https://pajrcasereporter.blogspot.com/2024/12/44f-diabetes-nud-ccf-wb-pajr.html
[16-06-2025] PPM 1: 1) Yes it would be important to highlight our engagement with the patient directly and highlight her inputs if not get her as co-author considering her privacy issues perhaps although I had invited her to be the author and shown her the first draft and she expressed fear that after we publish this finally we may all stop provide our regular PaJR service to her which was currently benefit her daily. I reassured her we will continue this unconditional service for all our patients life long.
Following are the pm transcripts of my conversation with her
[09/06, 17:34] Patient Advocate Diabetes 44F WB:
Sir, I have nothing much to say. You all have observed my day-to-day reports so well, and the way you've explained everything using AI tools and the cable system is wonderful… I really have nothing more to say. I’m extremely happy thinking that currently, my BP medicine is stopped (though in the past, it was stopped 3 times for around 3 months). And the dose of my diabetes medicine has also reduced. My lifestyle has changed a bit, and I’m truly happy. Yes, it’s true that I still have many problems and may continue to have them, but at least I’m not bedridden.
Even though it's just a little, I can now do my own work, I’ve gained confidence, and I’ve gotten back a much better life. I’m really grateful to you and your team members, and also to my daughter.
[09/06, 17:34] Patient Advocate Diabetes 44F WB:
But what will happen if this report gets published in a journal?
[09/06, 17:38] Patient Advocate Diabetes 44F WB:
For people like me who are suffering, and for the way you are using proper technical tools and evidence-based treatment — will this open up new avenues? I mean, will it lead to developments in the field of medical treatment for students?
[09/06, 17:42] Patient Advocate Diabetes 44F WB:
I have one question… After this report gets published in a journal, will you no longer see me if I face any problems? Will my treatment stop here? But I’m not completely cured yet. Even now, if I eat a bit too much or eat late, I get stomach pain, my sugar level rises — then what will happen?
[09/06, 17:46] Patient Advocate Diabetes 44F WB:
One thing I’ve noticed — people only think about changing themselves when they’re pushed too hard, or they don’t follow the guidance you give, like updating daily activities with photos. I don’t understand why.
[09/06, 19:39] cm:
No, no — we will take care of you lifelong, and also continue supporting all the others who are joining our PaJR group daily.
We want to publish your and everyone else’s case reports so that the rest of the world gets to know about this, and we can find answers to the many questions about your and others' conditions that are still unanswered. In a way, these case reports are already being shared through blogs, but if they get published in a journal, this movement can spread further in the scientific community, so that others like us can use this method to support many more patients.
[09/06, 20:52] Patient Advocate Diabetes 44F WB:
Okay, I feel a little more at ease now.
Truly golden inputs @PPM8 and @PPM9. Never have we seen such a rich perspective from the patient about the use of PaJR and AI by them.
[20/06, 06:49] PPM 8: Good morning sir, PPM9 and I spoke to the patient yesterday, and these were the answers we got from her:[20/06, 06:50] PPM 8: The statement "Patient's weight decreased" could be elaborate upon -1. Was the weight loss intentional?from December to June she has followed recommended diet and muscle strengthening exercises which makes her believe what made her lose her weight2. Was it clinically significant?She has lost more than 8kgs in 6 months (clinically significant(?))3. Were there any active efforts to lose the weight?Yes, she changed and tried to adhere to the recommended diet plan and performed strength training exercisesRegarding alopecia-She faced increased hair loss from December to April which she thinks could be due to the frequent antibiotics she was consuming during that timeWhat interventions through PaJR made a measurable impact?1. She is able to be in constant contact with Doctors2. She feels that she is being monitored very closely which helps her adhere to a good lifestyle3. It gives her mental strength and a sense of hope that she is not alone and that she will be able to overcome her health problems.4. She is able to pinpoint what food intake is affecting her blood glucose levels which she learnt to do because of the group.5. Sharing her hourly activity made her understand how her blood sugar levels were thought out the day and she could correlate her energy levels6. The group provides her with accountability especially which regard to food intake.7. She feels seen and heard8. It gives her motivation to make innovative healthy food for herself.9. She's able to ask and update about her symptoms in the group everyday which she wouldn't have been able to if not because of the group10. Her being a member of other patients group also helps her feel less alone11. She has been more conscious about outside food and is able to identify what is good for her to consume.12. She is deeply grateful that she is able to get better without much medication and without getting expensive tests which was the case before which would not result in any improvement.Were there any areas where the platform did not aid in relief?At some very few instances she did not get satisfying answers or solutions to her problemseg- why is she having recurring eye problems?why is she not able to straighten her arm even though she did what she was told to.Use of AI by the patientShe uses AI once every 2-3 days when she tries out a new food recipe and doesn't know the amount of calories, protein and fat content in it.What keeps her so motivated to update everything in the group?She feels accountable and empowered when she does, it's completely because of her internal interest as she understands how much the group helps her on a daily basis.
[21-06-2025 22:03] PA: Feeling dizziness, neck and arm pain, can't fold hand, sweating, breathing shortness from this evening.
[21-06-2025 22:03] PA: BP monitor is not working properly that's why she measured in medical shop. BP was 125 by 85 and heart rate 122. From last 3 months patient did not take any BP medicine.
[21-06-2025 22.28] PA: BP 93/56, P 96
[21-06-2025 23:52] PA: 124/85 BP -at the time of 9 pm.when she feels uneasiness nd too much weakness with sweating nd breathing shortness ,nd neck pain.it continues almost half n hour .after that she lays down on the bed.
[21-06-2025 23:58] PA: After 1.5 hours she repeatedly checked her BP nd it was 93/56 nd heart rate was 96 . That time she feels better than before.
[22-06-2025 06:34] PPM 1: Sounds like anxiety symptoms
[22-06-2025 06:51]PA: Fasting blood sugar levels is 120
[22-06-2025 07:25] PA: Morning tea and soaked chana
[22-06-2025 10:37] PPM 1: 👍
[22-06-2025 10:43] PA: The image shows a cup of tea and a bowl of chickpeas on a metal tray. The cup is filled with a reddish-brown liquid, likely tea, and has a handle on the left side. The bowl contains several chickpeas, some of which have sprouted. The tray is placed on a pink cloth with a floral pattern.
Key Elements:
- Cup of tea
- Bowl of chickpeas
- Metal tray
- Pink cloth with floral pattern
Relevant Details:
- The tea appears to be brewed from the chickpeas or another ingredient.
- The chickpeas are sprouted, indicating they have been soaked in water.
- The metal tray and cup suggest a traditional or cultural setting.
Conclusion:
The image depicts a simple yet meaningful scene, possibly related to a traditional practice or cultural ritual involving tea and chickpeas.
[22-06-2025 10:43] PA: Pl measure protein, fat and carb
[22-06-2025 10:43] PA: To provide an accurate measurement of protein, fat, and carbohydrates in the chickpeas and tea, I'll need to make some assumptions based on average values for these ingredients.
Chickpeas (100g serving):
- Protein: 19g
- Fat: 6g
- Carbohydrates: 61g
Tea (1 cup, brewed):
- Protein: negligible
- Fat: negligible
- Carbohydrates: 0-2g (depending on sweetener or cream added)
Total (approximate):
- Protein: 19g (from chickpeas)
- Fat: 6g (from chickpeas)
- Carbohydrates: 61-63g (from chickpeas and tea)
Please note that these values are approximate and may vary depending on specific ingredients, portion sizes, and preparation methods.
[22-06-2025 10:43]PA: The image shows a plate of food with a salad and what appears to be a type of flatbread or pancake. The flatbread is light brown and has holes in it, with some orange and green toppings. The salad consists of diced tomatoes, cucumbers, and lettuce.
To estimate the nutritional content of this meal, we can make some assumptions based on average values for these ingredients.
Flatbread (100g serving):
- Protein: 10-15g
- Fat: 2-3g
- Carbohydrates: 40-50g
Salad (100g serving):
- Protein: 2-3g
- Fat: 0-1g
- Carbohydrates: 5-7g
Total (approximate):
- Protein: 12-18g
- Fat: 2-4g
- Carbohydrates: 45-57g
Please note that these values are approximate and may vary depending on specific ingredients, portion sizes, and preparation methods.
[22-06-2025 10:43] PA: There r rice atta, chattu, besan little amount of grated carrots,salt nd little bit oil. Salad -tomato , cucumber nd little amount of salt
[22-06-2025 10:43] PA: With the ingredients you provided, here's an updated estimate of the nutritional content:
Flatbread (made with rice atta, chattu, besan, grated carrots, salt, and little oil):
- Protein: 10-12g (from besan, chattu, and rice atta)
- Fat: 2-3g (from oil and besan)
- Carbohydrates: 40-50g (from rice atta, chattu, and besan)
Salad (tomato, cucumber, and little salt):
- Protein: 1-2g (from tomato and cucumber)
- Fat: negligible
- Carbohydrates: 5-7g (from tomato and cucumber)
Total (approximate):
- Protein: 11-14g
- Fat: 2-3g
- Carbohydrates: 45-57g
Please note that these values are still approximate and may vary depending on specific ingredient quantities and preparation methods.
[22-06-2025 14:38] PPM 5: Brilliant! Very nice use of AI to know what calories the patient is planning to take in.
[22-06-2025 14:40] PA: The image shows a traditional Indian thali, which is a balanced meal consisting of various dishes. Here's a breakdown of the nutritional value of each component:
1. White Rice: Carbohydrates, fiber, and some B vitamins.
2. Yellow Dal (Lentil Soup): Protein, fiber, vitamins, and minerals like iron, potassium, and zinc.
3. Red Chutney or Pickle: Antioxidants, vitamins, and minerals from the ingredients used (e.g., tomatoes, chilies, garlic).
4. Vegetable Dish: Vitamins A and C, potassium, and fiber from the green beans, carrots, and other vegetables.
5. Dark Brown or Black Dish: Possibly a leafy green vegetable or legume-based dish, providing vitamins A and K, iron, and fiber.
This meal offers a good mix of:
- Carbohydrates (rice, dal)
- Protein (dal, possibly from the dark brown dish)
- Fiber (dal, vegetables, whole grains)
- Vitamins (A, C, K, B vitamins)
- Minerals (iron, potassium, zinc)
Keep in mind that the exact nutritional value depends on specific ingredients, portion sizes, and cooking methods.
[22-06-2025 14:40] PA: The image shows a traditional Indian thali with various dishes. Here's an approximate measurement breakdown:
1. White Rice: 1/2 cup to 3/4 cup (100-150g)
2. Yellow Dal (Lentil Soup): 1/2 cup to 3/4 cup (100-150g)
3. Red Chutney or Pickle: 1-2 tablespoons (15-30g)
4. Vegetable Dish: 1/2 cup to 3/4 cup (100-150g)
5. Dark Brown or Black Dish: 1/4 cup to 1/2 cup (50-100g)
Note: Measurements are approximate and may vary based on individual serving sizes and preferences.
[22-06-2025 14:44] PPM 5: Do capture any emotional ups and downs if possible. Was there anything that may have caused the anxiety?
Do note that in case of any fast change in symptoms or if you feel worried, always consult local doctor immediately.
[22-06-2025 17:03] PA: Tiffin plate....some fruits, boiled chana and (aparita) blue tea
[22-06-2025 18:09] PA: How much is this plate related with my blood sugar
[22-06-2025 18:09] PA: The plate contains Chola (chickpeas), Kala Jamun (black jamun), Guava, and Blue Tea. Let's analyze how each food item might affect your blood sugar levels:
1. Chola (Chickpeas):
- Chickpeas have a low glycemic index (GI), which means they may help regulate blood sugar levels.
- The fiber and protein content in chickpeas can slow down the digestion and absorption of carbohydrates, potentially reducing the impact on blood sugar.
2. Kala Jamun (Black Jamun):
- Kala jamun has a moderate GI, which might cause a slight increase in blood sugar levels.
- However, the fiber and antioxidant content in kala jamun may help mitigate this effect.
3. Guava:
- Guava has a low GI, which suggests it may not cause a significant spike in blood sugar levels.
- The fiber and antioxidant content in guava can also help regulate blood sugar levels.
4. Blue Tea:
- Blue tea is unlikely to affect blood sugar levels significantly, as it contains negligible amounts of carbohydrates.
Overall, the plate's food items might have a moderate impact on blood sugar levels, primarily due to the Kala Jamun. However, the fiber and antioxidant content in these foods can help regulate blood sugar levels.
If you have diabetes or concerns about blood sugar, consider the following:
- Portion control: Monitor the serving sizes of each food item to manage carbohydrate intake.
- Balanced meal: Ensure that your meal is balanced with protein, healthy fats, and complex carbohydrates to regulate blood sugar levels.
- Monitoring: Keep track of your blood sugar levels and adjust your diet accordingly.
Consult a healthcare professional or registered dietitian for personalized advice on managing blood sugar levels through diet.
[22-06-2025 18:12] PPM 1: Any blood sugar medicine was taken before and after this? Please mention or share a picture of that medicine
[22-06-2025 18:20] PA: Yes, sir, after breakfast and lunch she took metformin 500 in half tab
[22-06-2025 18:30] PA: After tiffin she takes metformin 500 and 2hours later sugar level is 119
[22-06-2025 18:35] PA: Is there any relation to the food quantity and blood sugar level ups and downs.
[22-06-2025 18:37] PA: Please correct those plates and quantity if necessary.
[22-06-2025 19:03] PPM 1: Food appears fine.
Can we have an account of the patient's hourly activities since morning including before and after meals?
[22-06-2025 19:27] PA: Yes sir
[22-06-2025 20:10] PA: At morning 6 o clock wake up and freshen up. Then 7.15am checked fasting blood sugar, then after cleaning the bed she takes a cup of tea with soaked chola at 7.45am. After bathing she does puja, meditation and then prepare breakfast at 8.40 am. After having breakfast she takes metformin 500 half tab and then goes to drop her daughter for tution by toto. Returns back by 9.15am and feels very tired, She needs to take rest. Then 10.30 am checked her sugar level. 11.15am opens her tailoring shop. 12.15pm she has her lunch and takes metformin 500 half tab. 1.30pm goes outside for some necessary work within 30 minutes and she returns back. 2.30 pm_did some stitching 30 mints for ordered work and applied a reflex point for reducing sugar level.
[22-06-2025 20:20] PA: 4 pm goes outside for 15 minutes, then takes snacks with above mentioned plate.5.30pm watering plants, chatting with school friends and daughter for 30 minutes. 6.pm checked blood sugar.
[22-06-2025 20:23]PA: After that she prepares and completes dinner by 7.45pm, then takes metformin 500 half tab.
[22-06-2025 20:46] PPM 1: 120 fasting?
[22-06-2025 20:46] PPM 1: 132 Post breakfast?
[22-06-2025 20:47] PPM 1: 211 post lunch?
[22-06-2025 20:49] PPM 1: 👆11:15AM to 2:30PM activities in detail are important to factor in to explain the single high 2 hours after lunch
[22-06-2025 20:59] PPM 5: Anything that explains the BP fluctuation, sweating and neck/hand pain yesterday?
[22-06-2025 21:31] PPM 1: For that we'll need to know her activities and thoughts hourly before the events yesterday
[22-06-2025 21:36] PA: She completed her dinner at 7.45pm, then took metformin 500 half tab
[22-06-2025 22:09] PA: Everything was normal yesterday afternoon, but she had severe neck and hand pain. She was sweating a lot and felt uneasy whole evening, even used an iced pack 2 times. At night instead of checking her BP at home she checked at medical shop for cross check. Her heart was pounding heavily. After returning home, she laid down quietly for an hour. Then she felt better. Today she feels better, the pain of her hand has reduced, but still has some discomfort when folding it.
[22-06-2025 22:12] PA: 2 hours later sugar level is 181
[22-06-2025 22:23] PA: She was feeling bit worried about her work. Sometimes her body feels very weak, does not permit any hard work. Sometimes feels very lonely and doesn't feel to talk to anyone.
[22-06-2025 22:31] PA: For few days now, she has been suddenly feeling uneasy from time to time, whenever she does more work, cook over gas oven or get into an argument or heated discussion. She starts sweating.
[22-06-2025 22:39] PA: On the other hand the patient feels that she may need to reduce the amount or quantity of food because after having two meals like lunch and dinner, feeling very uneasy, abdomen pain and shortness of breath.
[22-06-2025 22:50] PA: Can this happen due to change in rice? This has happened twice before, her sugar level would rise a lot, shortness of breath, dryness of mouth, weakness etc and used to have abdomen pain after meals but after changing the rice it got better. Could something similar be happening again? The last 2 times, her sugar level increased, but only after eating rice.
[23-06-2025 06:52] PPM 1: What was the exact change in rice? Was it in terms of quality or quantity?
[23-06-2025 06:53] PA: Quality
[23-06-2025 06:54] PPM 1: What are the different quality of rice she consumes?
[23-06-2025 06:54] PPM 1: Does the severe neck and head pain happen once a month or once a week?
[23-06-2025 06:55] PA: After cooking it was hard.
[23-06-2025 06:56] PPM 1: Alright so the quality depends on the cooking and not any particular variety of rice she consumes?
[23-06-2025 06:57] PA: Yes.
[23-06-2025 07:03] PPM 1: 👆@PPM5 the sequence of events in this patient have been very well described. We know that certain events in the past can be associated as a cascade to explain causality for certain events in the present and future.
Her present events of anxiety appears to have been triggered by her body pains
[23-06-2025 07:24] PA: Eating cooked hard rice causes abdomen pain, burning sensation , even small amounts make the stomach feel full.
[23-06-2025 07:25] PA: This has been happening since 2-3days
[23-06-2025 07:54] PPM 1: Is that due to rice being undercooked or is it a particular variety of rice that remains undercooked?
[23-06-2025 08:07] PPM 5: https://glycemic-index.net/glycemic-index-of-rice/
Glycemic index varies significantly with the type of rice. Also the way it cooked matters. Details in the article linked above.
[23-06-2025 08:43] PA: No, this kind of pain in the hand and neck, breathing shortness has occurred for a long time. According to previous history whenever blood pressure would rise, there used to be pain in the hand (pain down to the palm and tingling sensation) and neck with sweating as well. Last time when the patient was admitted in nursing home she was given iv saline (about 60 bottles). Hand pain has increased a few days later. For the last 2-3months BP medicine has been stopped and It is possible that the blood pressure increased slightly, the pulse rate is usually high, from 2018 she took Inderal 10, but stopped since few months. She also has history of decreased O2 level in the last addmission of nursing home. It was 70-72. While doing muscle strengthening exercises she realised that her right hand is weak. She had also fallen several times might be after effects. One more thing is that in her family history her paternal sides had rheumatoid arthritis.
[23-06-2025 08:46] PPM 1: The patient's blood pressure rise event appears likely secondary to pain and is very common.
Blood pressure per se doesn't cause any symptoms and is hence known as a silent killer. In this patient it appears to be the opposite.
Her blood pressures rise is due to pain and anxiety, the anxiety hormone adrenaline causes rise in blood pressure.
[23-06-2025 08:47] PPM 1: 👆@PPM5 another important consideration in formulating a closer diagnosis with lesser uncertainty is the duration of the disease
[23-06-2025 08:47] PA: The patient believes that no matter what the reason is now, with your guidance she will be able to recover quickly.
[23-06-2025 08:50] PPM 1: We believe so too.
[25-06-2025 09:34] PA: For breakfast 1 roti, mixed veg curry and pickle
[25-06-2025 12:02] PPM 5: Just a random suggestion do try if you think useful -
I've seen someone close whose pains in the arms reduced dramatically when they reduced vatta inducing food (per ayurveda). In this case, the daily dose of chole (chickpeas) may be causing vatta which causes the pain.
Can you try not having vatta inducing foods like chole, potato, peas, eggplant (brinjal) for one/two weeks to see if pains go down.
[25-06-2025 12:26] PA: Thank you sir.
[25-06-2025 12:48] PA: Sir, for the last few days the patient has been wondering the cause of too much pain in the arms, but also (fingers, shoulder joint, chest bone, jaw). She also feels she is consuming chola, nuts, masoor daal more these days. Please suggest that what can be eaten on an empty stomach with tea in the morning or snack time? The patient is diabetic and eats very little amount of rice and 1 roti. How can she get the required protein.
[25-06-2025 12:55] PA: As per ayurveda she doesn't take brinjal, ladies finger, taro type any veggies.
[25-06-2025 13:05] PPM 5: Would roti or palak paratha, or sevaiya upma, or oats, or moong dal chila be possible in the morning?
Do try and have tindli, ridge gourd, dudhi (squash), red pumpkin during meals.
[25-06-2025 14:29] PA: In empty stomach with tea or tiffin which one is better?
[25-06-2025 15:23] PPM 5: The first list - roti, paratha..
[25-06-2025 16.59] PPM 5: Glycemic index for each of these (via ChatGPT)
Here's a breakdown of the glycemic index (GI) values of the foods you mentioned. The glycemic index is a measure (0–100) of how quickly a food raises blood sugar. Lower values are better for diabetic and metabolic control:
---
🌾 Grain-based / Main Foods
Food Item Approx. GI Comments
Roti (Whole Wheat) 55–70 Medium GI; depends on how finely the flour is ground and what it's eaten with.
Palak Paratha 50–60 Slightly lower GI due to spinach (fiber); still medium GI.
Sevaiya Upma 60–70 Medium to high GI depending on vermicelli type (maida vs. wheat).
Oats (Rolled) 55 Medium GI; high fiber helps reduce sugar spikes. Instant oats have higher GI.
Moong Dal Chilla 30–40 Low GI; high in protein and fiber, very good for sugar control.
---
🥦 Vegetables during meals (Non-starchy → Generally Low GI)
Vegetable Approx. GI Comments
Tindli (Ivy Gourd) 15–20 Low GI; may help regulate blood sugar.
Ridge Gourd ~20 Very low GI, water-rich, great for diabetic diet.
Dudhi (Bottle Gourd) ~15–20 Low GI, high water and fiber content.
Red Pumpkin 60–75 High GI but low glycemic load if portion is small (high water content). Use sparingly.
---
✅ Takeaways for Diabetic-Friendly Meals
Best choices: Moong dal chilla, oats, tindli, ridge gourd, dudhi.
Caution: Roti and sevaiya upma are okay if portion controlled and paired with protein/fiber (dal, sabzi).
Limit: Red pumpkin (in small portions only).
[26-06-2025 06:27] PA: Morning Tea
[26-06-2025 07:03] PPM 5: Moong chilla etc anything in cooked form is good but unfortunately sprouted moong is not good for vatta dosha.
[26-06-2025 07:04] PPM 5: Some dos and don'ts
[27-06-2025 07.09] PA: Morning black tea with puffed rice.
[27-06-2025 08.28] PA: Breakfast roti with curry.
[27-06-2025 10:48] PPM 5: Nice!
Is that potato or pumpkin.. if potato try to avoid potato as it builds vatta.
[27-06-2025 12:13] PA: Thank you sir
[27-06-2025 12:52] PA: Homemade rath Yatra special dish made by patient.
[28-06-2025 09:04] PA: The patient can't understand what's happening. From last few days even today morning she felt very weak, even her vision turns dark. After doing little work. Even after a full meal like lunch and dinner she feels very weak and breathlessness. All the works which she has to do forcefully..if she closes her eye feels good.
[28-06-2025 09:20] PPM 5: Is this because of low BP @PPM1 Sir?
Would salt and lemon mixed with water (no sugar) help?
[28-06-2025 09:21] PA: Just now she had salt and lemon water.
[28-06-2025 09:27] PPM 1: Her recorded BP as shared and archived appears to be normal
Again the only way to get to the bottom of these symptoms is to analyse the events preceding and following them
[28-06-2025 10:11] PPM 5: Could this also be because of haemoglobin deficiency or thyroid imbalance?
[28-06-2025 10:14] PPM 1: From what I recall from memory if not her archived case report (@CR would it be possible to fish out her hemogram and thyroid function tests from there), she had a normal Hb and thyroid function test.
[28-06-2025 11.48] CR: 👆test reports of 28/12/24
[28-06-2025 12:04] PPM 5: TSH?
[28-06-2025 12:05] CR: Couldn't find. @PA do you have any Thyroid reports?
[28-06-2025 12:15] PA: Dated on 19/10/24
[28-06-2025 12:30] PA: Constant vomiting tendency
[28-06-2025 12:30] PA: No taste to eat anything. Slight pain in abdomen
[28-06-2025 12:30] PA: Whichever I am doing and eating have to do forcefully.
[28-06-2025 12:49] PPM 1: Please start the patient's hourly activities description from waking up yesterday till now specifically mentioning which hours the patient started feeling the symptoms and at which hours they continued
[28-06-2025 13:26] PA: Yesterday she ate prasad khichuri, that could be the reason for vomiting tendency.
[28-06-2025 13:37] PA: This morning she ate 4 Kheera slices, black plum and chole and potato mix
[28-06-2025 14:30] PPM 1: 👆 yesterday's?
[28-06-2025 14:58] PA: No. today snack time
[28-06-2025 15:01] PA: Woke up at 6.am
[28-06-2025 15:06] PA: Then freshen up and clean the room and bed feels very weak and vison turns dark. After that she checks her BP. Then lied down on the bed for some time.
[28-06-2025 15:16] PA: After that she gave lunch box to her daughter and had small quantity of rice and gram mixed chila. (At that time she felt very uneasy, and had little piece of chilla)
[28-06-2025 15:20] PA: After half an hour then she takes a glass of water with salt and lemon.
[28-06-2025 15:25] PA: Then she took bath and after that had severe nausea and vomiting. Then she had some relief.
[28-06-2025 15:26] PA: It continues for about 2-3hours.
[28-06-2025 15:31] PA: 11.15 am she had lunch but couldn't eat much. After that she takes metformin 500 half tab and relaxed for some time.
[28-06-2025 15:34] PA: Then she goes to her tailoring shop which is situated in front of the house.
[28-06-2025 15:36] PA: She has no taste
[28-06-2025 15:38] PA: Weakness is continuously there since morning.
[28-06-2025 16:04] PA: She takes some fruits and 2 spoon daal then takes metformin
[28-06-2025 16:07] PPM 1: Today's I guess?
[28-06-2025 16:07] PPM 1: 👆@PPM5
[28-06-2025 16:41] PPM 5: Hmm potato and channa - both bad for vaata but doesn't explain vomiting. Maybe something in the food from outside.
[28-06-2025 16:42] PPM 5: Should a latest blood test be done for TSH, Haemoglobin and any other indicators? Oct 2024 is too early. Hormonal changes may swing TSH quite a bit, no? @PPM1 Sir
[28-06-2025 16:48] PPM 1: Clinically she appeared euthyroid with a normal hemoglobin during her recent visit here. @PA when was her last visit here?
[28-06-2025 18:23] PA: She visited the last week of March this year. Mostly they reached 25th of March
[28-06-2025 18:25] PA: What is euthyroid? Can you tell me pl
[28-06-2025 18:43] PA: I think it may be right.If u noticed that in yesterday's lunch plate there were small pieces of paneer 2-3pic in veggies and all were homemade but after eating there were no complications. I think the dinner plate didn't suit.
[28-06-2025 18:45] PPM 5: @Meta AI what is euthyroid?
[28-06-2025 18:45] Meta AI: Euthyroid refers to a state of normal thyroid function. When your thyroid gland is working properly, producing the right amount of thyroid hormones, you're considered euthyroid. This balance is crucial for metabolism, energy, and overall health. If you've had thyroid issues or are experiencing symptoms, getting to a euthyroid state is usually the goal of treatment!
[28-06-2025 18:46] PPM 5: @Meta AI What are abnormal readings for thyroid? What parameter should be tested? What hormonal changes could be affecting thyroid?
[28-06-2025 18:46] Meta AI: Let's break it down:
Abnormal Readings:
1. TSH (Thyroid-Stimulating Hormone):
- High TSH (above 4.5-5 μU/mL): May indicate hypothyroidism (underactive thyroid).
- Low TSH (below 0.4-0.5 μU/mL): May indicate hyperthyroidism (overactive thyroid).
2. Free T4 (FT4):
- Low FT4 (below 0.8-1.2 ng/dL): May indicate hypothyroidism.
- High FT4 (above 1.7-1.8 ng/dL): May indicate hyperthyroidism.
3. Free T3 (FT3):
- Low FT3 (below 2.3-4.2 pg/mL): May indicate hypothyroidism.
- High FT3 (above 4.2-6.8 pg/mL): May indicate hyperthyroidism.
Parameters to Test:
1. TSH
2. Free T4 (FT4)
3. Free T3 (FT3)
4. Thyroid Antibodies (e.g., TPOAb, TgAb) to check for autoimmune thyroiditis
Hormonal Changes Affecting Thyroid:
1. Thyroid Hormones (T3 and T4): Imbalances can cause hypothyroidism or hyperthyroidism.
2. Thyroid-Stimulating Hormone (TSH): Produced by the pituitary gland, TSH regulates thyroid hormone production.
3. Thyrotropin-Releasing Hormone (TRH): Produced by the hypothalamus, TRH stimulates the pituitary gland to release TSH.
Other factors that can affect thyroid function include:
1. Iodine deficiency or excess
2. Certain medications (e.g., lithium, amiodarone)
3. Autoimmune disorders (e.g., Hashimoto's thyroiditis, Graves' disease)
4. Pregnancy or postpartum changes
5. Pituitary or hypothalamic dysfunction
Keep in mind that test results should be interpreted by a healthcare professional, considering individual factors and medical history.
[28-06-2025 20:26] PA: Does she need to test T3, T4, TSH and hemoglobin?
[28-06-2025 20:30] PPM 1: I have a feeling it will turn out to be normal but not much harm in testing once I guess
[28-06-2025 20:32] PA: Ok
[28-06-2025 20:33] PA: Day after tomorrow she will get done.
[29-06-2025 05:53] PA: Fasting blood sugar level is 106
[29-06-2025 06:51] PA: BP 122/77, PR 80. After 3 min standing BP is 87/60, PR 94
[29-06-2025 07:24] PPM 1: This is a very significant postural drop @PPM5 @PPM10 @CR @PPM2 @PPM3 @30F PA
Let's ask the patient to continue to monitor this also perhaps confirming this with another BP instrument and approach the local doctor in case she needs iv fluids.
@PA how is she feeling today? Does she have a lot of giddiness especially after standing from lying down?
[29-06-2025 07:26] PPM 1: @PPM5 as far as I can recall and @CR may know from her archived data this is probably the first time we are seeing this postural drop in this patient and as @PPM3 may LLM inform us that while this can be due to machine error, it generally commonly indicates hypovolemia and rarely dysautonomia.
[29-06-2025 07.31] PA: BP 127/85, PR 94, BP 84/59, PR 97
[29-06-2025 07:31] PPM 5: By any chance can it also be Addison's disease?
[29-06-2025 07:31] PA: As per Last week BP monitor
[29-06-2025 07:34] PPM 5: LLM output on ruling out these -
To rule out or confirm hypervolemia, dysautonomia, and Addison’s disease, you need to use a combination of:
Clinical signs and symptoms
Vital signs (especially blood pressure, heart rate)
Basic and targeted lab tests
Sometimes imaging or autonomic function tests
Here's a side-by-side approach to help differentiate and rule each one out:
---
🩸 1. Ruling Out Hypervolemia (Fluid Overload)
✅ Key Signs to Look For:
Swelling in legs, feet, face (edema)
Rapid weight gain (2–3 kg over a few days)
Shortness of breath, especially when lying down
High or normal BP
Jugular venous distension (JVD)
🧪 Tests:
Test What it shows
Chest X-ray Fluid in lungs (pulmonary edema)
BNP or NT-proBNP Elevated in heart failure (fluid overload)
Electrolytes, BUN/Creatinine Kidney function
ECG, Echocardiogram Underlying heart function
Urine output monitoring Low output in fluid overload with kidney failure
🚫 Hypervolemia is unlikely if:
No edema or weight gain
No crackles in lungs
Chest X-ray is clear
BNP is normal
No JVD
---⚡ 2. Ruling Out Dysautonomia
Key Signs to Look For:
Dizziness when standing
Heart rate jumps on standing (especially in POTS)
Fatigue, fainting, brain fog
GI issues, sweat changes
🧪 Tests:
Test What it shows
Orthostatic vitals Measure BP & HR lying, sitting, standing (after 3–10 min)
Tilt table test Definitive test for orthostatic hypotension or POTS
24-hr Holter/ECG HR variability, arrhythmias
QSART (sweat test) Tests autonomic nerve function
Valsalva test Measures autonomic reflexes
🚫 Dysautonomia is unlikely if:
BP and HR remain stable on position change
No dizziness or tachycardia with standing
Autonomic function tests are normal
---
🧬 3. Ruling Out Addison’s Disease (Primary Adrenal Insufficiency)
✅ Key Signs to Look For:
Extreme fatigue
Low BP (especially diastolic)
Darkened skin (esp. gums, scars)
Weight loss, nausea
Salt craving
Low blood sugar
High potassium, low sodium
🧪 Tests:
Test What it shows
8 AM Serum Cortisol Low (<3 µg/dL suggests Addison’s)
ACTH stimulation test (Synacthen test) No cortisol rise confirms Addison’s
Plasma ACTH High ACTH = primary (Addison’s); low = secondary cause
Electrolytes Low sodium, high potassium, low glucose
Renin and aldosterone High renin, low aldosterone in Addison’s
🚫 Addison’s is unlikely if:
Cortisol is normal or increases after ACTH stimulation
ACTH is not elevated
Electrolytes and blood sugar are stable
---
🧠 Summary Table:
Condition Key Signs First Tests Rule Out If...
Hypervolemia Edema, SOB, high BP BNP, Chest X-ray No fluid signs, normal imaging
Dysautonomia Dizziness on standing, HR jumps Orthostatic BP/HR, tilt table BP & HR stable on position change
Addison’s Fatigue, low BP, hyperpigmentation AM cortisol, ACTH stim Cortisol normal, no electrolyte changes
---
📌 If you are evaluating a real patient:
You can start with:
1. Orthostatic BP/HR check
2. AM cortisol + electrolytes
3. Chest X-ray + BNP if suspecting fluid overload
4. Refer for autonomic function testing if needed
Let me know the patient's age, history, and exact symptoms if you’d like a more focused diagnostic pathway.
[29-06-2025 07:41] PA: Please sir, don't suggest Iv fluids. Last Oct. 60 bottles of fluids were given. Even today she is terrified, whatever medicines or advice you give, she will follow but please don't say to iv again.
[29-06-2025 07:44] PA: Today is feeling better than Yesterday when she lays on the bed but after standing feeling weak and vision turns dark .. vomiting tendency is there.
[29-06-2025 07:47] PA: Today her schedule is very tight not possible to lie down on the bed all day.
[29-06-2025 07:56] PPM 5: @PPM1 Sir AI output
Prompt -
This patients vision turns dark if she stands up from a sleeping posture. Also has vomitting tendency.
AI output -
Thanks — that's a very important clinical detail. The fact that her vision turns dark when standing up from lying down, along with vomiting tendency, strongly points toward orthostatic hypotension, which may be due to:
---
Likely Causes Based on These Symptoms:
1. Addison’s Disease (Primary Adrenal Insufficiency) – HIGHLY SUSPECTED
Postural (orthostatic) hypotension
Fatigue, nausea, vomiting
Dark vision on standing = brain hypoperfusion
Possible hyperpigmentation
Low cortisol + low aldosterone = poor vascular tone, salt loss
2. Dysautonomia (e.g., Neurogenic orthostatic hypotension or POTS)
Especially if she also has GI symptoms and HR increase on standing
Nervous system unable to regulate BP correctly when changing position
3. Volume Depletion (hypovolemia) – less likely if BP is persistently low
Due to vomiting, diarrhea, poor intake, diuretics
But doesn’t fully explain persistent postural symptoms unless dehydration is severe
---
Step-by-Step Diagnostic Plan You Should Ask Her Doctor to Perform:
1. Orthostatic Vital Signs
Measure BP & HR:
Lying down (5 min)
Immediately on standing
After 3 min standing
Diagnostic if:
Systolic drops ≥20 mmHg or diastolic ≥10 mmHg
HR rise >30 bpm (suggests POTS)
Lightheadedness, vision darkening, nausea on standing
2. Basic Blood Tests
Test What It Detects
Serum Electrolytes (Na, K) Addison’s = Low Na, High K
8 AM Cortisol Low (<3 µg/dL) = suspicious
ACTH High with low cortisol = Addison’s
Glucose Often low in Addison’s
Renin & Aldosterone High renin, low aldosterone in Addison’s
3. ACTH (Synacthen) Stimulation Test
Confirms adrenal insufficiency if cortisol does not rise after stimulation
4. ECG / ECHO / Chest X-ray
To rule out cardiac cause or hidden fluid overload (if needed)
Optional Autonomic Tests (if cortisol is normal):
Tilt table test
Valsalva test
QSART (sweat test)
---
🧠 Working Hypothesis Based on What You've Shared:
> "Probable Addison’s disease or orthostatic hypotension due to dysautonomia, given postural symptoms, vomiting, and low diastolic BP."
---
🩹 What Can Help Temporarily (Until Tests Are Done):
Increase salt intake (unless contraindicated)
Drink oral rehydration or electrolyte-rich fluids
Slow posture changes (lie → sit → stand gradually)
Raise head of bed slightly during sleep
Avoid prolonged standing or heat
---
[29-06-2025 08:58] PA: She just completes her breakfast with upma and fruits then takes metformin 500 half tab
[29-06-2025 10.04] PA: BP 107/66, PR 85
[29-06-2025 10:07] PA: After having breakfast she took rest still now, then checked BP that is 107/66
[29-06-2025 10:09] PA: After 3 mints standing BP is 102/70
[29-06-2025 10:40] PPM 11: What medicines are she on apart from metformin?
[29-06-2025 10:41] PA: 2hours later sugar level is 153
[29-06-2025 10:45] PA: She takes metformin 500 half tab after breakfast, lunch and dinner.
[29-06-2025 10:45] PPM 11: Any other medicines?
[29-06-2025 10:46] PA: No sir
[29-06-2025 14:16] PPM 5: No darkness in vision after standing? When does that happen? Only in the morning when waking up?
[29-06-2025 14.35] PA: 126mg/dl
[29-06-2025 15:29] PPM 2: But again the heart rate is 'fixed' at 94 to 97 while the BP drops.
Certainly raises the case for Dysautonomia
[29-06-2025 15:30] PPM 2: What phenotype of Diabetes does she have you think sir? @Rakesh Biswas Sir
[29-06-2025 15:30] PPM 2: @PA has the patient been losing weight or lost weight before she was diagnosed with Diabetes?
[29-06-2025 15:57] PA: BP 122/81, PR 108Yes sir now she feels better even from yesterday takes lemon water with salt several times.
[29-06-2025 15:59] PA: She also feels that lemon water with salt and black tea enhances her energy when it feels weak.
[29-06-2025 16:02] PA: Most of the day she notices that either morning or evening feels weak, sweating etc.
[29-06-2025 16:08] PPM 1: Type 2 although monogenic is always a fallback possibility
She had a metabolic syn phenotype earlier which she worked upon and changed to what is her current DP.
@PA can the patient share the deidentified views of her previous abdomen and arms lateral view before she worked out and made significant changes to her body?
[29-06-2025 16:10] PA: No sir, It has been a weight loss since last sept. Before that she looked like round and chubby.
[29-06-2025 16:15] PPM 1: When was she first diagnosed to have diabetes?
[29-06-2025 16:17] PPM 1: Since last September the weight loss was because the patient was proactive about her health and while she needed glimiperide before that she's currently off glimiperide and with fair amount of sugar control.
Recent Pics
[29-06-2025 16:33] PPM 1: Please share images of her at the time she developed diabetes 3 years back
[29-06-2025 16:35] PPM 2: Does she have a salt craving?
[29-06-2025 16:35] PPM 2: But that should have made her diabetes better?
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