25-02-2025
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 ONLINECOMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BET EVIDENCE BASED INPUTS.
Afternoon ward:
19F with Type 1 Diabetes, diabetic ketoacidosis and lower limb cellulitis
Mother lost both her limbs by amputation due to diabetic foot a year back although mother had developed diabetes just two years ago.
25-02-2025
PPM 2 - Early changes of Charcot visible here. Loss of hair on legs, skin changes, almost flat foot arches, LMN type of wasting (minimally) all pointing to poor glycemic control and long duration of diabetes.
What's the current HbA1c and long term management plan?
PPM 1 - @PPM3 please check the data on file to answer these.
PPM 3 - HbA1c is 7.3 sir
She was non complaint to treatment.
Her history is suggestive of Type 1 DM sir, planning to discharge her on injectable insulin after DKA subsides.
PPM 1 - Any reasons the treating team found for her non concordance with the treatment?
PPM 3 - She herself told that she was on OHAs and she used to not take them regularly sir.
PPM 1 - Oh! Since when was she on OHAs? How long is her diabetes?
PPM 3 - Since 6yrs she’s having sir, i.e from the age of 13/14yrs.She was on OHAs since only 1 year and non complaint to medication.
PPM 1 - From age 13 to till 1 year back what was she taking for her diabetes?
PPM 3 - She did not take anything sir
Since 6 years she has complaints of polyuria, polyphagia and polydypsia
And since 1 year she is using medication occasionally
There was no apparent reason why she decided to go to hospital 1 year ago for treatment sir.
PPM 1 - Very interesting!
Then it couldn't have been a type 1 since 6 years although it now looks like a type one with ketoacidosis! @PPM2?
PPM 3 - Why couldn’t it be type 1 sir?
PPM 1 - Type 1 essentially means completely destroyed beta cells and hence prone to ketoacidosis and death if left untreated with insulin!
However there's a possibility that her beta cells behaved like type 2 initially with just 60-70% destruction and took 6 years to get totally destroyed producing severe insulinopenia enough to generate ketoacidosis!
But then the above scenario would be labeled rapidly progressive type 2. What other labels can one use from the diabetes ontology for a similar scenario @PPM2?
PPM 2 - I don't believe that HbA1c for half a second.
PPM 3 - Our hospital lab generally gives a lesser value than outside labs sir
It will be around 9/10, if our lab gives HbA1c as 7.3.
PPM 2 - It is very likely a Type 1 with a long honeymoon phase.
While that is the pathophysiology, Type 1 is now basically diagnosed with a C-peptide level of <200 pmol/l paired with a serum glucose of 72mg/dl or above and either Anti GAD, Anti IAA2, Anti Zn8 or any Anti ICA antibodies.
Can happen that she was teetering along the borders of these numbers for quite a while (honeymoon phase)
This is euphemism for "our hospital lab is incredibly corrupt and immoral in that in several cases it calculates the HbA1c by using a formula with fasting blood glucose and also does not upgrade itself to perform HPLC and still performs enzymatic based tests"
I've been there and done that.
Ambedkar, our biochemistry in house lab tech told me this when I probed on this issue. He himself gets his and his family tests done elsewhere, inspite of having KAP.
PPM 1 - This is a 19 year old girl with a younger brother and a mother with two amputated limbs and a long dead father and no one else in this world other than us (for the time being)! Even while giving consent in the file for something it was she who had to painfully write using the cardiac table in her ICU bed even as she continued her acidotic breathing as her brother looking after her in the ICU is just a minor.
While our departmental fund and devotion may tackle her issues we need to gear up foundationally to work around expensive lab test driven diabetes ontologies and develop our own low resource settings ontology for diabetes classification @PPM4.
PPM 1 - Yes, none of those tests will add any value to her current clinical condition.
However, what insulin she will be put on matters and I'm curious to know.
I also believe a thorough and detailed neurological and vascular examination would be excellent value addition to her care.
PPM 1 - We have discussed this with the Principal who used to be from Biochemistry department and the HOD biochemistry who agreed that our latex agglutination approach to Hba1c isn't great but we must remember again that we work in a low resource setting with sparse manpower and resources and have to make do with other perhaps even better current PaJR portable means of blood sugar control assessment than expensive Hba1c.
Mixtard 50:50 sponsored by "we the people"/tax payers/government.
Yes that's not difficult. Can be easily done and maintained on PaJR follow up.
PPM 2 - It's a solid bet and should be as good as those Lispros and Levemirs.
If anyone of the interested PGs can kindly share a head to head trial on this for further discussion and optimisation of treatment.
PPM 1 - 👍
[10-03-2025 10:25] PA: Doctor, this patient is having breathlessness and is in Gandhi Hospital.
[10-03-2025 10:32] PPM 1: Oh!
Why Gandhi?
Why not here?
[10-03-2025 10:45] PA: Don't know, casually called her about updating her health.
[10-03-2025 10:59] PPM 1: Alright
[10-03-2025 13:00] PA: She is still waiting there with nobody attending. She didn't come to Kamineni
for financial reasons.
[10-03-2025 13:06] PPM 1: Alright but how much did she have to spend with us last time? Oh now I
remember the treating unit had probably asked for some expensive antibiotics to continue which they
couldn't afford.
[10-03-2025 13:07] PA: Now how can we help her?
[10-03-2025 13:15] PPM 1: We need to know what are her current pressing issues.
How is her lower limb wound?
How is her sugar control?
Can she check her sugars every two hours after her meal and allow us to guide the dosage of her
insulin?
@PPM2 may agree that it's the non evidence based over-testing and overtreatment that she has received
till now (whatever may be the reason) that is perhaps the reason for her running out of resources
Even the government PHC also has adequate resources to manage her only there are no trained doctors
[10-03-2025 13.18] PPM 2: 👍
[10-03-2025 13:19] PA: Now they are attending to her and according to her brother her wound is okay
and sugar under control. will call her after some time and update.
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