40M TYPE 1 DIABETES MELLITUS WITH UNCONTROLLED SUGARS, ATROPHIED PANCREAS

 A 40 years old male, an auto driver by occupation came to OPD with C/O 


 loss of consciousness at around 3 am since 20 days

C/O nausea since 1 week

C/O weakness since 1 week


HOPI : 

Patient was apparently asymptomatic 20 days ago then developed hypoglycemic symptoms at around 3 am and patient became unresponsive.

Hypoglycemic symptoms were relieved on having some sugar syrup or chocolate.

Similar episode has been occurring on a daily basis from the past 1 week.

H/O of increased physical activity beyond patient's usual routine from past 20 days

                                    ⬇️   

H/O of which hypoglycemic event occurred early in morning 

No h/o sweating, palpitations during that episode. 

No h/o vomiting, blurring of vision during that episode 

No h/o of fever

No h/o pain abdomen, loose stools 

No h/o burning micturition, decreased urine output 

No h/o polyurea , polydypsia , polyphagia 

No h/o similar complaints in day time 


Year -2001  

23 years ago, he experienced head trauma for which he went to a private hospital, evaluated and was treated with "2 surgical stitches" in a head wound ( occipital region)

Then he had high sugars for the first time and was diagnosed with type-1-diabetes ,23 years ago in a local hospital and on advice was on medication INJ.BIPHASIC ISOPHANE INSULIN BD 10ml [ 40IU/ml ] ( ✅---❌---✅ ) since 23 years after the diagnosis of type-1-diabetes ( in the year 2001)



Year- 2001

He was diagnosed with type-1-Diabetes Mellitus.


31st OF MARCH, 2024

He had experienced a hypoglycemic episode approximately 25 days ago, around noon. He experienced sweating and fell asleep while driving his auto . He was immediately taken to a private clinic , evaluated, and got relieved .

The doctor informed him about his diabetes condition and his changing blood sugar levels and provided necessary warnings.

Following this event, his attendants closely monitored his condition on an hourly basis.



PAST HISTORY

K/C/O  -  TYPE 1 DIABETES MELLITUS SINCE 23 YEARS  and  ON MEDICATION   INJ.BIPHASIC ISOPHANE INSULIN BD 10 ml  [ 40 IU/ml ] (mrng & night )  SINCE THEN.

K/C/O. -  CHRONIC PANCREATITIS SINCE 2 YEARS 

N/K/C/O  -  HTN, ASTHMA,TB , EPILEPSY, CAD, CVA , THYROID DISORDERS.

H/O HEAD TRAUMA 23 YEARS AGO .

THEN THE PATIENT WAS ADMITTED IN A LOCAL HOSPITAL, EVALUATED AND WAS TREATED WITH "2 SURGICAL STITCHES" IN A HEAD WOUND( OCCIPITAL REGION) 


PERSONAL HISTORY


➤Occupation: Auto - Driver

➤Patient is married .

➤Patient takes mixed diet and has a normal appetite.

➤Bowel and bladder movements are normal 

➤No known allergies .

➤Addictions : he has been consuming alcohol 45 ml per 10 days from 1991 to 2001.

After which he was diagnosed with type-1-Diabetes Mellitus in the year 2001.

He has been consuming approximately 45 ml of alcohol every 15 days since 2001.


FAMILY HISTORY 

no relavant family history?


TREATMENT HISTORY 

ON MEDICATION INJ.BIPHASIC ISOPHANE INSULIN BD 10 ml [ 40 IU/ml ] (mrng & night ) SINCE 23 YEARS AFTER DIAGNOSIS OF TYPE-1-DIABETES ( IN THE YEAR 2001)


 General examination

Pt is concious , coherent, cooperative 

Well orientated to time,place and person 

He is moderately built, moderately nourished with very minimal visceral fat .




                 "v.minimal visceral fat"


No Pallor 

No icterus

 No cyanosis

No clubbing

No lymphadenopathy 

No pedal edema


VITALS

BP 12/70 mmHg

PR 86 bpm

TEMPERATURE 98 F 

Grbs 354 mg/dl as on 27-04-2024 , time : 6 am


SYSTEMIC EXAMINATION:


GASTROINTESTINAL SYSTEM EXAMINATION 

oral cavity: normal 

Per abdomen:

 No tenderness, no palpable mass


Inspection;

Shape of abdomen; scaphoid 

Position of umbilicus: central and inverted

No scars and sinuses are present

All quadrants are moving equally with respiration


Palpation:

No tenderness

No organomegaly


Auscultation:

Bowel sounds heard 


CARDIOVASCULAR SYSTEM EXAMINATION

Inspection - 

Chest Wall is Symmetrical

Precordial Bulge is not seen

No dilated veins, scars, sinuses

Apical impulse - Not Seen

Jugular Venous Pulse - Not Raised

 

Palpation - 

Apical Impulse - Felt at 5th Intercostal space in the mid clavicular line

No thrills, no dilated veins

 

 Auscultation - 

Mitral Area  -  First and Second Heart Sounds Heard, No other sounds are heard

Tricuspid Area -  First and Second Heart Sounds Heard, No other sounds are heard

Pulmonary Area - First and Second Heart Sounds Heard, No other sounds are heard

Aortic Area - First and Second Heart Sounds Heard, No other sounds are heard


RESPIRATORY SYSTEM EXAMINATION

Inspection -  

Chest is symmetrical

Trachea is midline

No retractions

No kyphoscoliosis

No Winging of scapula

No Scars, sinuses, Dilated Veins

All areas move equally and symmetrically with respiration


 Palpation - 

Trachea is Midline

No tenderness, local rise in temperature

Tactile Vocal Fremitus - Present in all 9 areas

 

Percussion - 

 Percussion                     Right                   Left

Supra clavicular:        resonant         resonant   

Infra clavicular:          resonant         resonant 

Mammary:                  resonant          Resonant

Axillary:                      resonant           resonant

Infra axillary:             resonant           resonant

Supra scapular:         resonant            resonant

Infra scapular:           resonant            resonant

Inter scapular:           resonant            resonant  

No tenderness


Auscultation - 

Auscultation:              Right.                   Left


Supra clavicular:.       NVBS                NVBS

Infra clavicular:          NVBS                NVBS

Mammary:                 NVBS                  NVBS    

Axillary:                     NVBS                   NVBS

Infra axillary:             NVBS                 NVBS

Supra scapular:          NVBS                NVBS

Infra scapular:           NVBS                 NVBS    

Inter scapular:           NVBS                 NVBS


 

No added sounds 

Vocal Resonance in all 9 areas- normal


CNS: NFND

HIGHER MENTAL FUNCTIONS:

CONCIOUS, COHERENT, CO-OPERATIVE

MMSE NORMAL 

speech : NORMAL

Behavior : NORMAL

Memory : NORMAL 

Intelligence : NORMAL 

Lobar Functions : NORMAL 


CRANIAL NERVE EXAMINATION:

3rd,4th,6th : pupillary reflexes present.

 No Nystagmus 


MOTOR EXAMINATION: Right Left


                                         UL LL UL LL


  BULK.                              N N N N

   TONE                              N N N N

   POWER                           N N N N  


   SUPERFICIAL REFLEXES:

                                         Right     Left    

   CORNEAL.                 present  present      

   CONJUNCTIVAL.       present  present

 

  PLANTAR  :- flexor


   DEEP TENDON REFLEXES:


                       RIGHT. LEFT

    BICEPS             2+. 2+

   TRICEPS.          2+. 2+

 SUPINATOR.       1+. 1+

   KNEE.                 2+. 2+

  ANKLE.               1+. 1+


SENSORY EXAMINATION:  normal 

CEREBELLAR EXAMINATION : normal 

SIGNS OF MENINGEAL IRRITATION: absent

GAIT : normal 

Cerebellar functions : normal 

Cerebellar signs : absent 


Provisional diagnosis : 

TYPE-1 DIABETES MELLITUS WITH UNCONTROLLED SUGARS 

ATROPHIED PANCREAS 

? SILENT PANCREATITIS SINCE 24 YEARS CAUSING   ? DIABETES SINCE 23 YEARS


INVESTIGATIONS IN SEQUENCE 


ANTI HCV Antibodies -RAPID ON 25-04-24


BLOOD UREA ON 25-04-24


CUE ON 25-04-24


HBsAg - RAPID ON 25-04-24


HAEMOGRAM ON 25-04-24


HIV 1/2 Rapid Test on 25-04-24


LFT ON 25-04-24


S.CREATININE ON 25-04-24


S.ELECTROLYTES ON 25-04-24


URINE FOR KETONE BODIES ON 25-04-24


GLYCATED HAEMOGLOBIN ON 25-04-24


ECG ON 25-04-24


USG ABDOMEN ON 25-04-2024


FBS ON 26-04-24 ( 08:15 AM ) 

PLBS ON 26-04-24 ( 2:05 PM ).



FINAL DIAGNOSIS- …?


TREATMENT GIVEN 

INJ.HAI S/C TID (according to sugars)

INJ.GLARGINE S/C OD ( according to sugars)



Date of discharge : 29/04/2024

Then the patient was discharged on 29/04/2024 with the following ADVICE:

1. INJ.HAI S/C  BD  6U----X----4U

2. TAB.BENFOMET PLUS  PO  OD FOR 15 DAYS

3.TAB.CREON 10000U PO OD  X---1---X FOR 15 DAYS


DAILY ACTIVITY CHART [ from 30-04-2024 ]


Rakesh Biswas sir :Why Creon?

Sadath : due to following reasons 

h/o stinky stools from past 23 years , semi solid stools + indigestion issues+ chronic calcific pancreatitis+ atrophy





27-04-2024

[4/28, 8:49 AM] Dr. Syed Sadath Hussaini:

 GRBS : 27-04-24

2:00 am - 88

4:00 am - 278

6:00 am - 354

11:30 am - 289

1:00 pm - 208

         ⬇️

Insulin - 6U HAI given

3:30 pm - 103

 6:00 pm - 192

 8:00 pm - 206

          ⬇️

 Insulin - 6U hai

 11:00 pm - 322


28-04-2024

Narsimha reddy sir 


Rakesh Biswas sir : @⁨Dr. Syed Sadath Hussaini⁩ Add this to the EHR

Dr.Syed Sadath Hussaini: Hv to update it sir  ...and I'll add this asap


Narsimha reddy sir : When did we start him on glargine @⁨Dr Manohit Sir Gm⁩ ??

Dr Manohit Sir Gm : Today morning sir, @8am


[4/28, 8:52 AM] Rakesh Biswas Sir GM HOD: It's generally taken at bedtime. 

Was he not on any long acting insulin before this while shifting from iv hourly monitored insulin drip to subcutaneous basal bolus?


[4/28, 8:55 AM] Dr.venkat sai Pg Gm: Any particular reason sir that it should be taken at bedtime only?


Rakesh Biswas sir : Good question. 


A review of literature shows that "Blood glucose concentration rises in the late afternoon in association with falling plasma insulin levels towards the end of the 24-h period after insulin glargine injection in some people with Type 1 diabetes using once-daily glargine at dinner-time plus a rapid-acting insulin analogue at meal-times. This is prevented by twice-daily injection of insulin glargine."


https://pubmed.ncbi.nlm.nih.gov/16911626/


[4/28, 8:42 AM] Dr.Syed Sadath Hussaini: 

GRBS : 28-04-24

2:00 am - 444

4:00 am - 423

6:00 am - 457 

Insulin - 4 units HAI given


8:00 am - 344 

6U glargine inj.


Patient: 10.30am  GRBS. 293 mg/dl


1:00pm

 


4:00 PM 


8:00 PM - GRBS 108


10:00 PM :  291


Narsimha reddy sir: 

1.What are hypoglycaemic Symptoms he was having since 20days ??

2.What events lead to this symptoms who was apparently normal 20days back ??

3. What is the cause of Pancreatitis & How many episodes of acute Pancreatitis he had if any ??

4. ⁠what was his life style ( Work habits ; Food Habits ) before & after diagnosis of Diabetes


[4/28, 10:06 AM] Dr. Syed Sadath Hussaini:  

1. h/o head trauma 23 years back with 2 surgical stitches in the head wound  (occipital region)

He had experienced a hypoglycemic episode approximately 25 days ago, around noon. He experienced sweating and fell asleep while driving his auto . He was immediately taken to a private clinic , evaluated, and got relieved .

The doctor informed him about his diabetes condition and his changing blood sugar levels and provided necessary warnings.

Following this event, his attendants closely monitored his condition on an hourly basis.


1A) hypoglycemic symptom : feeling sleepy 


it was noticed that patient has been sleeping alot ( deep sleep ) at around 3 /4 am on a daily basis from the past 20 days . patient used to respond/ wake up only on having some sugar syrup/ chocolate.


2A) events that lead to hypoglycemic symptoms from past 20 days

No other significant finding

except that the patient work load increased from past 20 days.

[ work load = auto driving+ construction work ] 



3A) no other significant symptom suggesting acute pancreatitis except stinky stool from past 23 years ( after dm 1 diagnosis) 


[4/28, 10:18 AM] Dr. Syed Sadath Hussaini: 

4.1A) before diagnosis of diabetes 

work: auto driver    

food: normal diet - rice + curries 

                                   veg+ non veg.

addiction : alcohol 

                    whisky - 45 ml / 10 days


[4/28, 10:25 AM] Dr. Syed Sadath Hussaini:

4.2A) after diagnosis - dm 

work - auto driving  (+ construction work from past 20 days)

food: controlled carbohydrate diet

Breakfast : single jowar roti ( occasionally tiffin)

lunch: rice + curry 

     single medium size tiffin box

dinner: single jowar roti / chapati 

                        (+) 

                       RICE 

Addiction: whisky 45ml / 15 days


10.30am GRBS. 293 mgdl



[4/28, 1:16 PM] Rakesh Biswas Sir GM HOD:

 Point 1 is amazing! 

Who doesn't sleep deeply at 3-4 AM 

Were they putting the chocolate into his mouth during deep sleep following which he was waking up!!??

45ml once in ten days!

 45ml once in 10-15 days is like medicine!!?? 

Was he taking any more than this earlier which may explain the CT findings of chronic pancreatitis (they were not findings of acute)

[4/28 , 2:50 PM] Sadath: 

i was continuously asking questions related to the same point sir .... asking what's the need to wake him up at around 3 am ........ patient drives auto so they should wake him up around 6 am

so i asked them does he starts sweating during night 3 am , or shakiness, pale?? , does he feels hungry and facing difficulty to speak, any nightmares , any seizures 

they say it's just for their satisfaction. they wake him up every hour from 12 : 00 am .... usually he responds....but around 3 :00 am he doesn't respond?(in the sense ,he do respond but v.minimal he barely speaks just 1-2 words before falling asleep again) 

so they serve him chocolate or sugar syrup after which he becomes completely alright, alert, attentive.

Sir about addiction: patient and his attenders were rock solid regarding his alcohol consumption quantity & lifestyle 

I asked, did they ever get the ct scan done in the last 23 years ?

they said no ( declined)

patient shld tell his complaints  but 

i was left with no choice sir other than asking him diagnosis directed questions


Rakesh Biswas sir :

Well done! 

I guess the chronic pancreatitis is a remarkable ultrasound diagnosis by our radiology team.

 Please bring him to ICU tomorrow afternoon and let's take the images of his pancreas 

The presumed "nocturnal hypoglycemia" manifesting as deep sleep to the relatives and their treating it with chocolates is strange and perhaps a never before event recorded anywhere globally?can you review the literature and check?


Sadath : Sir in this patient his presentation may be entirely silent

Chronic pancreatitis: a diagnostic dilemma-

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4735004/



[4/28, 3:44 PM] Dr. Syed Sadath Hussaini:

abstract from the literature 

In some patients, chronic pancreatitis can be entirely silent, and in presentation patients may present with the sequelae of exocrine or endocrine insufficiency: steatorrhea, weight loss and diabetes.

[4/28, 3:45 PM] Dr. Syed Sadath Hussaini: based on history 

steatorrhea "-ve"

weight loss "-ve"

diabetes+ 

 ➡️diabetes+ is in favour of diagnosis- chronic calcific pancreatitis ??


[4/28, 5:28 PM] Rakesh Biswas Sir GM HOD: That would mean silent pancreatitis since 24 years causing diabetes since 23 years!

Can you put all these values since admission into an Excel file to provide a quick graphical image?


 👆Although Xcel may not be as good as this



29-04-2024 ( Monday) 

[4/29, 7:00 AM] Rakesh Biswas Sir GM HOD:

 Please update his entire blood sugar trends since admission with insulin received before meals 

Can just share the values with date time in text and graph may be shared later or we can plot the values in Xcel and get the graph later


[4/29, 7:35 AM] Dr. Syed Sadath Hussaini:

 WPS Office: Complete office suite with PDF editor

Here's the link to the file:

https://in.docworkspace.com/d/sIFXO95v-Adv_u7EG

Shared from WPS Office:

https://kso.page.link/wps


Rakesh Biswas sir : 

Excellent 👏👏

Very nice graph has been generated too (close to answering our eternal question)

Can you see what were the deficiencies in the interventions since yesterday or prior that were responsible for the rise of the y axis?

And here's where our team too forgot about HAI at one point :


[4/29, 7:35 AM] Sadat 2019 Intern: WPS Office: Complete office suite with PDF editor



Here's the link to the file:

https://in.docworkspace.com/d/sIFXO95v-Adv_u7EG


Shared from WPS Office:

https://kso.page.link/wps




[4/29, 7:35 AM] Sadat 2019 Intern: Updated till 8:00 am , 28-04-2024




[4/29, 8:08 AM] Rakesh Biswas: Excellent 👏👏


Very nice graph has been generated too (close to answering our eternal question)


Can you see what were the deficiencies in the interventions since yesterday or prior that were responsible for the rise of the y axis?



[4/29, 8:52 AM] Sadat 2019 Intern: 

GRBS : 28-04-24

11:30 am - 293

1:00 pm - 148

4:00 pm - 330

08:00 pm - 108

10:00 pm - 291


GRBS : 29-04-24

8AM - 177, inj glargine 6u ,3 idli+chutney+sambar 

10 Am -272 

1 pm -166 ,3 chapathi+ lady's finger curry ,sambar 

4 pm - didn't check grbs

8pm -70 -2 jowar roti, tomato rasam 

10 pm - 170 



[4/29, 9:14 AM] Rakesh Biswas: 

Good 

Please also share the interventions (insulin type and dose administered before each value)


[4/29, 9:15 AM] Sadat 2019 Intern: Sir glargine long acting insulin

[4/29, 9:16 AM] Sadat 2019 Intern: 1st dose 8:00 am , 28-04-24

[4/29, 9:16 AM] Rakesh Biswas: No HaI given entire day?

[4/29, 9:16 AM] Sadat 2019 Intern: 2nd dose 8:03 am ,29-04-24


[4/29, 9:18 AM] Sadat 2019 Intern: Sir from 28-04-24 , 8:00 am to 29-04-24 , 8:00 am no HAI GIVEN SIR



[4/29, 9:19 AM] Rakesh Biswas: 👆Clearly he needed hai of at least 4U before lunch and dinner here

[4/29, 9:20 AM] Rakesh Biswas: 👆@⁨Narsimha Reddy Pg Gm⁩


[4/29, 9:22 AM] Vivek Kurma 2022 KIMs Pg Med: Today we will give sir based on grbs we were not sure if he would go into hypoglycemia again at night


Narsimha reddy sir: No Insulin was given at 8PM??

Sri teja ma'am:No sir

[4/30, 9:23 AM] Rakesh Biswas Sir GM HOD: Good 👏




30-04-2024

Sri teja ma'am: 

2Am - 76 ,1 small cup of rice with sambar ,2 marigold biscuits

4am - 137

8 AM -100,inj glargine 4u ,3 chapathi + lady's finger curry

1pm - brown rice 1 cup + fish -2pieces, didn't check grbs 

8 pm -86 ,white rice 2cups + sambar 

10 pm - 216



4/30, 9:24 AM] Rakesh Biswas Sir GM HOD: Was he feeling hungry at 2:00 AM?

[4/30, 10:14 AM] Sri Teja Ma'am Gm: No sir

[4/30, 11:09 AM] Rakesh Biswas Sir GM HOD: Then why did he eat rice, sambar and biscuits at that time? He doesn't have "Hypoglycemia unawareness"?

[4/30, 11:13 AM] Sri Teja Ma'am Gm: He called me at 2 AM sir

 I asked him to eat sir

[4/29, 12:11 PM] Rakesh Biswas: Thanks team! 

We are much more clearer now around the information about his insulin management


2:00 AM


4:00 AM



8:00 AM



8:00 PM 




10:00 PM



01-05-2024

Rakesh Biswas sir: 

Check if the data is correct :

1/5/24:


3 AM - 236

8 AM - 300 

inj glargine 6u given

 

4 idlis + chutney + sambar 

12 pm - 202

4pm -123

6:30pm -46 ,marigold biscuits -5,lemon juice 1small glass 

8pm -116, 1 cup rice + jowar roti 1+ aloo curry + bottle gourd curry

10 PM - 276


No night insulin?


Rakesh Biswas sir: We had correctly reduced his glargine to 4U on 30/4/24 but why was it increased to 6U again today? 

Was it because of the pre breakfast sugars came to 300? 

We need to understand that glargine doesn't act on the immediate meal but it's action goes into reducing the later sugars after 10-12 hours as you could all witness. 

We should have reduced the breakfast sugars with HAI


Kranthi sir : Yes sir



02-05-2024

2 AM - 201

8 AM - 247 6U GLARGINE 4 idlis + chutney + sambar

10 AM - 423

1:15 PM - 152 Brown rice + white rice + dal + curry

3 PM - 321

6PM -83 

8 PM - 114 Rice + tomota rasam + Dal


10 AM



Rakesh Biswas sir: How much insulin taken before this today? @⁨Dr. Syed Sadath Hussaini⁩ ?

Sadath : 6U - Glargine sir !


1:15PM (before lunch)


Lunch 



3PM (after lunch)


[5/2, 4:13 PM] Rakesh Biswas Sir GM HOD: No Insulin taken before lunch @⁨Dr. Syed Sadath Hussaini⁩ ?

[5/2, 4:13 PM] Rakesh Biswas Sir GM HOD: 👆

[5/2, 4:14 PM] Rakesh Biswas Sir GM HOD: 👆

[5/2, 4:16 PM] Rakesh Biswas Sir GM HOD: Glargine we said yesterday above @⁨Dr. Syed Sadath Hussaini⁩ that it will not reduce the post meal sugar spikes for which he needs HAI. Glargine was supposed to be given in reduced dose of 3U today along with HAI before breakfast!

[5/2, 4:18 PM] Rakesh Biswas Sir GM HOD: 👆@⁨Dr. Syed Sadath Hussaini⁩ Inspite of all this why did he again land up in the same soup? 

Now he's again going to go into hypoglycemia at 6PM!

[5/2, 4:20 PM] Rakesh Biswas Sir GM HOD: Someone should have called him and explained to him about what insulin to take etc earlier today Morning @⁨Narsimha Reddy Pg Gm⁩

[5/2, 4:22 PM] Narsimha Reddy Pg Gm: Okay Sir I will inform them

[5/2, 4:24 PM] Rakesh Biswas Sir GM HOD: Also share here what you have informed once after you inform them 

Also tag them to that collectively decided consensus

[5/2, 4:24 PM] Narsimha Reddy Pg Gm: Okay Sir

[5/2, 4:25 PM] Narsimha Reddy Pg Gm: @⁨Sri Teja Ma'am Gm⁩ please post here what have you communicated to patient so far

[5/2, 4:26 PM] Sri Teja Ma'am Gm: Sir today morning they didn't call us for insulin dose 

They directly called at 10:15 AM sir 

To inform post meal grbs sir 

Then they said that he has taken 6u glargine sir

[5/2, 4:30 PM] Narsimha Reddy Pg Gm: Did you communicate about this to patient on phone yesterday @⁨Sri Teja Ma'am Gm⁩

[5/2, 4:31 PM] Rakesh Biswas Sir GM HOD: Yes that's because although we had a discussion about how the 6U glargine led to his 6:00 PM hypoglycemia yesterday and day before this wasn't conveyed to the patient yesterday in a language he understands

[5/2, 4:41 PM] Narsimha Reddy Pg Gm: Informed the patient Regarding the peakless action of Glargine & its action on Pre Meal Sugars ; Need for HAI & its action on post prandial sugars.

[5/2, 4:42 PM] Narsimha Reddy Pg Gm: @⁨SUKESH 40/M Shiva Sir Pt.⁩ మీరు 

INJ.HUMAN ACTRAPID INSULIN 

కొనుకోండి ఇప్పుడు

[5/2, 4:50 PM] Narsimha Reddy Pg Gm: కొనుకున్న తర్వాత ఇక్కడ ఫోటో పెట్టండి


                              Inj.HAI

       


 6PM



8PM - DINNER 











03-04-2024

12AM - 298

4AM - 276

8AM -260 4U GLARGINE+8U HAI 

11AM -46 biscuits 8+ 2 bread slices +1 chocolate 

1PM -117

3:30 PM - 372

8pm -279


8AM (before breakfast)


Breakfast 


[5/3, 8:10 AM] Narsimha Reddy Pg Gm: @⁨Rakesh Biswas Sir GM HOD⁩ Sir Shall we go with 4U Glargine & 8U HAI ??

[5/3, 8:11 AM] Narsimha Reddy Pg Gm: Total Insulin Yesterday Was only 6U Glargine ??

[5/3, 8:37 AM] Rakesh Biswas Sir GM HOD: Yes


11 AM ( after breakfast)



[5/3, 11:10 AM] +91 90001 66698: @⁨Rakesh Biswas Sir GM HOD⁩ @⁨Narsimha Reddy Pg Gm⁩ 

Let's reduce HAI by 2 units?

[5/3, 11:17 AM] Patient.: I have one doubt insulin already he taken but you are telling like this what should we do

[5/3, 11:41 AM] Narsimha Reddy Pg Gm: @⁨Sri Teja Ma'am Gm⁩ What's the doubt he is having & what have you informed him ??

[5/3, 11:44 AM] Rakesh Biswas Sir GM HOD: 👆@⁨~Dr.Dinesh Datta⁩ @⁨Sri Teja Ma'am Gm⁩ We should have reviewed this as to what happened with only glargine yesterday before giving her 8U HAI! If we done this then we may have given her 4U HAI today

[5/3, 11:47 AM] Rakesh Biswas Sir GM HOD: It's a collective responsibility. That's the reason we need to communicate through texts with the advocate so that everyone is in the same page as to what has been communicated. 

Also please make sure to base y/our dose increment decisions on past data at least from the outcomes from the day prior. @⁨Narsimha Reddy Pg Gm⁩ Will need to list these learning insights in his project paper

[5/3, 11:49 AM] Rakesh Biswas Sir GM HOD: Hope your patient ate something after seeing this glucose value? 

Hope we have explained what "hypoglycemia unawareness" is? 


@⁨~Dr.Dinesh Datta⁩ Can you share some literature in the language the patient understands as to the implications of hypoglycemia unawareness that the patient is having?

[5/3, 11:51 AM] Narsimha Reddy Pg Gm: This time he had Sweating with Palpitations & Ate Biscuits it seems sir

[5/3, 11:54 AM] Rakesh Biswas Sir GM HOD: Oh! This peripheral neuropathy is also playing hide and seek adding some more flair to your diabetes clinical complexity project!


1PM


[5/3, 4:33 PM] Narsimha Reddy Pg Gm: @⁨Sri Teja Ma'am Gm⁩ did not take HAI here ??

[5/3, 4:33 PM] Sri Teja Ma'am Gm: Sir 

Pre lunch we didn't give HAI 

Shall we give HAI and GLARGINE at night


[5/3, 4:35 PM] Rakesh Biswas Sir GM HOD: Why didn't we give HAI pre lunch?

[5/3, 4:38 PM] Rakesh Biswas Sir GM HOD: It's like this :

Before breakfast :

HAI x +Glargine y

Before lunch :

HAI x

Before dinner :

HAI x+ glargine y


[5/3, 4:43 PM]  : X and y would be different at different times of the day and different days

[5/3, 4:56 PM] Rakesh Biswas Sir GM HOD: Yes but they need to be in place and acknowledged if 0

[5/3, 8:00 PM] Sri Teja Ma'am Gm: Sir

[5/3, 8:00 PM] Sri Teja Ma'am Gm: His grbs pre dinner is 279

[5/3, 8:00 PM] Sri Teja Ma'am Gm: How much hai and GLARGINE can we give now sir

[5/3, 8:04 PM] Narsimha Reddy sir Pg Gm: Shall we go with 4U Glargine & 4U HAI Sir @⁨Rakesh Biswas Sir GM HOD⁩

[5/3, 8:10 PM] Rakesh Biswas Sir GM HOD: How much Insulin was taken before this?

[5/3, 8:10 PM] Narsimha Reddy sir Pg Gm: Afternoon HAI was Missed Sir

[5/3, 8:11 PM] Rakesh Biswas Sir GM HOD: Why not taken HAI before lunch?

[5/3, 8:12 PM] Rakesh Biswas Sir GM HOD: How much was given yesterday night and what happened after giving that?

[5/3, 8:13 PM] Narsimha Reddy Pg Gm: Yesterday Afternoon & Night doses were also Missed

[5/3, 8:15 PM] Rakesh Biswas Sir GM HOD: Day before yesterday night?

[5/3, 8:20 PM] Narsimha Reddy Pg Gm: Same Story Sir

[5/3, 8:21 PM] Rakesh Biswas Sir GM HOD: Missed?

[5/3, 8:22 PM] Narsimha Reddy Pg Gm: Yes Sir

[5/3, 8:22 PM] Rakesh Biswas Sir GM HOD: What was his fasting today?

Narsimha reddy sir : 260



[5/3, 8:24 PM] Rakesh Biswas Sir GM HOD: 👆Got it 


So let's give him 3U of glargine and 4U of HAI

[5/3, 8:25 PM] Narsimha Reddy Pg Gm: @⁨Sri Teja Ma'am Gm⁩ Please inform them Personally in Call

[5/3, 8:30 PM] Rakesh Biswas Sir GM HOD: Maybe the call can be recorded and shared here


Dinner 



10 to 11 PM 


[5/3, 11:08 PM] Rakesh Biswas Sir GM HOD: After 4U of HAI before dinner?

[5/3, 11:09 PM]  40/M Pt.: After dinner



04-05-2024

8AM - 92 - 4U Glargine & 2U HAI - Had 4 Idly & Chutney

11AM - 91 

3PM - 45 - Had Rice & Curry

4:30PM - 328

8PM - 253 - 2U Glargine & 2U HAI 

11PM - 159

1AM - 213




12 AM 



[5/4, 8:18 AM] Narsimha Reddy Pg Gm: ఇక్కడ ఏమన్నా ఇబ్బంది అయిందా ?? ఏమన్నా తిన్నారా ??
[5/4, 8:19 AM] Patient : Noo
[5/4, 8:19 AM] Narsimha Reddy Pg Gm: ఒకే



2 AM .



8 AM 





Breakfast 




Narsimha sir : @⁨Rakesh Biswas Sir GM HOD⁩ Sir How Much to give Now ??


[5/4, 8:52 AM] SUKESH 40/M Shiva Sir Pt.: Sir tell me fast how much insulin will take

[5/4, 8:56 AM] Rakesh Biswas Sir GM HOD: 👆దీన్ని తనిఖీ చేయండి మరియు మీరే దాన్ని గుర్తించగలరో లేదో చూద్దాం. చేపలు పట్టడం ఎలాగో నేర్పడమే మా ఉద్దేశం. మీ చేపల కోసం మిమ్మల్ని మాపై ఆధారపడేలా చేయకండి! 🙂🙏


👆Dīnni tanikhī cēyaṇḍi mariyu mīrē dānni gurtin̄cagalarō lēdō cūddāṁ. Cēpalu paṭṭaḍaṁ elāgō nērpaḍamē mā uddēśaṁ. Mī cēpala kōsaṁ mim'malni māpai ādhārapaḍēlā cēyakaṇḍi! 🙂🙏


👆Check this and let's see if you can figure it out yourself. 


Our purpose is to teach you how to fish. Not make you dependent on us for your fish! 🙂🙏


[5/4, 8:57 AM] Rakesh Biswas Sir GM HOD: 👆ఇన్సులిన్ ప్లాన్ ఎలా ఉంటుందో అస్థిపంజరం కూడా ఇక్కడ తనిఖీ చేయండి


Insulin plān elā uṇṭundō asthipan̄jaraṁ kūḍā ikkaḍa tanikhī cēyaṇḍi


Also check here the skeleton of how the insulin plan looks like

[5/4, 8:57 AM] Rakesh Biswas Sir GM HOD: You too? ( Narsimha sir )

[5/4, 8:59 AM] Rakesh Biswas Sir GM HOD: 4U glargine and 2U HAI

[5/4, 9:02 AM] Narsimha Reddy Pg Gm: My plan is to go with 2U Glargine & 2U HAI Sir

[5/4, 9:09 AM] Rakesh Biswas Sir GM HOD: 👆Check again the fasting and ppbs yesterday. 

The hypoglycemia was caused by HAI not glargine. Only HAI needs to be reduced


[5/4, 9:09 AM] Rakesh Biswas Sir GM HOD: 2U glargine should be fine ( Narsimha sir )

[5/4, 9:12 AM] Sri Teja Ma'am Gm: They took this dose sir ( 4u Glargine & 2u hai )



11 AM 


[5/4, 12:47 PM] Rakesh Biswas Sir GM HOD: 2U HAI was a good decision. 

Let's keep our fingers crossed for glargine effect


[5/4, 2:31 PM] Narsimha Reddy Pg Gm: @⁨Sri Teja Ma'am Gm⁩ What about Prelunch Sugars & Any Symptoms at 11AM ( GRBS 91 )


Before lunch ( 1 pm ...? )



After lunch ( 3:30 PM ?)



[5/4, 4:34 PM] Rakesh Biswas Sir GM HOD: @⁨Narsimha Reddy Pg Gm⁩ Obviously because of the hypoglycemia he couldn't take HAI before lunch

[5/4, 4:39 PM] Rakesh Biswas Sir GM HOD: You were right! 2U of glargine would have been better

[5/4, 4:40 PM ] DINESH sir  : Sir,can we go for glargine single dose at night and HAI  during meals?

Easy to titrate?

[5/4, 4:52 PM] Rakesh Biswas Sir GM HOD: Yes we were doing that but our recent discussions also with inputs from a senior endocrinologist from US in the other PaJR group with a link to an article about twice daily glargine efficacy in this or another PaJR group may have influenced our decision that twice would also be good although twice titration has clearly been an issue here.

At this juncture we either fall back to once at night or embrace this current titration of twice daily. The other issue is he must be taking 5 pricks now as opposed to 4

NPH twice daily and HAI thrice on the other hand would have kept the pricks to 3!

Let's ask the patient once what he wants


[5/4, 5:08 PM] Dinesh sir : @⁨ Pt.⁩ 

Meeku idi ardam aindha?

Telugu lo cheppala?

[5/4, 5:54 PM] +91 Dinesh sir : Meeru ipudu 3 pootalu kalipi,rendu rakala insulin teeskuntunnaru.

Okati Glargine,inkoti HAI.

Deeni valana meeru roju ki 5   sarlu soodi guchukovalsi vastundhi and maku kuda rojuko 2 3 sarlu dosage adjust cheyalsi vastundhi.

Memu em anukuntunnam ante,glargine insulin rathri okate poota teeskunte,meals apudu HAI dosage easy ga adjust cheyagalamu.Patient ki kuda control baga untundi.

Idi kakapothe NPH ane inko Rakam insulin untundi..Glargine aapivesi,NPH and HAI ni kuda start cheyavachu.

Patient ki 'hypoglycemia unawareness'(sugar levels padipotunapudu symptoms lekapovadam) valana,risk thagginchutaku idi chepthunnamu.


Meeku okay ante,okasari patient ki explain chesi maku cheppandi.

Kotha plan repati nunchi modalu pedadamu

@⁨Rakesh Biswas Sir GM HOD⁩ Sir shall we communicate the same to Dr Ravi sir.

Explained it to patient advocate in their understandable language,regarding the options,risks and compliance factors

 I guess we can take it from here,just acknowledging his EBM advice of twice daily glargine,which maynot be feasible in this patient



[5/4, 6:33 PM] Rakesh Biswas Sir GM HOD: The issue could be the differences in the efficacies of glargine and NPH? Can you share any scientific papers that prove a significant efficacy difference between the two?

[5/4, 6:33 PM] Rakesh Biswas Sir GM HOD: He didn't advise it for this patient. That was for the 3 year old child

[5/4, 6:34 PM]  Dinesh sir: Sure sir,currently I'm in a temple with family..

Will share by tonight.

Meanwhile,pt advocate talks to the patient.

I'm thinking on glargine before sleep and titrated HAI during meals.

No NPH.

Let me review the literature and get back to our team

When there's no significant efficacy between two,why is the one with more pricks preferred?




Rakesh Biswas sir :

Good question. 


A review of literature shows that "Blood glucose concentration rises in the late afternoon in association with falling plasma insulin levels towards the end of the 24-h period after insulin glargine injection in some people with Type 1 diabetes using once-daily glargine at dinner-time plus a rapid-acting insulin analogue at meal-times. This is prevented by twice-daily injection of insulin glargine."


https://pubmed.ncbi.nlm.nih.gov/16911626/



[5/4, 6:38 PM] Rakesh Biswas Sir GM HOD: 👆Here's where we veered from our usual once day 

@ ⁨Dr. Syed Sadath Hussaini⁩ I hope all the PaJR conversations are updated in the patient's case report in your portfolio?



8 PM ( before dinner)


[5/4, 8:26 PM] Sri Teja Ma'am Gm: Giving 2 u glargine 2 u hai sir

[5/4, 8:29 PM] Dinesh sir  : @⁨Sri Teja Ma'am Gm⁩ Good evening Dr Sreeteja.

Any inputs on how we can personalise the insulin in this patient centric context?

[5/4, 8:32 PM]  Patient.: How much insulin we will take

[5/4, 8:47 PM] Narsimha Reddy Pg Gm: ఇంకా తీసుకోలేదా ??

[5/4, 9:16 PM] +91 Dinesh sir: Eroju rathriki 4 units glargine teeskondi.

Podduna em injection teeskokunda lechina ventane sugar levels share cheyandi.

Kudirithe artharathri ee oka rojuki 3 intiki sugar levels share cheyandi(repati nunchi avasaram ledu)

@⁨ Pt. 

[5/4, 9:17 ]  Pt. : Ippudu 2 units glargine 2 units hai tiskundu

[5/4, 9:18 PM] + Dinesh sir: Okay



[5/4, 9:50 PM] Rakesh Biswas Sir GM HOD: 👆As per this dose yesterday his post dinners and fasting were too well controlled although not bordering on hypoglycemia? @⁨~Dr.Dinesh Datta⁩ 


Rakesh Biswas sir: I agree with a safer choice of the dose decided by @⁨Sri Teja Ma'am Gm⁩

[5/4, 9:51 PM] Rakesh Biswas Sir GM HOD: Definitely wouldn't have suggested 4U glargine ( Dinesh sir)


Patient: 11:00 PM -  159

[5/5, 8:09 AM]  patient : 1:15AM - 213



05-05-2024

8AM - 151 - 2U Glargine & 2U HAI - Had 4 Idly with Chutney 

11AM - 197

1AM - 64 - Had Rice & Curry

4PM - 365 

8PM - 322 - 2U Glargine & 4U HAI - Had Rice & Curry

11PM - 258 

2:30AM - 266



8:00 AM ( before breakfast)



Breakfast 



[5/5, 8:29 AM] Rakesh Biswas Sir GM HOD: Well done @⁨Narsimha Reddy sir Pg Gm⁩  @⁨Pt. Attender⁩ @⁨~Dr.Dinesh Datta⁩ @⁨Sri Teja Ma'am Gm⁩ @⁨Dr. Syed Sadath Hussaini⁩         @⁨ 40/m Patient.⁩ and team. 👏

[5/5, 8:39 AM] Rakesh Biswas Sir GM HOD: @⁨~Dr.Dinesh Datta⁩ Check the updated version with the PaJR transcripts incorporated 


@⁨Dr. Syed Sadath Hussaini⁩ Has been a good worker that every intern and needs to emulate (although as per @⁨Dr.venkat sai Pg Gm⁩ 's hypothesis all this good work is possible from home as in wfh but then why are other interns and PGs unable to do it is a burning question) 


The next step for @⁨Dr. Syed Sadath Hussaini⁩ will be to start doing the thematic analysis of his cases and add value to our ongoing 30 projects with similar themes by starting to publish the insights of those projects along with their current PI s

[5/5, 11:59 AM]  Patient. Attender: After tiffin    11:00 AM - 197

[5/5, 1:25 PM] SPt. Attender: Before lunch at                1:00 PM -  64

[5/5, 1:53 PM] Rakesh Biswas Sir GM HOD: Is he taking 4U before or after lunch now?

[5/5, 1:56 PM] Narsimha Reddy sir  Pg Gm: He had Food 10 Min Back ( Rice ) but did not take any insulin Sir

[5/5, 1:56 PM] Narsimha Reddy Pg Gm: Can he take now ?? ( Patient ate his lunch 10 mins ago)

[5/5, 4:34 PM] Rakesh Biswas Sir GM HOD: Why not?

  

4:00 PM 

 


[5/5, 4:34 PM] Rakesh Biswas Sir GM HOD: No insulin taken? ( Around 2 PM )

[5/5, 5:17 PM] Narsimha Reddy Pg Gm: No Sir


8:00 PM  ( before dinner)


Rakesh Biswas sir:👆Ippudu 2 units glargine 4 units hai

Dinner 



[5/6, 8:34 AM]   patient: 11:00pm-  258

[5/6, 8:35 AM]  patient : 2:30 AM - 266



06-05-2024

8 AM ( before breakfast)


Narsimha reddy sir : 2U Glargine & 4U HAI


breakfast 



1 PM ( before lunch)


Lunch 


[5/7, 8:39 AM] Rakesh Biswas Sir GM HOD: 👆How much insulin taken here? @⁨Narsimha Reddy Pg Gm⁩
[5/7, 8:56 AM] Narsimha Reddy Pg Gm: 4U HAI Sir


8 PM ( before dinner)



Narsimha reddy sir : 3U Glargine & 6U HAI


Dinner 



07-05-2024


8 AM ( before breakfast)



Sri teja ma'am: 3u glargine 4u hai sir


Breakfast 



1:00 PM ( before lunch)



8:00 PM ( before dinner)


                               376 mg/dl


 Narsimha reddy sir :👆4U Glargine + 4U HaI


Patient : 11 00pm : 153



08-05-2024



Patient : 1.00am - 197

Patient : 6.00am - 61

Patient : Before breakfast at 8:00am 109

Patient : After breakfast at 11:00am 201

Patient : After noon before lunch at 1:00pm - 35

Patient : After lunch at 4:00pm 291

Patient : Before dinner at 8: 00 pm 185

8:00 AM ( before breakfast) 



Rakesh Biswas sir: 

7/4/24 ( i.e., yesterday) 

Fasting 8:35 AM 201

How much insulin taken after that? 


Sri teja ma'am: 3u glargine 4u hai sir


Rakesh Biswas sir : 👆2U glargine and 4U HaI taken by patient on 6/5/24

How much was taken by patient on 7/5/24 ?

The 7/5/24 dose and it's subsequent outcomes will decide 8/5 dose?


Rakesh Biswas sir: As everything seemed to have been alright after patient's taking 3U Glargine and 4U HaI based on the information supplied by the patient, he may take the same dose today


Breakfast : 



Dinner 



Narsimha reddy sir : take 3U Glargine & 4U HAI ( 8 pm , 08/05/24 )



09-05-2024: 

patient : After dinner at 12:00 am - 83

Patient : 3:00 AM - 81

Patient : Before breakfast at 8:00 - 215

8AM - 215 - 2U Glargine & 4U HAI 

1PM - 68 - 4 Biscuits & Rice 

8PM - 215 - 2U Glargine & 4U HAI - Had Roti ; Rice & Curry 

11:30PM - 175

2AM - 192 



8:00 AM ( before breakfast )


Narsimha Reddy sir : 2U Glargine & 4U HAI


[5/9, 10:14 AM] Rakesh Biswas Sir GM HOD: [08/05/24- 1PM  BEFORE LUNCH - 35] 👆@⁨Narsimha Reddy Pg Gm⁩ This was because of 3U of glargine yesterday?

[5/9, 10:15 AM] Rakesh Biswas Sir GM HOD: Did we miss his hypoglycemia unawareness on 7/5/24 and hence continued the same 3U of glargine?

 Narsimha reddy sir : Appears So Sir


Breakfast 



1 PM [ before lunch ] 



10-05-2024


8:00 AM [ before tiffin]


Rakesh Biswas sir:👆2U glargine 4U hai


Patient : Before dinner at 8:00 PM  -  386

[5/10, 8:27 PM] Rakesh Biswas Sir GM HOD: 4U glargine and 4U hai

[5/10, 8:28 PM] Rakesh Biswas Sir GM HOD: Can stop morning glargine tomorrow


[5/10, 11:04 AM] Narsimha Reddy Pg Gm: Going By this on 7th 3 & 4 U of Glargine Did not Cause Hypoglycaemia....But on 8th & 9th Morning 2U Glargine Caused Premeal Hypoglycaemia Sir ; On 8th Night 2U Glargine Caused Midnight Hypoglycaemia unlike 9th Sir. Shall We Stop Morning Glargine Sir ??

[5/10, 12:06 PM] Rakesh Biswas Sir GM HOD: Alright

[5/10, 12:08 PM] Rakesh Biswas Sir GM HOD: Where's evidence for midnight hypoglycemia with 2U glargine on 8/5/24 midnight (early morning 9/5/24)?


Rakesh Biswas sir: The issue could be the differences in the efficacies of glargine and NPH? Can you share any scientific papers that prove a significant efficacy difference between the two?


[5/10, 5:01 PM] +91 Dinesh sir: Makes compliance and pathophysiological sense.

Evidence(?)

[5/10, 5:04 PM] +91 Dinesh sir :https://www.ncbi.nlm.nih.gov/books/NBK76345/

Some study on this in t2dm P.

@⁨Sri Teja Ma'am Gm⁩ can you share this in PICO format?



[5/10, 5:06 PM] Dinesh sir : @⁨Rakesh Biswas Sir GM HOD⁩ a nice article worth appraising.Hope some of our team members extend the search by evaluating and appraising this article,preferably in PICO format.

[5/10, 5:09 PM] Rakesh Biswas Sir GM HOD: Is there a clinically significant difference in the efficacy or harm of either?

[5/10, 5:09 PM] +Dinesh sir: Spoiler alert-No(from the above article)



11-05-2024

patient  : 8:00am - 422

[5/11, 2:12 PM] Narsimha Reddy Pg Gm: ఇన్సులిన్ ఎంత తీసుకున్నారు ??

Patient : 11:00am - 367

[5/11, 4:07 PM] Narsimha Reddy Pg Gm: @⁨Dr. Syed Sadath Hussaini⁩ @⁨Sri Teja Ma'am Gm⁩ Can you Update This

[5/11, 4:11 PM] Sri Teja Ma'am Gm: Yes sir.




































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