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.
The PHR patient journey record PaJR transcripts below reflect the therapeutic uncertainities around the patient and their resolution through team based learning;
[22-10-2024 19.30] PPM 1: 40M with diabetes 10 years with recent concerns of AKI which appears to be NSAID induced.
[22-10-2024 19.35] PPM 1: Share the patient's investigations and seven point sugar profile when they become available @PPM3.
[22-10-2024 19.35] PPM 3: Ok sir.
[23-10-2024 09.18] PPM 3: GRBS of the patient
23-10-24 8am -
10 am - 161mg/dl
3 pm - 221mg/dl
7 pm - 139mg/dl
10 pm - 303mg/dl
2 am - 190mg/dl
7 am - 126mg/dl.
[23-10-2024 09.20] PPM 1: Please insert the interventions and the time they were administered. Please prepare a 24hr chart leaving blank the slots where the data may not have been collected.
[23-10-2024 09.21] PPM 1: Serum creatinine 2.0. Please get a quick CUE to check for proteinuria and share the images of his ultrasound kub ASAP
[23-10-2024 09.22] PPM 1: HGM normal.
USG report
[23-10-2024 11.52] PPM 1: Is he on glimiperide 2mg and metformin 500 mg!
No post two hours of after taking the drug was taken today! 😨😳
[10/23, 11:55 AM] PPM 1: Get his post lunch two hours without fail
[10/23, 11:59 AM] PPM 1: He has had an episode of hypoglycemia two weeks back AFTER he took a light meal and 7PM when he felt hungry and found his sugars were 75! Felt fatigued and had mild tremors
[10/23, 12:00 PM] PPM 3: Patient was not in ward at 10am to check his post breakfast sugars sir
[10/23, 12:00 PM] PPM 3: Ok sir
[10/23, 5:33 PM] PPM 3: GRBS
10am -119
1pm-170
4pm -190
[10/23, 7:32 PM] PPM 1: Can anyone convert this from voice to text @PA
[10/23, 7:34 PM] PA: After eating a sweet apple his sugar level became high
[10/23, 7:48 PM] PPM 1: Which high value is he talking about? What time?
[10/23, 7:48 PM] PPM 1: @Meta AI translate to Bengali
[23/10, 19:34] Patient advocate 23F Weight Gain: After eating a sweet apple his sugar level became high
[23/10, 19:48] PPM 1: Which high value is he talking about? What time?
[10/23, 7:48 PM] Meta AI: I don’t understand Bengali yet, but I’m working on it. I will send you a message when we can talk in Bengali.
[10/23, 7:49 PM] PA: আপনার সুগার এর কোন value টা বেশি , কোনটার কথা বলছেন?
আর কখন এর কথা বলেছেন?সময়টা উল্লেখ করুন
[10/23, 7:53 PM] 24F PA: সুগারের কোন value ta
[10/23, 8:13 PM] PPM 1: This is one of the reasons it's difficult to adapt to voice as it takes up a lot of our time!
[10/23, 8:13 PM] PA: He said at 6.45 evening his sugar level became high to 30 -40
[10/23, 8:15 PM] PPM 1: 30-40?
[10/23, 9:31 PM] PA: 30 to 40 point he said
[10/23, 9:38 PM] PPM 3: Grbs @7pm -229
[10/23, 9:39 PM] PPM 1: 👆What does that mean @~PDOC1 ?
[10/23, 9:39 PM] PPM 3: I didn’t understand sir
[10/23, 9:41 PM] PPM 4: What is the diagnosis for his Diabetes? Type 1 or Type 2 or Type 3?
[10/23, 9:43 PM] PPM 1: 2
[10/23, 9:43 PM] PPM 1: Will need someone to talk to him. Remind me tomorrow at OPD
[10/23, 9:43 PM] PPM 4: How and why please?
[10/23, 9:44 PM] PPM 1: 👆@PPM3
[10/23, 10:08 PM] PPM 3: He is having Diabetes since 10yrs and responding well to OHAs sir
[10/23, 10:28 PM] PPM 1: Two hours post dinner?
[10/23, 10:30 PM] PPM3: ThanksPPM5. Which OHAs?
[10/23, 10:40 PM] PPM 5: Currently on metformin and glimiperide sir
[10/23, 10:41 PM] PPM 4: Thanks again. Since when has he been on Glimepiride?
Can you please share his fasting, post prandial and HbA1c numbers please?
[10/23, 11:11 PM] PPM 3: He was on glimiperide +voglibose and metformin for last 2-3 months sir and currently on glimiperide and metformin as advised by PPM1 SIR
Fasting blood sugars -124
GRBS
7am-126 (pre-breakfast)
10am -119 (post breakfast)
1pm-170 (pre-lunch)
4pm -190 (post lunch)
7pm - 229 (pre dinner)
[10/23, 11:16 PM] PPM 4: Appears like this is MODY. Any family history chart for diabetes?
[10/23, 11:17 PM] PPM 3: And thanks so much for taking the time and sharing this
[10/23, 11:17 PM] PPM 4: Classic IFT with easily well-controlled post prandial sugars
[10/24, 7:36 AM] PPM 1: @PPM3 @24FPA please try to get his family tree made mentioning who are diabetic and share it here
[10/24, 7:36 AM] PPM 3: Ok sir
[10/24, 7:41 AM] PPM 1: Although that alone may not be able to distinguish MODY from type 2
[10/24, 7:44 AM] PPM 1: The diagnostic criteria for Maturity-onset diabetes of the young (MODY) include:
Age of onset: Diabetes that begins before age 25
Insulin production: Sustained insulin secretion and a serum C-peptide level of more than 200 pmol/L
Family history: Diabetes in at least two consecutive generations
Autoantibodies: Absence of pancreatic islet autoantibodies
Other features: Mild, stable fasting hyperglycemia, and no significant obesity
Considering all data around this patient particularly his trunkal fat and sarcopenia I'm currently putting more money on Type 2 than MODY
[10/24, 11:09 AM] PPM 1: The patient identifier is visible and hence having to delete
[10/24, 11:12 AM] PPM 4: Before age of 25 is generic. However, because quite a few go unnoticed, diagnosis before 45 and no Type 2 phenotype should raise suspicion
[10/24, 11:14 AM] PPM 4: Also important to know how his phenotype was at the time of diagnosis.
Sulphonylureas are known to cause trunkal obesity as they are insulin secretagogues
[10/24, 11:19 AM] PPM 1: Bottom-line is all these quests don't change our management plan which is essentially to bring all diabetics to shape and address sarcopenia and trunkal fat regardless of their diabetic type (as all types technically can become type 2 too)!
Our cornerstone remains normal diet and normal exercise (again the standard deviations around the normal is albeit debatable) for diabetics as well normal people (who are also congenitally afflicted with a sexually transmitted disease called life)!
[10/24, 11:21 AM] PPM 1: @PA Apnar diabetes jokhon prothom dhora pore 10 bochor aage tokhon apnar pet ebong muscle kemon chilo? Aekhon jemon ache temon chilo naki pet ta aro boro chilo?
[10/24, 11:21 AM] PPM 4: I agree to an extent. However you can reduce pill burden (Metformin and the voglibose previously), genetic link and if female the much higher risk of GDM.
[10/24, 11:23 AM] PPM 4: Fortunately/unfortunately I'm starting to see all diabetes with a "specialist" lens, heavily tinted currently by first World dynamics.
[10/24, 11:26 AM] PPM 1: Yes I have already thrown out the voglibose
Metformin is not given much leverage in general.
It's the secretagogue that rules
[10/24, 11:29 AM] PPM 4 Agreed.
I always believe making precise diagnoses can enable precise treatments and minimize adverse effects.
Noticing here that quite a few on Metformin eventually have B12 deficiency (not the serum levels thankfully but through macrocytosis, anemia and neuropathy) requiring b12 supplementation.
Which is why my obsession with diagnostic precision. You can then throw out the Metformin as well!
[10/24, 11:30 AM] PPM 4: Could you kindly let me know his HbA1c please?
[10/24, 11:35 AM] PPM 1: This would be a very interesting project
[10/24, 11:36 AM] PPM 1: Not done I guess?
[10/24, 11:37 AM] PPM 1: In our hospital one of our diabetes thesis PGs cracked the mystery of our Hba1c values never ever having risen more than 7.5-8 perhaps in years! Blame it on latex agg (ours) v HPLC (standard)
[10/24, 11:40 AM] PPM 4: And I was also told by a lab technician that they extrapolated it from fasting sugars!! 😵💫
[10/25, 4:10 PM] PPM 1: @PPM3 please pm me his signed informed consent ASAP.
10/25, 16.10] PA: 77mg/dl
[10/25, 8:37 PM] PPM 1: @SE can you help us with his graphical chart of sugar values since admission that were shared here
[10/25, 8:39 PM] PPM 1: In the daily blood sugar monitoring chart, it would be nice to also mention the diabetes drugs and their time taken apart from what was well done in the other patient's chart
[10/25, 8:45 PM] PPM 1: @~PA2🙂🙂 ke bolun apnar voice message ta ekhane text kore janate
[10/25, 20.45] PA: 105mg/dl
[10/25, 8:53 PM] PPM 1: Please text.
We can't hear voice messages or take calls
[10/25, 8:59 PM] PPM 1: @PPM3 please share all the sugar values in this patient since admission and also mention what medication and what dose he's currently on
[10/25, 20.59] PA: 140mg/dl
[10/25, 9:48 PM] PPM 1: Aekhon apnar patient er glimiperide koto dose nicchile?
[10/28, 2:10 PM]PA: খাবার পরে pp 180 ঔষধ এক বার খেয়েছি 12.05pm 28 তারিখ দুই দিন গাড়িতে ঔষধ বন্ধ ছিল
[10/28, 2:19 PM] PPM 1: Oshudher naam ebong dose?
[10/29, 2:42 PM] PA: খাবার দুই ঘন্টা পর ২০০ আরো এক ঘন্টা পর 75 ভাত সব্জি খাবার পর 90 কোনও প্রবলেম নাই ঔষধ কি তিন বেলা চলবে না দুই বেলা
[10/29, 2:46 PM] PA: খাবারের তালিকায় ছিল ভাত শাক সব্জি মাছ
[10/29, 3:31 PM] PPM 1: 👆Oshudher naam ebong dose ebong kone kone time a gotokal niyechen
PA: 
[10/29, 3:40 PM]PA: একটা খালি পেটে আর খাবার পর তিন বেলা তিন টা
[10/29, 4:54 PM] PPM 1: Blood sugar ta soptahe jekono aek din aeibhabe janaben👇
Fasting
Breakfast er 2 ghonta baade
Lunch er du ghonta bade
Dinner er du ghonta bade
[11/4, 10:43 AM] PA: সুপার খালি পেটে 100 খাবার পরে170 কিন্তু ট্য়লেটের প্রবলেম হচ্ছে পেটে কপ কপ ডাকে আর গেস্ হয় কিলিয়ার হয় না আর আম আম টয়লেট হয় গস হলে পেসার বারে
[11/4, 10:45 AM] PPM 1: Toilet er problem ta IBS
Shothik khawa ebong haatha chola activities korle bhalo hoye jabe.
Sheta ki bhabe korben ebong share korben sheta aei patient er group a click korle jante paben 👇
https://chat.whatsapp.com/JjNdlilfItm7FIxmVSh3Xs
[11/4, 10:48 AM] PA: ইউরিনে পেসার আছে কিন্ত ইসপ্রিট অল্প কম
[11/4, 10:51 AM] PPM 1: Otao urinary bladder er aek dhoroner IBS jeta overactive kimba underactive bladder bola hoi
[11/4, 10:52 AM] PPM 1: Etao join korte paren shudhu regular shothik khawa ta janar jonnye 👇
https://chat.whatsapp.com/BwTGZStKGN9I50hmyNKLPI
[11/4, 11:27 AM] PA: IBS টেবলেট বুঝতে পারতেছে না আগে পিছে নাম চাচ্ছে
[11/4, 12:27 PM] PPM 1: Na IBS er kono tablet nei
Oguno khawar dorkar nei
[11/4, 12:28 PM] PPM 1: IBS rog ta ekmatro shothik khawa dawa ebong shothik hourly daily activities er dwara thik habe
[11/5, 10:49 AM] PA: সকালে খালি পেটে 85
[11/5, 10:55 AM] PA: IBSখাবার পরে পেটে কোন প্রবলেম নাই টয়লেট কিলিয়ার ইউরিন ভালো হচ্ছে সরিলে এনার্জি আছে
[11/6, 8:23 PM] PA: সুগার 5pm টিফিন করার পরে 8pm 70 চকলেট খাবার পরে 85 ওষুধ কি বন্ধ রাখবো
[11/6, 9:00 PM] PPM 1: Hain bondho rakhun.
Oshudh er dose koto chilo gotokal ebong ajke? Oshudher chobi share korun jate dose ta dekha jai
PA: 
[11/6, 10:02 PM] PPM 1: Oshudher chobi share korun
Ekhane jeta lekha ebong apni ashole jeta khacchen duto alhada o hote pare
[11/7, 7:09 AM] PA: 7.am সুগার 100
[11/7, 8:56 AM] PPM 1: 👆
[03-08-2025 21:15] PPM 1: Unar creatinine beshi kabe theke jana geche?
Aer aage last kabe test korechilen ebong koto chilo?
Uric acid er jonye khawa dawa shothik korte habe ebong kichu ta creatinine barar jonyeo bereche!
Aekhon uni bortomane ki oshudh khacchen?
Aeto din ekhane kichu janan ni keno?
22.10.2024
[04-08-2025 16:56] PPM 1: Aer por serum creatinine blood test ta kora hoyechilo?
[04-08-2025 16:58] PPM 1: Apnar patient eta kotar shomoi khan?
Apnar patient er
Fasting blood sugar
Breakfast er du ghonta por blood sugar
Lunch er du ghonta por
Ebong
Dinner er du ghonta por blood sugar ta glucometer diye jekono chutir din kore janaben
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