40M Diabetes 10 years WB PaJR

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Here we discuss our individual patient's problems through series of inputs from available global online community of 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 uncertainties around the patient and their resolution through team based learning :

Here's the rest of the discussions not yet updated in the case report 👇

[10/22, 7:30 PM] PaJR PHR Moderator: 40M with Diabetes 10 years with recent concerns of AKI which appears to be NSAID induced.

[10/22, 7:35 PM] PAJR TRAINEE: দয়া করে এই পিডিএফ টি প্রিন্ট আউট করে এবং আপনার রোগীর সই সহ অন্যান্য তথ্য পূরণ করে আমাদের informedconsentpajr@gmail.com

এই এড্রেস এ মেইল করুন 

Please print out this PDF and fill in the other information with your patient's signature. Then, email it to us at informedconsentpajr@gmail.com.

[10/22, 7:35 PM] PaJR PHR Moderator: Share his investigations and seven point sugar profile when they become available @⁨PDOC1⁩

[10/22, 7:36 PM] PDOC1: Ok sir

[10/23, 9:18 AM]PDOC1: Grbs of the patient 

[10/23, 9:20 AM] PaJR PHR Moderator: Please insert the interventions and the time they were administered

Please prepare a 24 hour chart leaving blank the slots where the data may not have been collected

[10/23, 9:21 AM] PaJR PHR Moderator: Serum creatinine 2.0

Please get a quick cue to check for proteinuria and share the images of his ultrasound kub ASAP

[10/23, 9:22 AM] PaJR PHR Moderator: Hgm normal

The images have been deleted as they contained patient and institutional identifiers

PDOC1: 

USG report 

PDOC1: 

[10/23, 11:52 AM] PaJR PHR Moderator: 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] PaJR PHR Moderator: Get his post lunch two hours without fail

[10/23, 11:59 AM] PaJR PHR Moderator: 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] PDOC1: Patient was not in ward at 10am to check his post breakfast sugars sir

[10/23, 12:00 PM] PDOC1: Ok sir

[10/23, 5:33 PM] PDOC1: Grbs

10am -119

1pm-170

4pm -190

[10/23, 7:32 PM] PaJR PHR Moderator: Can anyone convert this from voice to text @⁨pajr_trainee⁩

[10/23, 7:34 PM] PAJR TRAINEE: After eating a sweet apple his sugar level became high

[10/23, 7:48 PM] PaJR PHR Moderator: Which high value is he talking about?

What time?

[10/23, 7:48 PM] PaJR PHR Moderator: @⁨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]PAJR MODERATOR: 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] PAJR TRAINEE: আপনার সুগার এর কোন value টা বেশি , কোনটার কথা বলছেন?

আর কখন এর কথা বলেছেন?সময়টা উল্লেখ করুন

PA : 

[10/23, 7:53 PM] Lajrupa Bhadra: সুগারের কোন value ta

[10/23, 8:13 PM] PaJR PHR Moderator: 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] PAJR TRAINEE: He said at 6.45 evening his sugar level became high to 30 -40

[10/23, 8:15 PM] PaJR PHR Moderator: 30-40?

[10/23, 9:31 PM] PAJR TRAINEE: 30 to 40 point he said

[10/23, 9:38 PM] pdoc1: Grbs @7pm -229

[10/23, 9:39 PM] PaJR PHR Moderator: 👆What does that mean @⁨~PDOC1⁩ ?

[10/23, 9:39 PM] +pdoc1: I didn’t understand sir

[10/23, 9:41 PM] +pdoc2: What is the diagnosis for his Diabetes? Type 1 or Type 2 or Type 3?

[10/23, 9:43 PM] PaJR PHR Moderator: 2

[10/23, 9:43 PM] PaJR PHR Moderator: Will need someone to talk to him. Remind me tomorrow at OPD

[10/23, 9:43 PM] PDOC2: How and why please?

[10/23, 9:44 PM] PaJR PHR Moderator: 👆@⁨PDOC1

[10/23, 10:08 PM] PDOC1: He is having Diabetes since 10yrs and responding well to OHAs sir

PA: 

[10/23, 10:28 PM] PaJR PHR Moderator: Two hours post dinner?

[10/23, 10:30 PM] PDOC2: Thanks Akash. Which OHAs?

[10/23, 10:40 PM] PDOC1:  Currently on metformin and glimiperide sir

[10/23, 10:41 PM]pdoc2: 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]pdoc1: He was on glimiperide +voglibose and metformin for last 2-3 months sir and currently on glimiperide and metformin as advised by Dr. MODERATOR 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] pdoc2: Appears like this is MODY. Any family history chart for diabetes ?

[10/23, 11:17 PM]pdoc1: And thanks so much for taking the time and sharing this

[10/23, 11:17 PM] pdoc2: Classic IFT with easily well-controlled post prandial sugars

[10/24, 7:36 AM] PaJR PHR Moderator: @⁨pdoc1⁩ @pajr_trainee⁩ please try to get his family tree made mentioning who are diabetic and share it here

[10/24, 7:36 AM] pdoc1: Ok sir

[10/24, 7:41 AM] PaJR PHR Moderator: Although that alone may not be able to distinguish MODY from type 2

https://pmc.ncbi.nlm.nih.gov/articles/PMC1327713/

[10/24, 7:44 AM] PaJR PHR Moderator: 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] PaJR PHR Moderator: The patient identifier is visible and hence having to delete

[10/24, 11:12 AM] pdoc2: 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]pdoc2: 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] PaJR PHR Moderator: 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] PaJR PHR Moderator: @⁨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] +PDOC2: 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] PDOC2: 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] PaJR PHR Moderator: 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] PDOC2: 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] +PDOC2: Could you kindly let me know his HbA1c please?

[10/24, 11:35 AM] PaJR PHR Moderator: This would be a very interesting project

[10/24, 11:36 AM] PaJR PHR Moderator: Not done I guess?

[10/24, 11:37 AM] PaJR PHR Moderator: 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] +PDOC25

: And I was also told by a lab technician that they extrapolated it from fasting sugars!! 😵‍💫

[10/25, 4:10 PM] PaJR PHR Moderator: @pdoc1⁩ please pm me his signed informed consent ASAP

Pa: 

[10/25, 8:37 PM] PaJR PHR Moderator: @Pajr_trainee⁩ can you help us with his graphical chart of sugar values since admission that were shared here

[10/25, 8:39 PM] PaJR PHR Moderator: 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] PaJR PHR Moderator: @⁨~PA2🙂🙂⁩ ke bolun apnar voice message ta ekhane text kore janate

Pa: 

[10/25, 8:53 PM] PaJR PHR Moderator: Please text.

We can't hear voice messages or take calls

[10/25, 8:59 PM] PaJR PHR Moderator: @⁨PDOC1 please share all the sugar values in this patient since admission and also mention what medication and what dose he's currently on

Pa: 

[10/25, 9:48 PM] PaJR PHR Moderator: 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] PaJR PHR Moderator: 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] PaJR PHR Moderator: 👆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] PaJR PHR Moderator: 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] PaJR PHR Moderator: 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] PaJR PHR Moderator: Otao urinary bladder er aek dhoroner IBS jeta overactive kimba underactive bladder bola hoi

[11/4, 10:52 AM] PaJR PHR Moderator: 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

Pa : 

[11/4, 12:27 PM] PaJR PHR Moderator: Na IBS er kono tablet nei

Oguno khawar dorkar nei

[11/4, 12:28 PM] PaJR PHR Moderator: 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] PaJR PHR Moderator: 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] PaJR PHR Moderator: 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] PaJR PHR Moderator: 👆