28-03-2025
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 ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENTS CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[28-03-2025 17:02] PPM 1: Currently admitted and @~PPM3 may share the history today
[28-03-2025 17:13] PPM 3: Sir, I'll take and share it tomorrow.
[28-03-2025 22:23] PPM 4: Sir patient GRBS 443MG/DL
[29-03-2025 07:24] PPM 1: When was that? Two hours after lunch or dinner?
Please don't use patient identifiers online to ensure patient privacy and confidentiality
Please share her
fasting,
2 hour post breakfast,
2 hour post lunch
2 hour post dinner
Every day here
Start her on tablet glimiperide 1mg before breakfast today along with 500 mg of metformin after
breakfast, lunch and dinner
[29-03-2025 07:25] PPM 4: Ok sir
[29-03-2025 11:04] PPM 1: Seems like someone has already started her on insulin or was it an SOS
dose? Please check and confirm here
[29-03-2025 11:31] PPM 1: @~PPM3 her case report can be done after you share her history
[29-03-2025 12:52] PPM 3: okay sir, I'll share it by tonight.
[29-03-2025 16:21] PPM 1: @~PPM 4 please share the image of the glucometer blood sugar chart that I
forgot to click in the afternoon
[29-03-2025 16:22] PPM 4: Ok sir
[29-03-2025 19:43] PPM 3: CHIEF COMPLAINT -
Patient came for a checkup reguarding her Diabetes mellitus type 2.
HISTORY OF PRESENTING ILLNESS -
The patient was apparently asymptomatic 4 years back and suddenly felt generalised weakness and dizziness because of which she got a full body checkup done which revealed that she had Diabetes mellitus type 2. The doctor had prescribed her METFORMIN HYDROCHLORIDE 500mg which she took for two months after which she stopped as she was having indigestion.
3 months back, the patient felt weakness and dizziness again due to which she went to the doctor and he prescribed METFORMIN HYDROCHLORIDE 500mg which she took for a month and stopped due the feeling of being unwell after taking the medication.
PAST HISTORY -
N/K/C/O HTN, Thyroid disorders, TB, Asthma, epilepsy, CAD, CVD
Surgical history -
LSCS delivery in the years 2008 and 2009
FAMILY HISTORY -
Her father is a known case of DM type 2 and hypertension since 15 years.
Her mother is a known case of DM type 2 and hypotension since 13 years.
PERSONAL HISTORY -
The patient is a home maker. She got married in the year 2006 at the age of 15.
Her husband, 39M, has alcohol induced cirrhosis, ascites and umbilical hernia.
This scenario has left the patient worried.
Diet - mixed
Appetite - Normal
Sleep - Adequate
Bowel - Regular
Bladder - Regular
Addictions - no specific addictions.
[29-03-2025 19:48] PPM 1: Well done 👏👏
[01-04-2025 11.27] PPM 1: Patient's blood glucose values
[01-04-2025 11.30] PPM 1: @~PPM3 @PPM2 note how the patient's sugars came down from 400 to
180-200 over few days till the glimiperide 1 mg steady state kicked in!
[02-04-2025 15.38] PPM 1: Update. She was tensed yesterday night and didn't sleep as husband has
fever.
[03-04-2025 17.09] PPM 1: Today's four point sugar profile
[04-04-2025 08.46] PPM 1:
[05-04-2025 09.12] PPM 1:
EMR summary:
Age/Gender: 36 Years/Female
Address:
Discharge Type: Relieved
Admission Date: 28/03/2025 12:54 PM
Name of Treating Faculty: (AP) (PGY3) (PGY2) (PGY1) (PGY1)
Diagnosis
UNCONTROLLED SUGARS
K/C/O TYPE 2 DIABETIS MELLITUS
Case History and Clinical Findings
C/O HEADACHE SINCE 3 MONTHS
PATIENT WAS APPARANTLY ASYMPTOMATIC 3 MONTHS AGO THEN SHE Developed HEADACHE WHICH WAS INSIDIOUS IN ONSET AND GRADUALLY PROGRESSIVE NOT ASSOCIATED WITH VOMITINGS, PHOTOPHOBIA, PHONOPHOBIA, BLURRING OF VISION, LACRIMATION. NO H/O SHORTMNESS OF BREATH, CHEST PAIN, PALPITATIONS, PEDAL, EDEMA, FEVER, COUGH, ABDOMINAL PAIN, ORTHOPNEA, BURNING MICTURITION
K/C/O DIABETIS MELLITUS SINCE 1 YEAR AND ON MEDICATION TAB.METFORMIN 500MG N/K/C/O HTN, THYROID, CAD, CVA, ASTHMA, EPILEPSY, PULMONARY TUBERCULOSIS O/E: -
BP-120/80MMHG PR- 78BPM
RR-20CPM
TEMP-98.2DEGREES SPO2- 99% AT RA GRBS-110MG/DL
CVS-S1S2 HEARD NO MURMERS
RS- BAE PRESENT NVBS
P/A- SOFT AND NON TENDER NO PALPABLE MASSES
CNS -NO FOCAL NEUROLOGICAL DEFECT
Investigation
HBsAg-RAPID 28-03-2025 2:32:PM Negative Anti HCV Antibodies - RAPID 28-03-2025 02:32:PM
Non Reactive
SERUM ELECTROLYTES (Na, K, C l) 28-03-2025 2:32: PM SODIUM 138 mmol/L 145-136
mmol/LPOTASSIUM 3.9mmol/L 5.1-3.5 mmol/LCHLORIDE 101 mmol/L 98-107 mmol/L SERUM CREATININE - 0.7
URINE FOR KETONE BODIES - NEGATIVE
HAEMOGLOBIN 13.3gm/dl 13.0 - 17.0 Colorimetric LOX -PAPTOTAL COUNT 11,600 cells/cumm 4000 - 10000 ImpedenceNEUTROPHILS 62 % 40 - 80 Light MicroscopyLYMPHOCYTES 32% 20 -
40 Light MicroscopyEOSINOPHILS 1 % 01 - 06 Light MicroscopyMONOCYTES 04% 02 - 10 Light
MicroscopyBASOPHILS 00 % 0 - 2 Light MicroscopyPCV 38.3 vol % 40 - 50 CalculationM C V 76.8 fl
83 - 101 CalculationM C H 26.7 pg 27 - 32 CalculationM C H C 34.7 % 31.5 - 34.5 CalculationRDW-
CV 15.2 % 11.6 - 14.0 Histogram
RDW-SD 46.6 fl 39.0-46.0 Histogram
RBC COUNT 4.99
millions/cumm 4.5 - 5.5 Impedence
PLATELET COUNT 1.50 lakhs/cu.mm 1.5-4.1 Impedence
SMEAR
RBC Normocytic normochromic Light Microscopy
WBC Within normal limits Light Microscopy PLATELETS Adeqaute Light Microscopy
HEMOPARASITES No hemoparasites seen Light Microscopy
IMPRESSION Normocytic normochromic bloodpicture with leukocytosis
FBS DONE ON 23/3/25 2:32:PM- 279 HBA1C DONE ON 23/3/25 2:32:PM-7.8
Treatment Given (Enter only Generic Name)
STRICT DIABETIC DIET
TAB.GLIMI 1MG PO/OD AT 8AM BEFORE BREAKFAST TAB.METFORMIN 500MG PO/OD AFTER BREAKFAST TAB.LOPERAMIDE 2MG PO/TID
Advice at Discharge
TAB.GLIMI 1MG PO/OD AT 8AM BEFORE BREAKFAST TO BE CONTINUED TAB.METFORMIN 500MG PO/OD AFTER BREAKFAST TO BE CONTINUED
Follow Up
REVIEW TO GM OPD AFTER 10 DAYS/SOS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE, DONOT MISS MEDICATIONS. In case of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care, when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT
ATTENDER SIGNATURE OF PG
INTERNEE SIGNATURE OF ADMINISTRATOR
SIGNATURE OF FACULTY
Discharge Date Date:5/4/2025 Ward:FMW Unit:3
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