30F DM1 8yrs, CKD 3yrs, COMA 20days Telangana PaJR

 

27-10-2025

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 PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.

[5.11 pm, 27/10/2025] PPM 1: She lost this thumb recently of gangrene possibly due to iatrogenic reasons right after a venous cannulation around the thumb. 

@PPM3 @PPM4 @PPM5 please share the rest of her history details as I forgot to image the handwritten notes

[6.48 am, 28/10/2025] PPM 1: MRI Brain of this patient 👇
https://youtube.com/shorts/Qd03jdVZWAg?si=HMzz1Ot0KB57pjw7

[4.22 pm, 31/10/2025] PPM 1: @PPM5 @PPM6 can you share her history a bit?

We know that she had diabetes detected during gestation 8 years back, husband left her soon after and she took on the added tag of a single mother managing child and diabetes that was thought to be insulin dependent and three years back she also developed renal failure and severe secondary hypertension ever since she began dialysis a year back. This time she came with hypertensive LVF followed by altered sensorium possibly due to uremic encephalopathy that was also managed as meningitis by the local team inspite of no CSF evidence of meningitis.

She was intubated for altered sensorium last week and was extubated yesterday.

She lost this thumb recently of gangrene possibly due to iatrogenic reasons right after a venous cannulation around the thumb. 

@PPM3 @PPM4@PPM5 please share the rest of her history details as I forgot to image the handwritten notes.

@PPM6 please share her previous EMR summary IP number so that I can get the data from staff.

[4.29 pm, 31/10/2025] PPM 1:

[11.24 am, 01/11/2025] PPM 5: Patient was first diagnosed with diabetes during her first pregnancy (3rd month) in 2017 and was started on insulin. she had recurrent hypoglycemia and visited multiple hospitals for the same and insulin dose was reduced. Then she developed hypertension in 2021, in 2023 she had pedal edema, facial puffiness and decreased urine output and consulted nephrologist and was diagnosed as diabetic Nephropathy started on medical management. In 2025 January she had pulmonary edema and was started on dialysis since then. 5 months ago she came for maintence hemodialysis and had fever for which cannula was placed in left wrist region which had swelling followed which gangrene of left thumb (1st distal phalanx) developed and self amputated after 1 month. Now she came for main stance hemodialysis after which she developed severe abdominal pain with vomitings. Next day she was in altered sensorium and low gcs for which she was intubated and extubated 2 days ago.
[1.09 pm, 01/11/2025] PPM 2: How and why was she diagnosed with Type 1 Diabetes?
[3.57 pm, 03/12/2025] PPM 1: Update:

Post discharge from her ventilator status in ICU, a fresh case sheet was opened on 6/11/25 by @PPM7  for regular dialysis

Got admitted again yesterday night with vomiting

[3.38 pm, 04/12/2025] PPM 1: Detailed history by @PPM8

EMR summary  

Age/Gender: 30 Years/Female

Address:

Discharge Type: Relieved

Admission Date: 06/11/2025 04:06 PM

Discharge Date: 04/12/2025 10:00 AM

Diagnosis

CKD ON MHD

UREMIC GASTRITIS(RESOLVING)

PEPTIC ULCER DISEASE (NO NSAID ABUSE)

?SEPSIS- CRBSI

Case History and Clinical Findings

PATIENT COMPLAINS OF BILATERAL LOWER LIMBS ACHING PAIN SINCE YESTERDAY

ASSOCIATED WITH FACIAL PUFFINESS SINCE 2 WEEKS

HOPI:PT WAS APPARENTLY ASYMPTOMATIC 1 YEAR AGO THEN DEVELOPED SOB SUDDEN ONSET, GRADUALLY PROGRESIVE .NO H/O FEVER, CHEST PAIN, LOOSE STOOLS, FACIAL PUFFINESS. 

HAEMODIALYSIS WAS DONE ON 22/10/25 AND WAS PRESENTED WITH SUDDEN ONSET SOB AND VITALS: BP-200/100MG, PR :112BPM, RR-28CPM.

PAST HISTORY: K/C/O HTN AND TYPE 2 DM SINCE 8 YEARS.

PERSONAL HISTORY: MARRIED, APPETITE -LOST, BOWEL MOVEMENT -REGULAR, NO

KNOWN ALLERGIRS, NO ADDICTIONS, MICTURITION - NORMAL

GENERAL EXAMINATION: NO PALLOR, NO EDEMA, NO ICTERUS, NO CYANOSIS, NO

CLUBBING, NO LYMPHADENOPATHY,

VITALS: - TEMP: AFEBRILE, BP: 160/70MMHG, RR: 21 CPM, PR:71 BPM, SPO2: 100% AT RA

SYSTEMIC EXAMINATION-CVS - S1 S2 +, NO MURMURS; RS - BAE +, NVBS HEARD; PER

ABDOMEN -SOFT NON TENDER; CNS- NFND

DIALYSIS DONE ON 07/11, 10/11 ,13/11, 17/11, 20/11, 22/11, 24/11, 27/11, 01/12, 04/12

Investigation

HEMOGRAM (06/11/25):- HB-10.1, PCV-29.0 TLC-12100, RBC-3.3, PLT-2.4

LIVER FUNTION TEST (06/11/25): TOTAL BILIRUBIN 0.83 MG/DL, DIRECT BILIRUBIN

0.20MG/DL, SGOT 18 MG/DL, SGPT 39MG/DL, ALKALINE PHOSPHATASE 188 IU/L, TOTAL

PROTEINS 4.8 G/L, ALBUMIN 2.5 G/DL, GLOBULIN 2.30G/DL, A/G RATIO 1.09

RFT (06/11/25): UREA 108 MG/DL CREATININE:4.80 MG/DL SODIUM :130 MG/DL POTASSIUM

3.9MG/DL CHLORIDE 92MG/DL

SERUM IRON (06/11/25):64ug/dl

HEMOGRAM (03/12/25): - HB-8.1, PCV-26.2 TLC-24000, RBC-2.6, PLT-3.3

USG (03/12/25):

FINDINGS:

VISUALISED BOWEL LOOPS APPEARS NORMAL, SHOWS NORMAL CALIBRE AND SHOWS

NORMAL PERISTALSIS

IMPRESSION:

GRADE II RPD CHANGES OF RIGHT KIDNEY

GRADE I RPD CHANGES OF LEFT KIDNEY

MILD ASCITIS

Treatment Given (Enter only Generic Name)

FLUID RESTRICTION <1.5 LITRE/DAY

SALT RESTRICTION <2G/ DAY

TAB VANCOMYCIN 250 MG PO/BD

TAB ZOFER 4MG PO/TID

TAB PAN 40MG PO BD

TAB NODOSIS 500MG PO/OD

TAB MOXIDINE 0.3MG PO/TID

TAB.PRAZOSIN 10MG PO/OD

TAB ISOLAZINE 20/375MG PO/TID

TAB.ECOSPIRIN GOLD 75/75/20MG PO/HS

TAB LEVIPIL 500MG PO/BD

TAB SHELCAL PO/OD

TAB BUSCOPAN PO/OD

Page-3

KIMS HOSPITALS

Advice at Discharge

FLUID RESTRICTION <1.5 LITRE/DAY

SALT RESTRICTION <2G/ DAY

TAB VANCOMYCIN 250 MG PO/BD

TAB ZOFER 4MG PO/TID

TAB PAN 40MG PO BD

TAB NODOSIS 500MG PO/OD

TAB MOXIDINE 0.3MG PO/TID

TAB.PRAZOSIN 10MG PO/OD

TAB ISOLAZINE 20/375MG PO/TID

TAB.ECOSPIRIN GOLD 75/75/20MG PO/HS

TAB LEVIPIL 500MG PO/BD

TAB SHELCAL PO/OD

TAB BUSCOPAN PO/OD

Follow Up

REVIEW TO NEPHROLOGY OP AFTER 1 WEEK FOR MHD/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/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: 4/11/2025

Ward: AMC

[9:24 pm, 04/12/2025] PPM 8: Found out she also has secondary amenorrhea since 15 months

[8:57 am, 05/12/2025] PPM 1: [04/12, 06:56] Anonymous Pm: Uncertainties 

1.Why did she present for diabetes with hypoglycemia episodes 

2.Will the oha trail help her

3.What really happened for the cause of emergency lscs 

4.Why did she develop hypertension?

5.Cause of CKD

6.Why cholelithiasis?

7.Recurrent infections

[04/12, 15:10]hu2: 👆 Current age?

How do we know those were hypoglycemic episodes?

[04/12, 17:53] Anonymous Pm: The attender is telling 

[04/12, 17:54] Anonymous Pm: 30F

[04/12, 22:44]hu2: Can't give OHAs in CKD

[04/12, 22:45]hu2: 4 was because of 5

5 is a mystery unless we think it was due to diabetic nephropathy

[04/12, 22:53] Anonymous Pm: Gliclazide?

[04/12, 22:57]hu2: Not in full blown CKD

[04/12, 22:56] Anonymous Pm: Why even diabetes 

[04/12, 22:56] Anonymous Pm: Not a metabolic syndrome phenotype

[04/12, 22:57]hu2: Type 1

[04/12, 22:55] Anonymous Pm: Secondary amenorrhea is also added to that uncertainties now

[04/12, 22:57]hu2: Any chronic illness like CKD will result in that

[04/12, 22:57] Anonymous Pm: Why?

[04/12, 22:58]hu2: Why not ask general knowledge questions to @⁨Meta AI?

[04/12, 22:58] Meta AI: Fire away with your general knowledge questions! I'm here to help and provide information on a wide range of topics. Go ahead and ask me anything!

[04/12, 22:58] Anonymous Pm: Why would CKD lead to secondary amenorrhea

[04/12, 22:58] Anonymous Pm: @⁨Meta AI⁩

[04/12, 22:58] Meta AI: It looks like you didn't get a chance to ask your question yet. Go ahead and ask me anything you'd like to know! I'm here to help.

[04/12, 22:59]hu2: @⁨Meta AI⁩ why does secondary amenorrhea happen in chronic anemia and chronic renal failure?

[04/12, 22:59] Meta AI: Secondary amenorrhea in chronic anemia and chronic renal failure can occur due to disruptions in the hypothalamic-pituitary-gonadal (HPG) axis.

Chronic Anemia:

1. Hypothalamic dysfunction: Chronic anemia leads to hypoxia, stress, and malnutrition, disrupting GnRH secretion and causing amenorrhea.

2. Low estrogen: Anemia reduces estrogen production, impacting menstrual cycles.

3. Nutritional deficiencies: Deficiencies in iron, vitamins, and minerals affect ovarian function.

Chronic Renal Failure (CRF):

1. Uremic toxins: Toxins accumulate, disrupting GnRH and LH/FSH secretion.

2. Hyperprolactinemia: CRF increases prolactin, suppressing GnRH and estrogen.

3. Hormonal imbalance: CRF alters estrogen, progesterone, and testosterone levels, impacting menstruation.

These factors contribute to menstrual irregularities and secondary amenorrhea [1][2][3].

References:

1. Sharma et al. (2018). Menstrual disorders in chronic kidney disease. Indian J Endocrinol Metab.

2. Anttila et al. (2017). Hypothalamic-pituitary-gonadal axis in chronic kidney disease. J Clin Endocrinol Metab.

3. Mathew et al. (2019). Menstrual disturbances in chronic anemia. J Clin Diagn Res.

[04/12, 23:04] Anonymous Pm: Not satisfactory enough, I'll do my own reading