65 year old male with Decreased urine output, Increased frequency and Poor stream since 3months
THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT’S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS/HER GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.
Updated Data till 6/12/23-
A 65 year old male resident of chandur came with chief complaints of decreased urine volume, increased frequency of urination and poor stream since 3 months .
History of Presenting illness -
Patient was apparently asymptomatic 3 months back he then noticed decreased urine volume, poor stream which is not associated with pain, burning micturition, blood in urine, fever. Frequency of urination is increased.
Past history-
No similar complaints in the past.
He is a known case of diabetes since 20years. Since then he is on medication:
Sitagliptin 100mg
Metformin 500mg
Dapagliflozin 10 mg
Inj insulin isophane 48u—46u
Inj insulin glargline 0U—16U
He is a known case of hypertension since 20years, since then he is on medication:
Olmesartan 20 mg
Amlodipine 5mg
Hydrochlorthiazide 12.5mg
Not a known case of asthma, Tuberculosis, epilepsy, CAD, CVD
Family history-
Irrelevant
Personal history-
Diet- mixed
Appetite- normal
Bowel and bladder movements- normal
Sleep- inadequate
No addictions
Vitals -
Temperature- afebrile
Pulse rate- 80 beats/min
Respiratory rate -17 cycles/min
Blood pressure- 124/82 mmhg
General examination:
Patient’s consent was taken
Patient was examined In a well lit room.
He was conscious, coherent , cooperative
No pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
Pitting type of pedal edema is present.
Mid arm circumference 28cm
Triceps skinfold thickness 18 mm
Abdominal girth 96 cm
Fvf 3.26
Mamc: 25.4
Investigations:
REGULAR UPDATES OF BLOOD GLUCOSE LEVELS :
Day 1(2/11/23)
8:00 Am.-215
12:00 pm - 289.
4:00 pm -341
6:00 pm (evening) - 356
10:00 pm - 327
[11/2, 23:02] Rakesh Biswas Sir: Also in that note ask him to mention what interventions at what time he has taken
[11/2, 23:10] Student: Ok sir
Day 2(3/11/23)
8:00 Am.-143.
12:00 pm - 274.
4:00 pm - 344
6:00 pm (evening) - 304
10:00 pm - 340
[11/3, 22:28] Rakesh Biswas Sir: 👆@~Deeptha Dhanasekaran
[11/3, 22:30] Rakesh Biswas Sir: అతను ఏ సమయంలో ఏ మందులు తీసుకుంటున్నాడో దయచేసి పేర్కొనండి
ask him to mention what interventions at what time he has taken
Atanu ē samayanlō ē mandulu tīsukuṇṭunnāḍō dayacēsi pērkonaṇḍi
[11/3, 22:50] Student: Ok sir
Day 3(4/11/23 )
8:00am -192
12:00 pm -348
4:00 pm - 349
6:00 pm -278
10:00 pm -225
Day 4 (5/11/23)
8:00 Am - 99
12:00 pm -278
4:00 pm - 327
6:00 pm- 320
10:00 pm - 183
[11/5, 18:43] student: Sir the patient is concerned that his sugar levels are not getting under control even after using the medication
[11/5, 18:50] Rakesh Biswas Sir: Yes
We need to optimize the dose
First we need to separate the biphasic insulin into separate watery soluble insulin and milky NPH insulin.
Just asK him to share the image of his current biphasic insulin and you may find it's cloudy.
But we also need to check the label if that insulin is 30:70 or 50:50
Please ask him to share the above information
We shall then add 4U of soluble watery insulin to each of his biphasic insulins to address the current post insulin peaks and then after repeating the blood sugars again we shall further titrate the dose
[11/5, 19:05] student: Ok sir
[11/5, 19:46] Rakesh Biswas Sir: Also the expensive tablets and last insulin at night (glargine) that he's taking is possibly not helping him in terms of sugar control but also draining him of resources and can be stopped once we titrate and optimize the soluble and isophane insulin dose.
For example instead of giving him the tablet we can give him a titrated soluble watery insulin before lunch everyday
[11/5, 20:11] student: Ok sir
Day 5(6/11/23)
7:00 am- 154
11:30 am-323
4:00 pm-408
6:15 pm-417
10:00 pm- 302.
[11/6, 22:09] Rakesh Biswas Sir: రేపటి నుండి ప్రస్తుత బైఫాసిక్ మిల్కీ ఇన్సులిన్కు 4U వాటర్ ఇన్సులిన్ని రెండుసార్లు జోడించండి భోజనానికి ముందు తీసుకున్న టాబ్లెట్ను ఆపండి మరియు 8U నీటి ఇన్సులిన్ తీసుకోండి
Rēpaṭi nuṇḍi prastuta baiphāsik milkī insulinku 4U vāṭar insulinni reṇḍusārlu jōḍin̄caṇḍi bhōjanāniki mundu tīsukunna ṭābleṭnu āpaṇḍi mariyu 8U nīṭi insulin tīsukōṇḍi
From tomorrow add 4U watery insulin to the current biphasic milky insulin twice
Stop the tablet taken before lunch and take 8U of watery insulin
[11/6, 22:11] Rakesh Biswas Sir: రేపటి నుండి కూడా దయచేసి మీ పేషెంట్ తీసుకుంటున్న ప్రతి ఫుడ్ ప్లేట్ చిత్రాలను షేర్ చేయండి. దయచేసి రోగి పేరును సోషల్ మీడియాలో షేర్ చేయకండి, తద్వారా మేము అతని గోప్యతను కాపాడుతాము
Rēpaṭi nuṇḍi kūḍā dayacēsi mī pēṣeṇṭ tīsukuṇṭunna prati phuḍ plēṭ citrālanu ṣēr cēyaṇḍi. Dayacēsi rōgi pērunu sōṣal mīḍiyālō ṣēr cēyakaṇḍi, tadvārā mēmu atani gōpyatanu kāpāḍutāmu
From tomorrow also please share the images of every food plate that your patient is taking.
Please don't share the patient's name in social media so that we can protect his privacy
Day 6 (7/11/23)
7:20 am- 129
11:45 am -308
4:00 pm-319
6:00pm -281
10:00 pm -215
Day 7 (8/11/23)
8:00 am- 137
12:00 pm-311
4:00 pm -366
6:00 pm - 222
10:00 pm-230
[11/8, 06:47] Rakesh Biswas Sir: Looks like he hasn't made any of the changes as per my message in Telegu above but I guess we need to make gentle progress and not rush here
[11/8, 06:53] Rakesh Biswas Sir: Let me rephrase this analysis and thought :
Given this and prior daily blood sugar and intervention data meticulously shared by this patient it appears that :
We need to address two areas 1) Pre lunch high and 2) post lunch high and an easy way to do that would be to add 4U unit of soluble insulin to his pre breakfast isophane by first loading the 4U soluble into his insulin syringe
Later before lunch instead of the expensive but ineffective tablet, he needs to add 8U of soluble Insulin before his lunch and then these doses can be slowly titrated over the next few days
[11/8, 06:55] Rakesh Biswas Sir: నేను ఈ విశ్లేషణ మరియు ఆలోచనను పునఃప్రారంభించనివ్వండి: ఇది మరియు ముందు రోజువారీ రక్తంలో చక్కెర మరియు జోక్య డేటాను ఈ రోగి ఖచ్చితంగా పంచుకున్నప్పుడు ఇది కనిపిస్తుంది: మేము రెండు ప్రాంతాలను పరిష్కరించాలి 1) ప్రీ లంచ్ హై మరియు 2) పోస్ట్ లంచ్ హై మరియు దీన్ని చేయడానికి సులభమైన మార్గం ఏమిటంటే, ముందుగా అతని ఇన్సులిన్ సిరంజిలోకి 4U కరిగే లోడ్ చేయడం ద్వారా అతని ప్రీ బ్రేక్ఫాస్ట్ ఐసోఫాన్కు 4U యూనిట్ కరిగే ఇన్సులిన్ను జోడించడం. ఖరీదైన కానీ పనికిరాని టాబ్లెట్కు బదులుగా లంచ్కు ముందు, అతను తన భోజనానికి ముందు 8U కరిగే ఇన్సులిన్ను జోడించాలి మరియు తరువాత కొన్ని రోజులలో ఈ మోతాదులను నెమ్మదిగా టైట్రేట్ చేయవచ్చు.
Nēnu ī viślēṣaṇa mariyu ālōcananu punaḥprārambhin̄canivvaṇḍi: Idi mariyu mundu rōjuvārī raktanlō cakkera mariyu jōkya ḍēṭānu ī rōgi khaccitaṅgā pan̄cukunnappuḍu idi kanipistundi: Mēmu reṇḍu prāntālanu pariṣkarin̄cāli 1) prī lan̄c hai mariyu 2) pōsṭ lan̄c hai mariyu dīnni cēyaḍāniki sulabhamaina mārgaṁ ēmiṭaṇṭē, mundugā atani insulin siran̄jilōki 4U karigē lōḍ cēyaḍaṁ dvārā atani prī brēkphāsṭ aisōphānku 4U yūniṭ karigē insulinnu jōḍin̄caḍaṁ. Kharīdaina kānī panikirāni ṭābleṭku badulugā lan̄cku mundu, atanu tana bhōjanāniki mundu 8U karigē insulinnu jōḍin̄cāli mariyu taruvāta konni rōjulalō ī mōtādulanu nem'madigā ṭaiṭrēṭ cēyavaccu.
[11/8, 08:10] Student: Sir yesterday I have explained this to the patient but he prefers to come to the opd and talk to u.
Day 8 (9/11/23)
7:30 am -182
6:00pm-299
10:00pm 240
[11/9, 07:47] Rakesh Biswas Sir: 👆
[11/9, 08:14] Student: Sir he will come today
[11/9, 08:19] Rakesh Biswas Sir: Looking forward to it!
Rarely do we expect to meet our opd patient for pure counselling, his information mess having been prior sorted asynchronously, thanks to the efforts of our students!
Day 9 (10/11/23)
8:00 am -166
12:00 pm- 372
5:00 pm-356
7:00 pm-343
10:00 pm-253
Day 10 (11/11/23)
8:00 am-142
12:00 pm -249
4:00 pm -384
6:00 pm-413
10:00pm -283
[11/11, 06:38] Rakesh Biswas Sir: 👆He didn't come?
He's still taking the same medications without any changes that we suggested
[11/11, 10:09]Patient Attender: We came on 09-11-23 (Thursday) 11-30am but you are not there sir on that time
[11/11, 13:07] Rakesh Biswas Sir: Even @~Deeptha Dhanasekaran @Himaja Ma'am Gm Pg
wasn't there?
I was there in opd
[11/11, 13:08] Rakesh Biswas Sir: Who did you show your patient ? Why is your patient taking the same Medicines?
[11/11, 13:30]Student: Sir I had exam so I couldn’t come
[11/11, 14:10] Himaja Ma'am Gm Pg: Today I am in opd
He is talking about Thursday
[11/11, 17:01] Rakesh Biswas Sir: I was there at 11"30 AM on Thursday
Day 11(12/11/23)
7:30am-125
12:00 pm-277
4:15pm-310
7:00 -183
10:00 pm-253
[11/12, 22:34] patient attender: 9:50am biphasic isolated 48ml
2:10 pm udapa trio 1 tablet
7:50 pm biphasic isolated 46 ml
9:00pm nobeglar 16ml
[11/20, 10:02] Patient Attender: Puri tamoto pappu and putnalu
Day 12 (13/11/23)
8:00 am- 95
12:00 pm -235
4:00 pm -316
6:00 pm-300
10:00pm -279
[11/13, 20:38] Rakesh Biswas Sir: కాబట్టి మీ రోగి అదే మందులు మరియు మోతాదును తీసుకున్నాడు, కానీ నిన్న అతని చక్కెరలు మెరుగ్గా నియంత్రించబడినట్లు కనిపిస్తున్నాయా?
Kābaṭṭi mī rōgi adē mandulu mariyu mōtādunu tīsukunnāḍu, kānī ninna atani cakkeralu meruggā niyantrin̄cabaḍinaṭlu kanipistunnāyā?
So your patient took the same medicines and dose but yesterday his sugars appear better controlled?
[11/13, 20:53] Student: Yes sir
Day 13 (14/11/23)
6:00pm 351
7:50PM H ACTRAPID 4U AND BIPHASIC ISOPHANE 46U
9:00PM NOBEGLAR 16U
10:00pm 210
[11/14, 06:50] Rakesh Biswas Sir: His serial blood sugar trends since Day 1 of his sharing here appears to be more or less unchanged.
@~Deeptha Dhanasekaran Can you share all the imaged values here as typed text and also later prepare an osce case report of his as shown here 👇
https://vaishnavimaguluri.blogspot.com/2023/07/general-medicine-case-report-osce.html?m=1
[11/14, 08:57] Student: Ok sir
Day 14(15/11/23)
8:00 am-125
12:00 pm -217
4:00 pm -357
6:00 pm-310
10:00pm -317
[11/15, 10:17] Rakesh Biswas Sir: Ninna Lunch mundu aem tiskuntara? Lunch 2 ghanta tarwata sugar enta occhindi?
[11/15, 10:58] Patient Attender: Yesterday didn't check because they were in Narketpally hospital
[11/15, 12:36] Rakesh Biswas Sir: Today's?
[11/15, 22:44] Rakesh Biswas Sir: Thanks
Please increase insulin actrapid before lunch to 8U
Before dinner please increase insulin actrapid to 6U
Day 15(16/11/23)
8:00 am-130
12:00 pm -283
4:00 pm -288
6:00 pm-292
10:00pm -305
[11/16, 10:32] Patient Attender: Morning tiffin with iddle
[11/16, 12:58] Rakesh Biswas Sir: Kuragailu panlu anni plate to kavali
[11/16, 14:07] Patient Attender: Rice with menti kura curry and charu
[11/16, 20:02] Patient Attender: Multi pindi roti with leaf curry
[11/16, 20:17] Rakesh Biswas Sir: Add pappulu
Salads
[11/16, 20:17] Rakesh Biswas Sir: 👆
[11/16, 20:37] Patient Attender: Multi pindi( ragulu+jonnalu+saddalu+godumalu+korralu)
[11/16, 20:40] Rakesh Biswas Sir: Gaddi ginjelu manchi
Plate to pao bagam pappulu kavali, sagam kuragailu, panlu
[11/16, 22:11] Patient Attender: Afternoon before lunch H ACTRAPID 8U
[11/16, 22:15] Patient Attender: NOBEGLAR INSULIN is it continue or stop (it may be over tomorrow)
Day 16 (17/11/23)
8:00 am-112
12:00 pm -250
4:00 pm -374
6:00 pm-366
10:00pm -348
[11/17, 10:30] Rakesh Biswas Sir: Continue
[11/17, 10:32] Rakesh Biswas Sir: అల్పాహారానికి ముందు, భోజనానికి ముందు మరియు రాత్రి భోజనానికి ముందు జోడించిన మానవ యాక్ట్రాపిడ్ ఇన్సులిన్ను +2 పెంచండి
Alpāhārāniki mundu, bhōjanāniki mundu mariyu rātri bhōjanāniki mundu jōḍin̄cina mānava yākṭrāpiḍ insulinnu +2 pen̄caṇḍi
Increase added human actrapid insulin before breakfast, before lunch and before dinner by +2
[11/17, 10:34] Rakesh Biswas Sir: బైఫాసిక్ ఇన్సులిన్ ముగిసేలోపు తెలియజేయండి
Baiphāsik insulin mugisēlōpu teliyajēyaṇḍi
Inform before the biphasic insulin gets over
[11/17, 10:51] Patient Attender: Jonna rice and chikkudukaya curry with curd
[11/17, 14:05] Patient Attender: Keera and carrot ,rice with pappu
[11/17, 20:20] Patient Attender: Multi pindi roti with pappu and chikkudukaya curry
Day 17(18/11/23)
8:00 am-110
12:00 pm -269
4:00 pm -307
6:00 pm-241
10:00pm -341
[11/18, 08:12] Rakesh Biswas Sir: ఈ ఫలితాలను చూస్తే, మీ పేషెంట్ ఆ బాటిల్ అయిపోయిన తర్వాత బైఫాసిక్ ఐసోఫాన్ ఇన్సులిన్ను ఆపివేయవచ్చని అనిపిస్తుంది. మేము ప్రతిరోజు భోజనానికి ముందు మూడుసార్లు మానవ యాక్ట్రాపిడ్ ఇంజెక్షన్లను +2కి నెమ్మదిగా పెంచుతాము
Ī phalitālanu cūstē, mī pēṣeṇṭ ā bāṭil ayipōyina tarvāta baiphāsik aisōphān insulinnu āpivēyavaccani anipistundi. Mēmu pratirōju bhōjanāniki mundu mūḍusārlu mānava yākṭrāpiḍ in̄jekṣanlanu +2ki nem'madigā pen̄cutāmu
Looking at these results it seems your patient can stop the biphasic isophane insulin once that bottle is over.
We shall slowly increase everyday the human actrapid injections three times before every meal by +2
[11/18, 08:16] Rakesh Biswas Sir: ఈరోజు ఆక్ట్రాపిడ్ మోతాదును అల్పాహారానికి ముందు 8U, భోజనానికి ముందు 10U మరియు రాత్రి భోజనానికి ముందు 6Uగా తీసుకోండి.
Īrōju ākṭrāpiḍ mōtādunu alpāhārāniki mundu 8U, bhōjanāniki mundu 10U mariyu rātri bhōjanāniki mundu 6Ugā tīsukōṇḍi.
Today take the actrapid dose as 8U before breakfast, 10U before lunch and 6U before dinner
[11/18, 08:21] Rakesh Biswas Sir: 👆నిన్న, మీ రోగి రాత్రి భోజనానికి ముందు ఇంజెక్షన్ ఆక్ట్రాపిడ్ 6U తీసుకోలేదా? మొనట్టి ఫలితం ఇక్కడ అతను తీసుకున్నట్లు చూపిస్తుంది కానీ నిన్నటి ఫలితంలో అది కనిపించడం లేదు
Ninna, mī rōgi rātri bhōjanāniki mundu in̄jekṣan ākṭrāpiḍ 6U tīsukōlēdā? Monaṭṭi phalitaṁ ikkaḍa atanu tīsukunnaṭlu cūpistundi kānī ninnaṭi phalitanlō adi kanipin̄caḍaṁ lēdu
Yesterday, didn't your patient take injection actrapid 6U before dinner? Monatti result here it shows that he had taken but in yesterday's result it's not showing
[11/18, 08:22] Rakesh Biswas Sir: @~Dr.Dinesh Datta @~Praneeth Kotha Google translate didn't understand "Day before yesterday" so I had to write monnati in English which it transliterated! Wonder if the language sounds right?
[11/18, 08:33] student: Ok sir
[11/18, 11:27] Patient Attender: Chapathi and beerakaya curry with keera
[11/18, 12:29] Dr.Dinesh : It's good translation
[11/18, 14:29] Patient Attender: Lunch with groundnut,Putnam,rice and ridgegourd curry
[11/18, 19:52] Patient Attender: Multi pindi roti and ridge gourd curry
[11/18, 22:11] Patient Attender: Biphsic isophane insulin after taking tomorrow morning it may be over
[11/18, 22:43] Rakesh Biswas Sir: Tomorrow insulin actrapid to be taken as
10U before breakfast
10U before lunch
8U before dinner
Day 18(19/11/23)
8:00 am-152
12:00 pm -363
4:00 pm -392
6:00 pm-354
10:00pm -382
[11/19, 08:08] Patient Attender: Can we continue biphsic isophane insulin 48u with actrapid 10u before breakfast
[11/19, 08:15] Rakesh Biswas Sir: Till it's finished yes.
It doesn't appear to be working effectively as it's may have declined during prolonged storage
How is his insulin stored?
[11/19, 08:40] Patient Attender: Keeping in freeze
[11/19, 09:16] Rakesh Biswas Sir: Deep freeze!?
Or the egg compartment?
[11/19, 09:53] Patient Attender: Egg compartment
[11/19, 09:56] Rakesh Biswas Sir: How many days old was the vial? When was the manufacturing date?
[11/19, 10:06] Rakesh Biswas Sir: How do we find out the cold chain from February 2023 to the patient's egg compartment here? @~Dr. Avinash Kumar Gupta @Himaja Ma'am Gm Pg @~Dr.Dinesh Datta
[11/19, 10:06] Rakesh Biswas Sir: More salads, fruits and vegetables desirable in the plate
[11/19, 10:10] Dr.Avanish: No such tracking available in India sir for insulin.
[11/19, 10:11] Dr.Avanish: Its easy tech to make it available along with temperature monitoring during the full journey. But not easy to implement.
[11/19, 10:16] Rakesh Biswas Sir: That's a very interesting insight emerging here @~Praneeth Kotha ?
[11/19, 10:21] Dr.Avanish: Medicine box can have a tiny IOT based Bluetooth device (like a pebble/button) that can monitor from start to end and easily reusable. Without any screen and bells/whistles. It may not cost more than 100 INR on large scale production. For demo of idea sharing this link https://www.amazon.in/Petzlifeworld-Aquarium-Thermometer-Accurate-Temperature/dp/B0BQ6ZDDW5/ref=mp_s_a_1_10?crid=6Y3L2TR627U8&keywords=temperature+monitoring+pebble&qid=1700369292&sprefix=temperature+monitoring+pebble%2Caps%2C244&sr=8-10
[11/19, 10:31] Rakesh Biswas Sir: An electronic thermometer? That would be great for our Communicable disease fever project!!
@~Praneeth Kotha You can divide all healthcare projects grossly into CD and NCD
CD is relatively more rewarding to modern medicine practitioners of acute care as it has time tested solutions providing gratifying outcomes while NCD is much more challenging and less glamorous and more vast including genetic, traumatic, autoimmune, toxic and neoplastic etiologies
[11/19, 10:31] Dr.Avanish: Yes sir
[11/19, 10:32] Dr.Avanish: Pebble sense ambient/environment temperature.
CD project sense skin/body temperature.
[11/19, 10:36] Dr.Avanish: Reference for CD https://www.celsium.com/products/celsium-body-temperature-monitoring#:~:text=Celsium%20%2D%20wearable%20temperature%20monitor,-10%20reviews&text=Celsium's%20revolutionary%20temperature%20monitoring%20system,4%20seconds%20via%20our%20App.
[11/19, 11:44] Student: Sure sir
[11/19, 13:52] Patient Attender: Korra annam,cucumber,apple and groundnuts
[11/19, 20:13] Patient Attender: Multi pindi roti with cucumber curry
[11/19, 22:34] Rakesh Biswas Sir: Increase human actrapid +2 tomorrow
12U before breakfast
12U before lunch
12U before dinner
We may slowly need to increase by double or triple this dose over the next few weeks
Day 19(20/11/23)
8:00 am-146
12:00 pm -377
4:00 pm -469
6:00 pm-422
10:00pm -356
[11/20, 14:04] Rakesh Biswas Sir: Roasted pappu?
[11/20, 14:08] Dr.Dinesh: Raw putnalu causes GI disturbances,especially stomach ache or cramps
[11/20, 14:35] Patient Attender: Korralu rice with tamoto pappu ,groundnuts and keera
[11/20, 19:54] Patient Attender: Multi pindi roti with cucumber curry
[11/28, 10:24] Patient Attender: Chapati with cluster beans
Day 20(21/11/23)
8:00 am-243
12:00 pm -435
4:00 pm -527
6:00 pm-455
10:00pm -417
[11/21, 08:56] Patient Attender: What about today insulin
[11/21, 09:18] Rakesh Biswas Sir: Keep increasing the dose of injection actrapid by +2 everyday till the sugars come down below 200 after every meal @~Deeptha Dhanasekaran @~Dr. Avinash Kumar Gupta @Lohith Varma Sir GM Pg Please guide
[11/21, 11:06] +91 73825 17519: Ok sir
[11/21, 11:19] Patient Attender: Goduma ravva upma and gherkins (dondakaya) curry with putnaalu
[11/21, 14:12] Patient Attender: Korra rice with gherkins(dondakaya) curry and keera
[11/21, 17:51] Patient Attender: Sugar levels are increased high 527 at 4'0 clock time
[11/21, 18:00] Rakesh Biswas Sir: Can take 4U now and repeat test and share
[11/21, 18:03] Rakesh Biswas Sir: 👆From tomorrow increase by +4
16U before breakfast
16U before lunch
16U before dinner
We may slowly need to increase by double or triple this dose over the next few weeks
[11/21, 18:07] Patient Attender: Can he take today night before dinner 12u+4u
[11/21, 18:24] Rakesh Biswas Sir: Yes
What time does he take dinner?
[11/21, 18:26] Patient Attender: 8'0 clock
[11/21, 18:26] Rakesh Biswas Sir: 👆
[11/21, 19:46] Patient Attender: Multi pinddi roti with tamoto pappu
[11/21, 19:46] Rakesh Biswas Sir: 👆Not taken this at 6 PM?
[11/21, 19:47] Patient Attender: He is taking now
[11/21, 19:56] Patient Attender: When he taking this insulin he will use 100u syringe
[11/21, 19:56] Patient Attender: Now he will continue this syringe only
[11/21, 19:57] Patient Attender: Is it use this or 40u syringe
[11/21, 20:24] Rakesh Biswas Sir: Share the vial image of the actrapid
[11/21, 20:37] Rakesh Biswas Sir: Use 40U/ml syringe
Day 21(22/11/23)
7:30am-224
12pm-421
4pm-378
10pm-286
[11/22, 06:57] Rakesh Biswas Sir: Make it 18U of Human actrapid before every meal today
[11/22, 12:07] Patient Attender: Edli chatni and sambaaru With gouva fruit
[11/22, 12:08] Patient Attender: Morning breakfast (10'0 clock)
[11/22, 14:09] Patient Attender: Korra rice and vadiyala curry with gouva fruit and boiled nuts
[11/22, 14:11] Rakesh Biswas Sir: @~Deeptha Dhanasekaran Are you able to update (all that has been shared here since the group was created) to the case report?
[11/22, 16:00] Student: Yes sir I have updated it in my blog
https://deeptha26.blogspot.com/2023/11/65-year-old-male-with-bph-symptoms.html
[11/22, 16:29] Rakesh Biswas Sir: The insulin dose adjustments that we have been discussing daily above and also his diet plates haven't been updated?
All you need to do is select all the conversations above since the first day of this PaJR and copy paste them to the blog under a new heading called "PaJR conversational decision support CDSS"
Please check that there shouldn't be any identifiers
Also upload his food plates
[11/22, 16:42] Student: Ok sir
[11/22, 22:04] Rakesh Biswas Sir: From tomorrow
22U of actrapid before breakfast and lunch
20U before dinner
Day 22(23/11/23)
7:30am-178
12pm-349
5pm-347
10pm-248
[11/23, 09:51] Patient Attender: Ukma ravva and tamato pappu with coconut chatni
[11/23, 15:08] Patient Attender: Korra rice and kakarakaya pulusu
[11/23, 19:48] Patient Attender: Multi pindi roti with tamoto pappu and bitter gourd pulusu
[11/23, 20:13] Rakesh Biswas Sir: 👆
[11/23, 22:36] Rakesh Biswas Sir: Tomorrow
24U human actrapid before every meal
Day 23(24/11/23)
7:30am-194
12pm-325
4pm-326
10pm-295
[11/24, 09:57] Patient Attender: Chapati with bitter gourd and keera
[11/24, 15:09] Patient Attender: White rice, korra rice with tamoto pappu and gova guava fruit
[11/24, 20:12] Patient Attender: Goduma ravva upma with tamoto curry
Day 24(25/11/23)
7:30am-167
12pm-382
4pm-453
6pm-378
10pm-373
[11/25, 08:18] Patient Attender: What about insulin dose
[11/25, 09:30] Rakesh Biswas Sir: Human actrapid 26U before every meal
Nobeglar at bedtime 18U
[11/25, 10:18] Patient Attender: Chapati with Cluster beans curry
[11/25, 14:30] Patient Attender: White and corra rice with cluster beans and keera
[11/25, 20:04] Patient Attender: Goduma ravva upma with bottle gourd
[11/25, 23:23] Rakesh Biswas Sir: Tomorrow
HAI 28U before each meal
Day 25(26/11/23)
7:30am-167
12pm-405
4pm-423
6pm-395
10pm-412
[11/26, 09:52] Patient Attender: Roti with Dondakaya curry
[11/26, 14:00] Patient Attender: White and korra rice with ladies fingers curry and guava fruit
[11/26, 14:42] Rakesh Biswas Sir: Lot of rice!!
[11/26, 21:28] Patient Attender: Goduma ravva upma with ladies fingers curry
Day 26(27/11/23)
7:30am-146
12pm-234
4pm-190
6pm-219
10pm-197
[11/27, 06:30] Rakesh Biswas Sir: Make HAI 30U before meals and add tablet Metformin 500 mg after every meal from today
[11/27, 09:57] Patient Attender: Goduma ravva upma with ridge gourd dal
[11/27, 14:03] Patient Attender: Korra and white rice with bitter gourd carry and guava fruit
[11/27, 19:44] Rakesh Biswas Sir: ఈ ప్లేట్ పండ్లు మరియు కూరగాయలు మరియు పప్పుల కంటే ఎక్కువ ధాన్యాలను కలిగి ఉన్నట్లు కనిపిస్తుంది
Ī plēṭ paṇḍlu mariyu kūragāyalu mariyu pappula kaṇṭē ekkuva dhān'yālanu kaligi unnaṭlu kanipistundi
This plate appears to be having more grains than fruits and vegetables and pulses
[11/27, 19:45] Rakesh Biswas Sir: 👆ఈ ప్లేట్ పండ్లు మరియు కూరగాయలు మరియు పప్పుల కంటే ఎక్కువ ధాన్యాలను కలిగి ఉన్నట్లు కనిపిస్తుంది
Ī plēṭ paṇḍlu mariyu kūragāyalu mariyu pappula kaṇṭē ekkuva dhān'yālanu kaligi unnaṭlu kanipistundi
This plate appears to be having more grains than fruits and vegetables and pulses
[11/27, 19:59] Patient Attender: Goduma ravva upma with bitter gourd curry, putnaalu and groundnuts
[11/27, 20:27] Rakesh Biswas Sir: Salads?
[11/27, 22:13] Rakesh Biswas Sir: 👍looks like adding metformin helped well.
Let's continue the same dose tomorrow
Day 27(28/11/23)
7:30am-142
12pm-294
4pm-254
6pm-247
10pm-189
[11/28, 14:02] Patient Attender: Rice with cabbage curry , guava fruit and putnaalu
[11/28, 20:01] Patient Attender: Multi pindi roti cabbage curry
[11/28, 22:05] Rakesh Biswas Sir: Continue same doses
[12/1, 10:14] Patient Attender: Chapati with Cucumber tamoto curry
Day 28(29/11/23)
7:30am-132
12pm-196
4pm-122
6pm-142
10pm-166
[11/29, 10:37] Patient Attender: Idle with chutney and sambar
[11/29, 13:58] Patient Attender: Korra rice with cluster beans and keera
[11/29, 19:53] Patient Attender: Goduma ravva upma with Cluster beans curry
[11/29, 21:01] Rakesh Biswas Sir: @~Praneeth Kotha Are you archiving everything in his case report link?
Day 29(30/11/23)
7:30am-131
12pm-148
4pm-198
6pm-270
10pm-230
[11/30, 09:37] Patient Attender: Vada
[11/30, 10:02] Student: Sir I am working on the case report link for another patient(31M Metabolic syndrome HTN 4yrs), not this patient.
[11/30, 14:06] Patient Attender: Korra rice with onion dal and keera
[11/30, 14:09] Rakesh Biswas Sir: It has become ideal control now
Reduce the doses by -2
Injection Human actrapid Insulin 28U before every meal
Continue same dose of metformin and Inj glargine
[11/30, 15:13] Rakesh Biswas Sir: Yes glargine is the real name for the injection nobeglar that your patient is using
[11/30, 15:15] Patient Attender: Ok sir
Day 30(01/12/23)
7:30am-140
12pm-250
4pm-228
6pm-299
10pm-144
[12/1, 14:14] Patient Attender: Rice with tamoto pappu and keera
[12/1, 16:22] Rakesh Biswas Sir: 👍
[12/1, 19:46] Patient Attender: Goduma ravva upma with ladies fingers curry
[12/1, 22:58] Rakesh Biswas Sir: Let's make HAI 30-30-28
[12/4, 11:10] Patient Attender: Chapati with Dondakaya pappu
Day 31(02/12/23)
7:30am-124
12pm-252
4pm-160
6pm-151
10pm-167
[12/2, 11:59] Patient Attender: Jonna rice with ladies fingers curry
[12/2, 14:09] Patient Attender: Rice with chukka kura and guva fruit
[12/2, 21:53] Patient Attender: Goduma ravva upma with chukka kura
[12/2, 22:21] Rakesh Biswas Sir: Tomorrow HAI 30-28-28
Day 32(03/12/23)
7:30am-129
12pm-225
4pm-229
6pm-263
10pm-182
[12/3, 10:10] Patient Attender: Jonna idly with palli chakney
[12/3, 13:26] Patient Attender: Rice with pappu and keera
[12/3, 19:39] Patient Attender: Goduma ravva upma with pappu
[12/3, 21:57] Patient Attender: Sir sugar levels are less so can we proceed with surgery
[12/3, 21:57] Rakesh Biswas Sir: Yes can
Day 33(04/12/23)
7:30am-146
12pm-271
4pm-232
6pm-242
10pm-173
[12/4, 14:02] Patient Attender: Rice with Dondakaya pappu and gova fruit
[12/4, 22:31] Rakesh Biswas Sir: 30-30-28 tomorrow
Day 34(05/12/23)
7:30am-111
12pm-279
4pm-201
6pm-204
10pm-187
[12/5, 11:20] Patient Attender: Idle with palli chutney
[12/5, 14:27] Patient Attender: Rice with pappu and keera
[12/5, 19:39] Patient Attender: Goduma ravva upma with cucumber curry
Meals taken on 5/12/23:
Morning breakfast:
Lunch:
Dinner:
Day 35(06/12/23)
7:30am-129
12pm-247
4pm-238
6pm-252
10pm-218
[12/6, 11:11] Patient Attender: Puri with pappu
[12/6, 14:17] Rakesh Biswas Sir: Salads?
[12/6, 15:12] Patient Attender: Rice with onion pappu and guva fruit
[12/6, 15:12] Patient Attender: And keera
[12/6, 23:00] Patient Attender: Goduma ravva upma with pappu
Meals taken on 06/12/23:Morning breakfast:
Lunch:
And keera
Dinner:
Copied from link which was updated till 18/11/23:
https://deeptha26.blogspot.com/2023/11/65-year-old-male-with-bph-symptoms.html?m=1
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