it to 6u,10 sir.
This is free and very easy to do and learn.
PA - Today fasting sugar 144mg/dl, 6U Humalog.
At 8.40pm 10U Humalog
18-02-2025
PA - Fasting sugar level 141mg/dl on 17-02-2025
At 7am 6U Humalog, 8pm 10U Humalog, but glargine only 4U because of deficiency.
Today fasting at 6am 191mg/dl, 6U Humalog.
PPM 1 - Fasting wasn't that bad inspite of sudden dose reduction in glargine!
19-02-2025
PA - Yesterday at 1 pm 12U Humalog.
8 pm 10U Humalog
10.30pm 16U glargine.
PPM 2 - Is she taking Humalog only twice a day?
PA - On 19th. Fasting sugar level at 6am:153mg/dl
No sir 3times.
PPM 2 - Okay noticed now. Thanks for clarifying.
PA - Thank you sir.
PPM 2 - Ideally, she should always have a few pens of both insulins with her. It is strongly recommended that doses should not be missed.
PA - Sure sir.
At 6:30am: 4u HUMALOG
20-02-2025
PA - Yesterday 1 pm 12U Humalog
8 pm 10U Humalog
10.30 pm 16U glargine
On 20th Fasting sugar is 144mg/dl. 4U Humalog sir.
PPM 1 - 👍
22-02-2025
PA - Fasting sugar on 21-02 25 is 136mg/dl
Glargine at 10pm 20U.
Skipped Humalog for the whole day
Today on22-02-25 fasting sugar is 180mg/dl.
PPM 1 - 👍
No comments:
Post a Comment