27M Diabetes on Insulin 15yrs, Hypoglycemic seizures, Retinopathy Telangana PaJR

 

Thursday June 27, 2024

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.

DISCHARGE SUMMARY ***
Pay Type: Paying
Age/Gender: 27 Years/Male
Address: 
Discharge Type: Relieved
Admission Date: 10/06/2024 09:46 AM

Diagnosis
HYPOGLYCEMIC SEIZURES 

TYPE 1 DM SINCE 15 YRS

SEIZURE DISORDER 15 YRS AGO
ANEMIA [IDA-NUTRITIONAL]
HYPOTHYROIDISM SINCE 2 YRS

Case History and Clinical Findings

C/O SEIZURES 1 EPISODE ONE HOUR AGO

HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 1 HR AGO THEN HE DEVELOPED
SEIZURES 1 EPISODE OF VOMITING, NON-PROJECTILE, NON-BILIOUS FOOD AS CONTENT

NO H/O FEVER/COLD/COUGH
NO H/O POST ICTAL CONFUSION N
NO H/O GIDDINESS
NO H/O ABDOMINAL PAIN
NO H/O CHEST PAIN CHEST TIGHTNESS
NO H/O SOB, ORTHOPNEA, PND
NO H/O BOWEL AND BLADDER ABNORMALITIES
NO H/O BLEEDING MANIFESTATIONS
PAST HISTORY

K/C/O DM ON MIXTARD 20 IU 15 years 
K/C/O SEIZURES 10 YRS BACK
K/C/O Hypothyroidism ON THYRONORM 100 MG
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PERSONAL HISTORY:
DIET - MIXED
APPETITE - NORMAL
SLEEP - ADEQUATE
BOWEL& BLADDER MOVEMENTS - REGULAR
ADDICTIONS - NIL

GENERAL PHYSICAL EXAMINATION:

PATIENT IS CONSCIOUS, COHERENT &COOPERATIVE, WELL ORIENTED TO TIME AND PLACE.
NO PALLOR/ ICTERUS / CYANOSIS / CLUBBING / LYMPHADENOPATHY / OEDEMA.

VITALS:
BP; 110/80MM HG
PR: 90 BPM
RR: 22 CPM
TEMP; 98F
SPO2: 98 @ RA
GEBS- 205 MG/ DL

SYSTEMIC EXAMINATION:
CNS: NFND
REFLEXES:
B T S K A
R +2 +2 + 1 +2 +
L +2 +2 +1 +2 +
CVS:
S1, S2 HEARD, NO MURMURS
RS:
BAE +, NVBS
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P/A:
SOFT, NON-TENDER

COURSE IN THE HOSPITAL: 

A 27 YR OLD MALE PATIENT CAME WITH C/O INVOLUNTARY

MOVEMENTS AND CONFUSION WITH GRBS OF 23 MG/DL AND WAS DIAGNOSED AS HYPOGLYCEMIC SEIZURES. PATIENT IS A K/C/O DM I AND SEIZURE DISORDER SINCE 15 YRS FOR SEIZURES HE USED ANTIEPILEPTICS FOR 3 YEARS AND STOPPED MEDICATION. FOR DM I HE WAS ON MIXTARD 20U-X-20U BD FOR GLYCEMIC CONTROL HE WAS PUT ON HAI TID
OPTHALMOLOGY OPINION WAS TAKEN AND PATIENT HAS DIABETIC RETINOPATHIC CHANGES [ MILD NPDR] PATIENT HAS HYPOTHYROIDISM SINCE 3 YRS WAS ON 100 MCG CHANGES TO 75 MCG BUT PATIENT HAD FLUCTUATING SUGARS AND. ENDOCRINE OPINION WAS TAKEN IN VIEW OF? BRITTLE DIABETES? HYPOPITUTARISM AND SIR HAS ADVICED INJ.LANTUS 8U AT NIGHT WITH 4U HAI TID BUT PATIENT HAS HYPOGLYCEMIA AT NIGHT.

SO PT IS BEING Discharged UNDER OCTREOTIDE 100 MG STAT AND LOW DOSE

STEROID TO MAINTAIN EUGLYCEMIA

PATIENT IS BEING Discharged UNDER

HEMODYNAMICALLY STABLE CONDITION

Investigation

Name Value Range
Name Value Range

COMPLETE URINE EXAMINATION (CUE) 10-06-2024 10:38:AM

COLOUR Pale yellow APPEARANCE Clear REACTION Acidic SP. GRAVITY 1.010 ALBUMIN +SUGAR Trace BILE

SALTS Nil BILE PIGMENTS Nil PUS CELLS 3-4 EPITHELIAL CELLS 2-3 RED BLOOD CELLS Nil CRYSTALS Nil CASTS Nil AMORPHOUS DEPOSITS Absent OTHERS Nil
HBsAg-RAPID 10-06-2024 10:38:AM Negative POST LUNCH BLOOD SUGAR 10-06-2024 10:40:AM
101 mg/dl 140-0 mg/dl
BLOOD UREA 10-06-2024 10:40:AM 25 mg/dl 42-12 mg/dl 

SERUM CREATININE 10-06-2024 10:40:AM 1.4 mg/dl 1.3-0.9 mg/dl
SERUM ELECTROLYTES (Na, K, C l) 10-06-2024 10:40:AM SODIUM 141 mmol/L 145-136
mmol/L POTASSIUM 3.5 mmol/L 5.1-3.5 mmol/L CHLORIDE 104 mmol/L 98-107 mmol/L LIVER
FUNCTION TEST (LFT) 10-06-2024 10:40:AM Total Bilurubin 0.44 mg/dl 1-0 mg/dl Direct Bilurubin
0.14 mg/dl 0.2-0.0 mg/dl SGOT(AST) 30 IU/L 35-0 IU/LSGPT(ALT) 33 IU/L 45-0 IU/L ALKALINE
PHOSPHATASE 180 IU/L 128-53 IU/L TOTAL PROTEINS 6.4 gm/dl 8.3-6.4 gm/dl ALBUMIN 3.8
gm/dl 5.2-3.5 gm/dl A/G RATIO 1.48
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4
T3, T4, TSH 11-06-2024 05:50:AM T3 0.85 ng/ml 1.87-0.87 ng/ml T4 6.67 micro g/dl 12.23-6.32 micro
g/dl TSH 0.37 micro-Iu/ml 5.36-0.34 micro-Iu/ml peripheral SMEAR 11-06-2024 03:50:PM RBC:
Microcytic hypoochromic WBC: With in normal limits PLATELET: Adequate
STOOL FOR OCCULT BLOOD 11-06-2024 03:50:PM Negative (-ve)ABG 12-06-2024 07:40:AM PH
7.342 PCO2 33.8 PO2 73.3HCO3 17.8 St. HCO3 18.9 BEB -6.6BEecf -6.8TCO2 37.2O2 Sat 94.3O2
Count 14.1
SERUM CREATININE 12-06-2024 10:41:PM 1.6 mg/dl 1.3-0.9 mg/dl SERUM ELECTROLYTES (Na,
K, C l) 12-06-2024 10:41:PM SODIUM 136 mmol/L 145-136 mmol/L POTASSIUM 3.8 mmol/L 5.1-3.5
mmol/L CHLORIDE 102 mmol/L 98-107 mmol/L
PHOSPHOROUS 3.0 mg/dl 4.5-2.5 mg/dl
FBS: 287 MG/DL
PLBS: 101 MG/DL
HBA1C 8.2%

Treatment Given (Enter only Generic Name)

INJ.LEVITIRECETAM 1GM IV/OD
INJ. GLARGINE SC/OD 8 UNITS 8 PM
INJ.HAI SC/TID ACCORDING TO GRBS
INJ.OCTREOTIDE 100 MG IV/ STAT
TAB.THYRONORM 100 MICRO GRAMS PO/OD
Advice at Discharge
INJ.GLARGINE S/C OD [8 UNITS]
TAB.LEVITIRACETAM 500 MG PO/OD
TAB. THYRONORM 75 MCG PO/OD 1-0-0 8 AM
INJ.HAI S/C TID [6-6-6]
TAB. DEFOCORT 6 MG 0-1-0 2PM
Follow Up

REVIEW TO GENERAL MEDICINE OPD AFTER 2 WEEKS ON MONDAYS.

When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR
ATTEND EMERGENCY DEPARTMENT.
Preventive Care
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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: hospital phone helpline For Treatment Enquiries Patient/Attendant 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:15/6/24
Ward: AMC
Unit: I

[04-11-2024 21:12] PPM 3: Meeku government iche insulin dose adjust cheyali ante kodhi rojulu meeru 

Fasting blood sugar (padigadupuna)

Breakfast tarvatha Rendu gantalaki

Lunch Tarvatha Rendu gantalaki

Dinner Tarvatha Rendu gantalaki 

Sugars check chesukuni maku Ikkada chepthe memu dose adjust chestam

[04-11-2024 21:16] PA: Meter Panicheyatledu sir

[05-11-2024 06:46] PPM 1: @PPM3 he's giving us a lot of points regarding the tech resource challenges to speak about on November 28!

[23-12-2024 10:56] PA: E insulin use cheyocha sir 50/50

[23-12-2024 11:19] PPM 1: 👆Did you get an opportunity to talk to this most erratic patient in our PaJR? Suddenly out of the blue he puts forward a local requirement without meeting any of our requirements of hyperlocal information continuity!

If we can buy in a better provider patient relationship in such challenging patients we will be considerably moving forward to scaling our service delivery mechanisms @PPM2

[23-12-2024 11:30] PA: Use cheyocha sir

[23-12-2024 20:10] PPM 1: Any insights as to why he's so erratic in his sharing and why he doesn't make it easy for us to try and help him?

[23-12-2024 20:22] PPM 1: Okay!

[23-12-2024 20:38] PA: Morning 15 units Insulin

2 chapathi

Afternoon Rice ladies finger curry

Night Rice amla pickle

[23-12-2024 21:41] PPM 2: Because the burden of data sharing is on the advocate. We need a sensor asap

[24-12-2024 09:25] PPM 1: Well captured

If only we could capture patient data in a more seamless manner!

[26-12-2024 07.46] PA: Breakfast 3 small dosa

[29-12-2024 12.26] PA: Good afternoon sir, lunch rice with cauliflower

[29-12-2024 16:14] PPM 1: @CR he seems to be making amends

However can we hope for him ever to share his insulin doses and blood sugar outcomes even once a week for the fasting and three 2 hour post meals sugars?

[06-06-2025 13:26] PA: Good Afternoon Sir

[06-06-2025 16:20] PPM 1: He seems to have returned 6 months later!

[07-06-2025 20:21] PA: Yes Sir

[08-06-2025 07:45] PA: Human mixtard insulin 16

[08-06-2025 10:17] PPM 1: Fasting blood sugar?

Also please let us know the blood sugar after two hours of this mixtard 16 and also two hours after lunch and dinner.

@CR @PPM4 @PPM2 we may need to talk with this patient who's otherwise quite experienced with his diabetes but has an erratic patient advocate when it comes to actual sharing his data

[08-06-2025 07.45] PA: Breakfast 3 small dosa, one cup tea. Human Mixtard Insulin 16U

[08-06-2025 12:34] CR: Spoke to him.

[14-06-2025 12:22] PA: Morning insulin human mixtard 15 units.  

[14-06-2025 12:23] PA: Tiffen dosa

[14-06-2025 12:29] PA: After 2 hours test 91mg/dl

[16-06-2025 11:42] PA: Morning 15 units insulin Rice 2 hours test 170

[16-06-2025 21:33] PPM 1: How many times is this patient taking mixtard? 

What about his night dose?

[16-06-2025 21:36] PA: 2 hours after test sir

[16-06-2025 21:52] PPM 1: Morning 15U

Evening?

[17-06-2025 06:43] PA: 8 units mixtard sir day by day

[17-06-2025 07:08] PPM 1: So everyday 

15U mixtard in the morning

And

8U mixtard in the evening?

[17-06-2025 07:25] PA: Yes sir

[17-08-2025 08:02] PA: E insulin government hospital lo echaru edi use cheyocha Sir

[17-08-2025 10:07] PPM 1: Patient ippudu enni rol ninchi em insulin use chestunnaru?

@CR is there any updated version of his PaJR case report?

[17-08-2025 10:41] CR: I will do it today

[17-08-2025 10:56] CR: We couldn't find his consent form in the e mail. That's why no case report I guess.

[17-08-2025 12:35] PPM 1: Alright.

@PPM5 can you get him to download the consent form and sign with full address, age, gender, complaints, date and rescan it and send?

[17-08-2025 12:37] PA: E insulin use chesthunna sir

[17-08-2025 12:53] PPM 1: Yes it's the same

[17-08-2025 12:55] PA: Okay Sir

[12:47 pm, 20/02/2026] PA: Good Afternoon Sir

[12:47 pm, 20/02/2026] PA: 3 Days nunchi Akali avvatledu Sir

[2:27 pm, 20/02/2026] PA: Reply Sir

[8:24 pm, 20/02/2026] PPM 1: 👆@PPM2 this patient's advocate from Telangana represents one of our most challenging patients in terms of follow up, resurfacing from time to time in this PaJR group.

[8:48 pm, 20/02/2026] PPM 2: Yes can see sir.

[8:48 pm, 20/02/2026] PPM 2: Problem poorthi ga cheppandi

[8:48 pm, 20/02/2026] PA: ఒక సార్

[8:51 pm, 20/02/2026] PA: 3 డేస్ నుంచి ఆకలి అవ్వట్లేదు మోషన్ ప్రాబ్లం ఎలోడోపర్ ఆర్ oflox oz Sestil Ad Tablets vesukunna తగ్గట్లేదు సార్ ఆకలిగా అవట్లేదు కడుపు గ్యాస్ గా ఉంది

[9:59 pm, 20/02/2026] PPM 2: Mee sugar levels ela vunnayi?

[9:59 pm, 20/02/2026] PPM 2: Meeru insulin edi teeskuntunaru?

[10:00 pm, 20/02/2026] PPM 2: @PaJR Health go through this here https://medicinedepartment.blogspot.com/2024/06/pajr-case-report-of-27m-diabetes-on.html and present how his diabetes has been and what insulin the patient is taking

[10:00 pm, 20/02/2026] PaJR Health: Based on the clinical record provided, here is the summary of the patient's diabetic history and current insulin regimen:

*DIABETIC HISTORY & STATUS*

🔹 *Duration:* The patient is a 27-year-old male with Type 1 Diabetes Mellitus (T1DM) for 15 years.

🔹 *Glycemic Control:* His sugars have been described as "fluctuating," with a recent HbA1c of 8.2%. He has a history of "brittle diabetes," characterized by severe swings in blood glucose levels.

🔹 *Complications:* 

📋 *Hypoglycemic Seizures:* He was recently admitted (June 2024) following a seizure episode triggered by a dangerously low blood sugar level (GRBS of 23 mg/dL).

📋 *Diabetic Retinopathy:* Ophthalmology evaluation confirmed Mild Non-Proliferative Diabetic Retinopathy (NPDR).

📋 *Hypothyroidism:* He has been managing hypothyroidism for 2-3 years, which can further complicate glucose stability.

*INSULIN REGIMEN*

The patient’s regimen was adjusted during his last hospital course to better manage nocturnal hypoglycemia and daytime fluctuations:

🔹 *Basal Insulin:* Inj. Glargine (Lantus) – 8 Units subcutaneously once daily at 8 PM.

🔹 *Prandial (Mealtime) Insulin:* Inj. Human Actrapid (HAI) – 6 Units subcutaneously three times daily (TID) before meals. 

💡 *CLINICAL NOTE:* The medical team previously noted nocturnal hypoglycemia when on this dose of Glargine, leading to a complex discharge plan that included low-dose steroids (Defocort) and Octreotide to help maintain euglycemia and prevent further life-threatening drops in sugar.

*REFERENCE RECORD*

1. 27M Diabetes on insulin 15 years Telangana PaJR

https://medicinedepartment.blogspot.com/2024/06/pajr-case-report-of-27m-diabetes-on.html

[10:04 pm, 20/02/2026] PPM 2: @PA mee patient insulin edi teeskuntunaru and blood sugar ela vundi

We may expect to wait for a few months before he resurfaces in this group with another SOS!

Maybe synchronous calls are a solution but we would need trained AI telecallers for that. Let's make that too a PaJR first agenda

[9.39 am, 21/02/2026] PPM 3: Synchronous calls will come with the responsibility of handling emergencies, which I think the PaJR group will be unable to provide due to resource constraints and most patients being at far off places from the actual hub (KIMS)

AI telecallers is a great idea though, and would add another dimension to PaJR along with the bot

[9.54 am, 21/02/2026] PPM 2: Will be on my shortlist.

[10.06 am, 21/02/2026] PPM 1: The AI can be trained to tell patients to get in touch with their local doctor for the much needed clinical examination very similar to how human PaJR agents currently tell that to PaJR patients?

[10.08 am, 21/02/2026] PPM 1: In fact if AI agents can learn and imbibe how human PaJR agents actually function across most groups that itself would be a great way to create a good PaJR bot?

[10.08 am, 21/02/2026] PPM 2: Don't think we can have best of both worlds where we meticulously deidentify all patient data and then ask the AI agent to identify the patient and call it?

[10.08, 21/02/2026] PPM 1: As simple as call hu1

[10.09 am, 21/02/2026] PPM 2: A dangerous can of worms I'd rather not open