03-02-2025
This is an Online E Log Book to discuss our patient's de-identified health data shared after taking his signed informed consent. Here we discuss our patient's problems through series of inputs from available global online community experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.
PPM 1 - This patient is also Diabetic since 10 years! Trying to fix his insulin dose. Wife is expert with the glucometer!
Problem 1: Currently sugars are uncontrolled to the tune of 250 fasting and 400 pp as they have no one to guide their insulin dosages
The attached image shows in the syringe markings as to what dose he's on of plain insulin 10U and Mixtard 3U! The mixtard vial is available from Government abd they are buying the soluble insulin at 200/- per vial unlike 80M @PA @PPM2
Problem 2: Peripheral neuropathic pains bilateral lower limbs since one month since he was operated in the lumbar region in November 2024 here for suspected lumbar Kochs! Started Antitubercular therapy two months.
EMR SUMMARY
Age/Gender : 40 Years/Male
Address :
Discharge Type: Relieved
Admission Date: 21/11/2024 02:44 PM
Date of Operation
2/12/24 (L5-S1+L5 LAMINECTOMY+PLIF )
Diagnosis
INFECTIVE L4-L5 SPONDYLODISCITIS ?KOCHS
Case History and Clinical Findings
PATIENT CAME WITH C/O PAIN IN THE BACK(LOWER BACK) SINCE 2 MONTHS HOPI:
PATIENT IS APPARENTLY ASYMPTOMATIC 2 MONTHS AGO, LATER HE DEVELOPED PAIN OVER THE LOWER BACK, PAIN IS SUDDEN IN ONSET, PROGRESSIVE IN NATURE AND RADIATING TO B/L LOWER LIMBS
H/O TINGLING PRESENT H/O TRAUMA 2 MNTHS AGO
H/O FEVER PRESENT 2 MONTHS BACK NO BURNING MICTURITION
PAST HISTORY;
K/C/O T2-DM ON REGULAR MEDICATION SINCE 5 MONTHS(INJ.BIPHASIC INSULIN) N/K/C/O HTN/BA/TB/EPILEPSY
NO PREVIOUS SURGICAL HISTORY NO OTHER COMPLAINTS GENERAL EXAMINATION:
PATIENT IS C/C/C GC FAIR
VITALS:
AFEBRILE
BP-130/80MMHG
PR-82BPMSYSTEMIC EXAMINATION:
CVS: S1,S2 HEARD, NO MURMURS RS: BAE+,NVBS
CNS:NFND
P/A- SOFT, NON TENDER
LOCAL EXAMINATION OF LS SPINE:
SKIN- NORMAL NO SWELLING NO DEFORMITY
TENDERNESS+ OVER L4-L5 LEVEL RIGHT LEFT
SLRT 0-90 DEGREES 0-90 DEGREES HIP-F AND E 5/5 5/5
KNEE-F AND E 5/5 5/5 ANKLE-F AND E 5/5 5/5 EHL AND FHL 5/5 5/5
SENSATIONS + + DISTAL PULSES + +
GM REFERRAL WAS TAKEN ON 22/11/24 I/V/O HIGH SUGARS
IMPRESSION: INJ.MIXTRAD 50/50 (18U---0 12U) AND STRICT DIABETIC DIET
OPHTHALMOLOGY OPINION WAS TAKEN ON 22/11/24 I/V/O DIABETIC RETINOPATHY CHANGES
IMPRESSION: NO DIABETIC RETINOPATHY CHANGES ARE NOTED ON EXAMINATION Pulmonology OPINION WAS TAKEN ON 23/11/24 I/V/O HISTORY OF ASTHMA IMPRESSION:CONTINUE SAME TREATMENT
GM OPINION WAS TAKEN ON 23.11.24 I/V/O PLAN TO CONVERT HAI NPH TO GLARGINE AND HAI
IMPRESION:INJ.LANTUS INSULIN 8U S/C POST MEAL 9PM, INJ.HAI S/C PREMEAL TID AFTER INFORMING GRBS
GM OPINION WAS TAKEN ON 29/11/24 I/V/O HIGH SUGAR CONTROL AND FITNESS FOR SURGERY
IMPRESSION: INJ. HAI S.C/TID(10-10U-10U)PREMEAL, INJ.GLARGINE 6U(LANTUS) S.C POSTMEAL 9PM, STRICT DIABETIC DIET AND TAB.METFORMIN 500MG PO/OD AND PATIENT CAN BE TAKEN UP FOR SURGERY WITH GRBS<200MG/DL AND MODERATE RISK.
GM REFERRAL WAS DONE ON 2/12/24 I/V/O DIABETIC CONTROL POSTOPERATIVELY IMPRESSION:I.V FLUIDS NS@125ML/HR, INJ. HUMAN ACTRAPID INSULIN I UNITS S/C STAT AND PLAN TO START INJ.LANTUS INSULIN AFTER BREAKING NBM.
1 UNIT OF PRBC BLOOD TRANSFUSION WAS DONE ON 4/12/24
GM REFERRAL WAS DONE ON 11/12/24 I/V/O UNCONTOLLED SUGARS IMPRESSION:INJ. HUMAN ACTRAPID INSULIN S/C TID(10U-10U-6U) BEFORE FOOD, INJ.GLARGINE(LANTUS) 8U S/C ONE HOUR AFTER DINNER
Investigation
NameValueNameValueRFT 21-11-2024 05:35:PM UREA24 mg/dlCREATININE0.8 mg/dl URIC ACID3.9 mmol/LCALCIUM10.0 mg/dlPHOSPHOROUS3.6 mg/dlSODIUM137 mmol/LPOTASSIUM4.3 mmol/L. CHLORIDE101 mmol/LLIVER FUNCTION TEST (LFT) 21-11-2024
05:35:PM Total Bilurubin0.97 mg/dl Direct Bilurubin0.19 mg/dl SGOT(AST)12 IU/LSGPT(ALT)13 IU/LALKALINE PHOSPHATASE536 IU/LTOTAL PROTEINS7.1 gm/dlALBUMIN3.83 gm/dl A/G RATIO1.17COMPLETE BLOOD PICTURE (CBP) 21-11-2024 05:35:PM HAEMOGLOBIN9.2 gm/dl TOTAL COUNT7600 cells/cummNEUTROPHILS65 %LYMPHOCYTES25 %EOSINOPHILS04
%MONOCYTES06 %BASOPHILS00 %PLATELET COUNT3.51SMEARmicrocytic hypochromic anemia COMPLETE URINE EXAMINATION (CUE) 21-11-2024 05:35:PM COLOUR Pale yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMINtraceSUGAR++++BILE SALTS Nil BILE PIGMENTS Nil PUS CELLS2-3EPITHELIAL CELLS2-3RED BLOOD CELLS Nil CRYSTALS Nil CASTS Nil AMORPHOUS DEPOSITSAbsentOTHERSNilHBsAg-RAPID21-
11-2024 05:35:PM Negative Anti HCV Antibodies - RAPID21-11-2024 05:35:PM Non Reactive POST LUNCH BLOOD SUGAR22-11-2024 11:29:AM302 mg/dl COMPLETE BLOOD PICTURE (CBP) 22- 11-2024 07:17:PM HAEMOGLOBIN9.8 gm/dl TOTAL COUNT8600 cells/cummNEUTROPHILS60
%LYMPHOCYTES30 %EOSINOPHILS04 %MONOCYTES06 %BASOPHILS00 %PLATELET
COUNT3.8SMEARmicrocytic hypochromic anemia PERIPHERAL SMEAR22-11-2024 07:17:PMRBC : microcytic hypochromic WBC : With in normal limits PLATELET : Adequate imp; microcytic hypochromic anemia POST LUNCH BLOOD SUGAR24-11-2024 04:46:PM268 mg/dl SERUM ELECTROLYTES (Na, K, C l) 26-11-2024 11:23:PM SODIUM139 mmol/LPOTASSIUM4.1 mmol/LCHLORIDE102 mmol/LSERUM ELECTROLYTES (Na, K, C l) 29-11-2024 04:12:PM SODIUM136 mmol/LPOTASSIUM3.8 mmol/LCHLORIDE101 mmol/LSERUM ELECTROLYTES (Na, K, C l) 01-12-2024 10:01:PM SODIUM138 mmol/LPOTASSIUM3.6 mmol/LCHLORIDE102 mmol/LABG 02-12-2024 03:14:PM PH7.29PCO238.8PO2155HCO318.3St.HCO318.6BEB-7.1BEecf- 7.0TCO239.5O2 Sat98.7O2 Count12.3COMPLETE BLOOD PICTURE (CBP) 02-12-2024 10:30:PM HAEMOGLOBIN7.9 gm/dl TOTAL COUNT11600 cells/cummNEUTROPHILS86 %LYMPHOCYTES10
%EOSINOPH
ILS01 %MONOCYTES03 %BASOPHILS00 %PLATELET COUNT2.90SMEARmicrocytic
hypochromic anemia with neutrophilic leukocytosis ABG 03-12-2024 12:01:AM PH7.38PCO235.1PO275.2HCO320.8 St. HCO321.6BEB-3.3BEecf-3.4TCO244.5O2 Sat95.8O2 Count10.4SERUM ELECTROLYTES (Na, K, C l) 03-12-2024 12:01:AM SODIUM133 mmol/LPOTASSIUM3.9 mmol/LCHLORIDE106 mmol/LCOMPLETE BLOOD PICTURE (CBP) 04-12- 2024 10:18:AM HAEMOGLOBIN8.3 gm/dl TOTAL COUNT10300 cells/cummNEUTROPHILS77
%LYMPHOCYTES17 %EOSINOPHILS01 %MONOCYTES05 %BASOPHILS00 %PLATELET
COUNT2.66SMEARMicrocytic hypochromic anemia COMPLETE BLOOD PICTURE (CBP) 05-12- 2024 10:27:AM HAEMOGLOBIN9.5 gm/dl TOTAL COUNT9900 cells/cummNEUTROPHILS73
%LYMPHOCYTES20 %EOSINOPHILS01 %MONOCYTES06 %BASOPHILS00 %PLATELET
COUNT2.57SMEARMicrocytic hypochromic anemia
Treatment Given(Enter only Generic Name)
PATIENT WAS CLINICORADIOLOGICALLY DIGNOSED AS INFECTIVE L4-L5 SPONDYLODISCITIS AND PAC WAS DONE ON 1/12/24 AND L5-S1+L5 LAMINECTOMY+PLIF SURGERY WAS DONE BY DR.ANIL KUMAR ON 2/12/24 AND PATIENT WAS SHIFETD TO POSTOPERATIVE WARD IN HEMODYNAMICALLY STABLE CONDITION. POST-OP DAY2,5,10 DRESSINGS WERE DONE AND COMPLETE SUTURE REMOVAL WAS DONE AND PATIENT IS BEING DISCHARGED UNDER HEMODYNAMICALLY STABLE CONDITION.
1) INJ MAGNEXFORTE 1.5MG IV BD
2) INJ AMIKACIN 500MG IV OD
3) INJ METROGYL 100ML IV TID
4) INJ PAN 40MG IV OD
5) INJ NEOMOL 1GM IV TID
6) INJ ZOFER 4MG IV BD
6) INJ TRAMADOL 50MG IN 100ML NS SLOW IV SOS
7) TAB.SHELCAL-CT PO/OD
8) TAB.LIMECEE 500MG PO/BD
9) TAB.AKT4 PO/OD
10) TAB.BANDON FORTE PO/OD
11) INJ.HAI S.C/TID ACC TO GRBS
12) INJ LANTUS S/C AT 7PM ACCORDING TO GRBS
Advice at Discharge
1) TAB.DALACIN-C 600MG PO/TID X 3 WEEKS
2) TAB. PAN 40MG PO/OD X 5DAYS
3) TAB. XYKAA 1GM PO/BD X 5DAYS
4) TAB.SHELCAL-CT PO/OD X 15DAYS
5) TAB.LIMCEE 500MG PO/BD X15DAYS
6) TAB.AKT4 PO/OD CONTINUED
7) TAB.BENEDONE FORTE 20MG PO/OD CONTINUE
8) INJ.HAI S.C/TID (10U-10U-6U) BEFORE FOOD TO CONTINUE
9) INJ. GLARGINE(LANTUS) 8U S/C ONE HOUR AFTER DINNERTO CONTINUE
Follow Up
REVIEW TO ORTHO OPD AFTER 3 WEEKS/SOS ON MONDAY OR THURSDAY
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
Drugs
Drug-Dosage Drug-Dosage Drug-Dosage
10CC SYRINGES -(BD)- 2CC SYRINGE (BD)- 3WAY 100CM EXTENSION(VEIN-O-LINE)-
ABSORBENT COTTON - 400 NETT- AIRACAL - D TAB(CALCIUM- D3)- AKT4 - KIT-
AMPIMOL -1000MG - TAB- AMPIMOL -1000MG - TAB(PARACETAMOL)- AQSILK-1-0 R/C AM5037-
AQSOLVE -1 R/C- 2421 - ARM SLING POUCH - SMALL [MGRM]- ASTHALIN - 2.5 ML-
ATROMED - INJ (ATROPINE)- BECOFUL -Z FORTE (B -COMPLEX CAPSULES)- BENADON - 40MG - TAB(PYRIDOXINE)-
BETT ( T T) -0.5ML- (TETANUS TOXOID)- BLOOD SET (LIFE LINE)- BUDASURE - 2ML RESPULES-
BUPRIGESIC 5MCG -PATCH- CARLY 200MG - TAB(CEFIXIME)- CBC- AD-1ML INJ(ADRENALIN)-
CHYMIST FORTE TAB- CILCONTROL -10MG TAB(CILNIDIPINE)- CLANDURA - 300MG CAP (CLINDAMYCIN
)-
CORTIBEST -100MG INJ(HYDROCORTISONE)- CREPE BANDAGE - 6' (MEDIGRIP)- DEXONA 2ml - INJ-
DISPOVAN SYRINGES - 5 ML- DUOLIN - 2.5 ML RESPULES- DYNOPLASTER ( MEDIGRIP) )-
ECG LEADS (EASY TRODE)- EFIPRES-30MG 1ML- ENEMA 100ML-
EVIKEM - LC TAB(L-CARNITINE -VIT -E)- FENT -2ML INJ [FENTANYL]- FLEXO METAL REINFORCED TRACHEAL TUBE CUFFED - NO:7.5MM-
FLEXO METALIC REINFORCED TRACHEAL TUBE CUFFED-7.0 MM- FOLEYS CATHETER - 16FG MEDIKIT- FOLEYS CATHETER -14SIZE -MEDIKIT-
GUEDEL AIR WAYS - NO:2 (LIFE O LINE)- HUMAN ACTRAPID - 10ML INJ- HUMAN MIXTURED - 40 U-
HYDROGEN PEROXIDE 100 ML- IGNIUM - 1ML INJ(NEOSTIGMINE)- IMETZA -XR-500MG (METFORMIN)-
INSULIN SYRINGE - 1ml [DISPOVAN]- IO DRAPE-MEDIUM ID-3025- IV CANNULA - 20G - MEDIKIT-
IV CANNULA -18G- MEDIKIT- IV DNS -500ML (PUNISKA)- IV NS - 500ML (PUNISKA)-
IV NS 1000ML(PUNISKA)- IV NS 100ML -PUNISKA- IV RL - 500ML - (PUNISKA)-
IV SET - MEDIKIT- IV SETS [POLYMED)- JETROL - CZ - TAB(CALCIUM+CALCITRIOL)-
JYDAME -500MG - INJ(AMIKACIN)- KENAZ -TAB(ACECLOFENAC&PCM)- LACTOLUS-TAB [LACTIC ACID BACILLOUS]-
LANTUS-100IU/ML - 3ML- LEMON - SEE TAB(LIMCEE)- LENIOL - 100ML (PARACETMOL)-
LIDFAST 2%JELLY (LIGNOCAINE)- METROGA- 400MG TAB(METRONIDAZOLE )- METRONIDAZOLE - 100ML -PUNISKA-
MEZOLAM - 10 ML- NEBULIZER MASK ADULT (LIFE LINE SYSTEM0- NEOROF 1 % - 20 ML(PROPOFOL)-
NEOVEC - 4MG - INJ- OXYGEN MASK ADULT - (LIFE O LINE)- PANCOLY - 40MG INJPANTOPRAZOLE)-
PANRAS - 40MG TAB(PANTOPRAZOLE)- PAPER PLASTER - 1- PARACYN - 650MG - TAB(PARACETA)MOL-
PETCRYL - 1-0 R/C 2534- PIMET - POVIDONE IODINE SOLUTION - 100ML- POTASSIUM CHLORIDE - 10 ML-
PYROLATE - 1 ML- REVERSEE- 2ML - INJ(SUGAMMADEX )- ROLLER BANDAGES - 6'-
SHAVING SET -PREPARATION BLADE- SHERCEF - 1GM INJ(CEFTRIAXONE)- SKIN STAPLER (AQMEN )-
STERILE WATER - 10 ML- SUCCITHEM - 10ML(SUCCINYLCHOLINE)VAIL- SUCTION CATHETER - NO:14 [ROMSONS]-
SUCTION CATHETER 16FG MEDIKIT- SURGICAL BLADE - NO. 11 - SURGICAL BLADE - NO. 22-
SURGICAL BLADE NO-15- SURGICAL GLOVE -6.5 -(AQMAX)- SURGICAL GLOVE -7.0 -(AQMAX)-
SURGICAL GLOVE -7.5 -AQMAX)- SURGICAL GLOVES - 7.5 (SENTINEL)- SURGICAL SPIRIT - 100 ML-
TACZO-H - TAB(TELMA&HYDROCHLOROTHIAZIDE)- TAMSUGRAP - TAB- TILIGON OINT(MUPIROSINE)-
TRAMADOL - 2ML - INJ- TRANEP - 1GM INJ(MEROPENEM)- TRAXAMAK - INJ - 5ML (TRANEXAMIC)-
URINE BAG -[ROMO - 10]- URINE BAG ADULT - MEDIKIT- VOMIAMP -4MG TABLET(ONDANSETRAN)-
VOMIRAS - INJ(ONDANSETRON )- XSULIN 30/70 (BIPHASIC ISOPHANE INSULIN 40IU0- ZOCALM - 0.25MG TAB(ALPRAZOLAM)-
ZOSTUM -1.5G INJ(CEFOPERAZONE&SULBACTAM)-
Discharge Date
Date:12/12/24
Ward: MALE ORTHO WARD
Unit: I
03-02-2025
PPM 1 - @PA please share his blood sugar values two hours after dinner and also share an image of his food plates as well as the insulin syringe loaded.
He just got his repeat MRI done. Also reviewing his past MRI images and comparison
Also has raised alkaline phosphatase likely due to bone involvement which made someone refer again to ask us if his antitubercular therapy can be continued.
05-02-2025
PA - 10 units
PPM 1 - Let us know his blood sugar after two hours.
5 units
PA - Yesterday post dinner. 👆. Jawa.
PA - Today fasting sugar 👇
PPM 1 - we'll need to ask them to post the loaded syringe after first loading the plain insulin (which looks like water) and then post how much mixtard they have loaded (again the numbers in the syringe should be visible)
Also we need them to post their food plates before eating.
PA - Okay sir.
PPM 1 - 👍👆fasting?
Please let him first load plain insulin (looks like water) to 14U and then load mixtard (looks like milk) 8U in the morning today before breakfast.
PPM 1 - Thanks sir.
PA - 👍Looks like milk8 units.
PA - Plain insulin 14U 👆
Sorghum Jawa for breakfast.
PPM 1 - All your plates including breakfast should contain this proportion of fruits and vegetables with protein.
PA - At 20.17 the sugar level is 479mg/dl
How many units of plain insulin should the patient take?
PPM 1 - How much taken before lunch?
PA - 6 plain insulin 4 mixtard.
PPM 1 - That was too less! Why? What was the blood sugar after lunch?
PA - 370mg/dl.
PPM 1 - Before lunch should have been only plain insulin 10U.
PPM 1 - Okay, Take 14U plain insulin
8U mixtard.
06-02-2025
PA - Fasting sugar 309mg/dl.
PPM 1 - Today before breakfast take 16U plain and 10U mixtard and share the sugar value two hours after that
PA - 16U plain insulin and 10U mixtard.
PPM 1 - 👍
PA - Sorghum jawa breakfast at 8.26am
08-02-2025
PA - Fasting sugar 273mg/dl. How much insulin should the patient take?
PPM 1 - The two hours post breakfast was not shared with us.
This morning test is telling us the effect of what insulin the patient took yesterday night. Can you share what dose of insulin was taken by the patient yesterday night before dinner and yesterday afternoon before lunch?
@PA hopefully this advocate may be able to respond only problem I anticipate from his responses here is that it's likely that the advocate here is going to school in the morning and no one is recording the other values?
Whenever you don't hear from us quickly I'm assuming you would likely take the same dose as taken the day before around the same time.
PA - If the patient shares his regular sugar levels, then @PPM1 can prescribe the dosage.
PPM 1 - Yes but then the advocate probably needs to attend his school in the mornings and I'm not sure mother remembers the values and from what I recollect she may not be able to text or even write them down.
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