72 year old female with uncontrolled diabetes.
Name - A. Rishi koundinya
Batch - 2017
DR. RAKESH BISWAS (HOD).
DR. SRI HARSHA (SR).
DR. SHAILESH (PGY3).
DR. KRANTHI (PGY1).
"This is an online E log book 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 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. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box"
CHIEF COMPLAINTS:
Decreased appetite since 3days
Shortness of breath since 3 days
Vomiting since 2 days
HOPI:
Patient is apparently asymptomatic 6 days ago there is an episode of fever 6 days back and relieved on medication and presented to OPD with chief complaints of decreased appetite since 3 days and vomiting since 2 days which is non projectile , food which is taken prior is the content of vomiting. There is shortness of breath since 3 days experiencing on rest.( Grade 4 mmrc).
PAST HISTORY:
1year back:
There is a past episode of decreased urine output and burning micturation, swelling of both limbs and decreased appetite and vomiting s and admitted in the hospital and given medication.
2 years back
There is slight pain in the knee joint and consulted a doctor and given a intra articular injection and there is increase in pain since then.
There is history of constipation since 2 years.
Patient is a known case of diabetes and hypertension since 20 years and on medication regularly.
PERSONAL HISTORY:
She is a housewife and does her daily activities by herself
Diet: mixed
Appetite: decreased
Sleep: adequate
Bowel and bladder: regular
No addictions.
GENERAL EXAMINATION:
Patient is conscious coherent and we'll orientated to time place and person.
Vitals:
Pulse- 80bpm
RR - 24cpm
BP - 130/70 mmHg
SpO2 - 96%
CVS - S1 S2 +
RS - BAE+
P/A - soft and non tender
There is pallor.
Edema of bilateral lower limbs.
INVESTIGATIONS:
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2D ECHO
USG REPORT
Fever chart
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PAST BLOOD AND URINE CULTURE REPORTS:
INVESTIGATION CHART AUGUST 2022
INVESTIGATIONS IN JUNE 2022
X RAY CHEST
X RAY KUB
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Blood and urine culture reports
AUG 2021
SEP 2021
MARCH 2022
JUNE 2022:
NCCT REPORTS
B/L PUJ DILATION
Atherosclerosis of aorta and it's bifurcation.
CONVERSATION WITH A PATIENT ADVOCATE FROM THE FIRST TIME OF ADMISSION :
AUGUST 2021
[8/8/2021, 7:53 PM] pt. Advocate: Dr PGY3 2018 has called me..saying that u have asked her to take mothers health history
[8/8/2021, 7:55 PM] Rakesh Biswas: Yes. She is our senior PG and she her inputs will be useful to understand her problem better. Please share all the history that you know with her
[8/23/2021, 2:53 PM]ptAdvocate: Today i sent blood sample and urine sample for routine evaluation ,,will lupdate u further sir
[8/26/2021, 11:13 PM] ptAdvocate:Sir ,after giving antibiotics therapy also she was having burning micturation ,,so after multiple cue examinations,,it was found that there is a fungal infection ..so,,fluconazole was started, n immediately after 2 to 3 days burning micturation subsided ..n adviced to continue antifungal 7 days post discharge...but was not taken properly ..now..again she complains burning micturation...at the end moment of urination ....she is strictly adhere to diet....any advice to restart antifungal medication.??or any extra medication like citralka
[8/27/2021, 7:51 AM] Rakesh Biswas: Let us rexamine the urine for pus cells and culture asap
[8/27/2021, 7:53 AM] Rakesh Biswas: Her details are here :
https://18100006002.blogspot.com/2021/08/70-years-old-female-with-recurrent-utis.html?m=1
The good news in terms of renal function is that the previous creatinine was 4.4 and now it's nearly half of that so it's like a 50% improvement in her kidney function 👏
[9/8/2021, 5:54 PM] pt Advocate: Hi sir good evening
Today evening i will get report of cue n culture of mother ..will share with u immediately...sir as a good diet ,as per her kidney condition ,can she take meat of goat or desi chicken ?? Quantity?? Frequency??n also about eggs quantity n frequency
[9/22/2021, 3:55 PM] pt Advocate: Sir
Goodevening
Mother complaining loss of appetite...snce 15 days ..
Plz advice medication
[9/22/2021, 4:47 PM] Rakesh Biswas: We need to evaluate her in detail
[9/22/2021, 5:12 PM] Rakesh Biswas: Any syrup can worsen her sugar control and may not be recommended. We need to evaluate her by talking to her and understand the cause of her loss of appetite. Can I ask one of my students to talk to her like last time Dr PGY3 2018 had done?
[9/22/2021, 6:09 PM] pt Advocate: Sir time???
[9/22/2021, 6:28 PM] Rakesh Biswas: Let me ask my students
[9/25/2021, 9:01 PM] ptAdvocate: Sir ,has she presented mothers health details to u
[9/25/2021, 9:01 PM] Rakesh Biswas: Yes
[9/25/2021, 9:01 PM] pt Advocate: She feeling vomiting sensation.
MARCH 2022:
[10/5/2021, 7:34 PM] Rakesh Biswas: Let her take Tab Nitrofurantoin 100mg twice a day for one week and then repeat the cue and culture
[10/5/2021, 7:58 PM]ptAdvocate: Shd start immediately
[10/5/2021, 7:59 PM] Rakesh Biswas: Can
[10/5/2021, 10:30 PM] :ptAdvocate: Sir suggest any good brand
[10/5/2021, 10:30 PM] ptAdvocate: In mkarket
[10/6/2021, 7:50 AM] Rakesh Biswas: Scientifically all brands are supposed to be equal although market science is something that is still under wraps
[10/13/2021, 4:38 PM] Rakesh Biswas: Antifungals were given as her urine culture in our institution showed candidal infection but the current culture done elsewhere doesn't show Candida. We can send the urine culture again to our institution if we are strongly suspecting Candida. You can talk to our Microbiology resident here who can advice if you would like to send her urine culture sample here again.
She can take citralka
[10/13/2021, 4:56 PM] ptAdvocate: Ok sir ..recent report not showing any such fungal infection ,,,then what caln be the reason of burning micturation sir?
[10/13/2021, 5:26 PM] Rakesh Biswas: UTI. How many days of antibiotics over now?
[10/13/2021, 5:29 PM] ptAdvocate: 100 mg bd 6 days
[10/13/2021, 5:37 PM] ptAdvocate: Is there side effect of loss of appetite onb taking nitrofurantoin??
[10/13/2021, 5:38 PM] ptAdvocate: If yes then what to take for appetite loss,
Aristozyme??
[10/13/2021, 7:12 PM] Rakesh Biswas: Yes if the side effects of loss of appetite is difficult to tolerate then one may have to stop nitrofurantoin
[10/13/2021, 7:14 PM] Rakesh Biswas: 👆but she seemed to have this even before starting nitrofurantoin
[10/13/2021, 8:15 PM]ptAdvocate: Yes sir
[10/13/2021, 8:16 PM] ptAdvocate: The same she said when i asked her
[10/19/2021, 4:04 AM] ptAdvocate: Sir ,is there a possibility of ic(interstitial cystitis)....
In such condition can we suggest elmiron 100 mg???to reduce burning micturation or irritation
[10/19/2021, 8:12 AM] Rakesh Biswas: Can try and see
[10/19/2021, 8:19 AM] ptAdvocate: What need to observe during medication ....like kidney fuction test?
[10/19/2021, 8:26 AM] Rakesh Biswas: Urine CUE , RFT, LFT, hemogram
[10/19/2021, 8:36 AM] ptAdvocate: I want to follow your advice sir...being on safe side
[10/19/2021, 8:41 AM] Rakesh Biswas: Try this questionnaire on her first to verify the diagnosis of IC :
https://www.aafp.org/afp/2011/0515/p1175.html#:~:text=Interstitial%20Cystitis%20Symptom%20and%20Problem%20Questionnaire&text=A%20total%20score%20(symptom%20%2B%20problem,in%20favor%20of%20the%20diagnosis
[3/9, 2:45 PM] ptAdvocate: Suggest routine tests for mother sir ...she complaints whitenes in urine
[3/9, 4:03 PM] Rakesh Biswas: Urine CUE and culture sensitivity
March 2022
[3/26, 7:55 AM] Rakesh Biswas: How is her urinary symptoms now?
[3/26, 9:31 AM] ptAdvocate: Like??
[3/26, 9:35 AM] Rakesh Biswas: Any problem in her passing urine she is complaining of currently?
[3/26, 9:36 AM] pt Advocate: Will ask her
[3/26, 9:36 AM] Rakesh Biswas: When was the last time she took an antibiotic for her urinary symptoms?
[3/26, 9:36 AM] PT advocate: Few days before
[3/26, 9:36 AM] Rakesh Biswas: What antibiotic?
[3/26, 9:37 AM] pt Advocate: Mahacef cv 200
[3/26, 9:37 AM] Rakesh Biswas: Did her symptoms subside?
[3/26, 9:37 AM] pt Advocate : Yes
[3/26, 9:37 AM] Dr Zeeshan BDS Nalgonda: Fever ,shivaring subsided
[3/26, 9:38 AM] pt Advocate : Immediately she started as she complained fever
[3/26, 9:39 AM] Rakesh Biswas: Assuming that she took the antibiotics after 15/3 and her symptoms have subsided today as of 26/3, then she can just repeat the culture
[3/26, 9:42 AM] pt Advocate : The day she developed symptoms, next day went to physician n took antibiotics n same day symptoms subsided
[3/26, 9:42 AM] pt Advocate : Or most probably next day of taking
[3/26, 9:43 AM] Rakesh Biswas: Date?
[3/27, 10:30 AM] pt Advocate : Will conform
[3/27, 10:34 AM] pt Advocate : But what am thinking ,according to this report only 2 antibiotics r effective to mother ...but took amoxicillin, which is resistant as per report ..time being it got subsided,,but again today morning again she developed symptoms like shivaring fever n pain in all bones ...so, to subside infection as first preference what shd do??? Shd go with antibiotics which r non resistant
[3/27, 10:40 AM]pt Advocate : This test done on 18 march ,,so just 2,3 days before of this ,,she developed symptoms of fever n shivaring
[3/27, 10:43 AM] pt Advocate : Fisrt a fall the purpose of this report is to know the bacteria or the disease causing organism n to know the effective antibiotic..to which the bacteria is not resistant ...so that primarily can fight the infection
[3/27, 11:05 AM] Rakesh Biswas: Yes but as per your history inspite of the report showing antibiotic resistance in vitro she appeared to have responded to the same resistant antibiotics in vivo
[3/27, 11:11 AM] pt Advocate : Yes then how
[3/27, 11:12 AM] pt Advocate : N wht to do now practically to relieve
[3/27, 11:13 AM] Rakesh Biswas: 👆you said she's relieved
[3/27, 11:14 AM] pt Advocate : She said first she took only 2 antibiotics..n stoped taking ,,,then for 4,5 days ..now again i have started full course of same antibiotics bcoz today early morning developed fever n shivaring with body pains
[3/27, 11:14 AM] pt Advocate : Is this bcoz of discontinued antibiotics therapy or some thing like bcoz of resistance?
[3/27, 12:11 PM] Rakesh Biswas: Resistance
[3/27, 7:18 PM] pt Advocate : Last time miropenum 500 mg iv given for 5 days
[3/27, 7:19 PM] pt Advocate : N this is effective as per test report ..so shall give merupinam only
[3/27, 7:37 PM] pt Advocate : Meropenem 500 mg
[3/27, 7:37 PM] pt Advocate : This was give bd 5 dys
[3/28, 3:20 PM] pt Advocate : Sir starting meropenem inj at home ...any measuremts or parameters need to check before giving??
[3/28, 4:08 PM] Rakesh Biswas: Will need to discuss this with the doctor monitoring her at home
[3/28, 6:12 PM] pt Advocate : Today giving first dose
[3/28, 9:38 PM] pt Advocate : Today given antibiotic.
[3/28, 9:38 PM] Dr Zeeshan BDS Nalgonda: What to give for loss of appetite
[3/28, 10:24 PM] Rakesh Biswas: If it is due to UTI it will subside with meropenem
[3/29, 11:46 PM] pt Advocate : Sir this meropenem 500 mg yesterday night ....today she took only one dose of 500 mg ....not taken 2nd dose,,is that ok or must give 2nd dose today itself?
[3/30, 6:37 AM] Rakesh Biswas: Can give two doses twelve hourly today
[3/30, 4:15 PM] Rakesh Biswas: What is her current dose of insulin she is taking and what was her last Hba1c?
[3/30, 4:33 PM] pt Advocate : Last hba1c 10
[3/30, 4:34 PM] pt Advocate : 22 units morning 14 units night
[3/30, 4:53 PM] Rakesh Biswas: When?
[3/30, 4:53 PM] Rakesh Biswas: What insulin?
[3/30, 4:54 PM] Rakesh Biswas: I'm sometimes unable to hear the voice messages due to lack of time
[3/30, 10:35 PM] pt Advocate : Almost 1 yr before
[3/30, 10:35 PM] pt Advocate : Humalog mix 50
[3/30, 10:35 PM] pt Advocate : Pen insulin
[3/30, 10:35 PM] Rakesh Biswas: It needs to be done every three months
[3/30, 10:36 PM] pt Advocate : Ok sir from nw onwrds
[3/30, 10:38 PM] pt Advocate : Long acting sir
[3/30, 10:40 PM] Rakesh Biswas: No it's a combination of both Long and short acting lispro
[4/1, 6:49 PM] pt Advocate : First dose of meropenem 500 was given at night ....
Second day morning dose given lately ...evening dose missed bcoz of some reason
3rd day morning evening 2 doses given
4th day 2 doses given ...today is 5 th day ..total till today evening 8 doses will be completed ..means 5 days n 8 doses.like wise ,shd continue remaining 2 doses till tomorrow ,to complete total 10 doses...?? Or just 8 doses 5 days is enough??
[4/1, 6:59 PM] Rakesh Biswas: The number of doses is not important. What is important is if the urinary bacteria have been eradicated and her symptoms are relieved.
Problem is what will happen if she next develops UTI again due to a meropenem resistant organism. We also see that often happening in our practice
[4/1, 7:02 PM] pt Advocate : Ok
Then how to know if all bacteria got iradicates
[4/1, 7:02 PM] pt Advocate : Iradicated*
[4/1, 7:05 PM] Rakesh Biswas: Repeat urine culture
[4/1, 7:06 PM] Rakesh Biswas: It's variable depending on the organism and severity
[4/1, 7:13 PM] pt Advocate : Last time bacteria was different
[4/1, 7:13 PM] pt Advocate : Yes
[4/1, 7:14 PM] pt Advocate : It was kleibsella
[4/1, 7:15 PM] pt Advocate : Sir ,usually..e coli needs how many doses of meropenem 500 for complete eradication..
[4/1, 7:16 PM] pt Advocate : Or it varies person to person n severity may be ?
[4/1, 7:16 PM] Rakesh Biswas: Yes everything depends on the response
[4/1, 7:17 PM] pt Advocate : Now she seems fine sir
[4/1, 7:17 PM] pt Advocate : After 8 doses
[4/1, 7:17 PM] pt Advocate : Is there any such studies ?
[4/1, 7:20 PM] Rakesh Biswas: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0237365
[4/1, 7:25 PM] Rakesh Biswas: "reinfection by the same microorganism at 30 days was 8.6% in the short treatment group and 10% in the long one (P = 0.8)"
https://journals.plos.org/plosone/article/figure?id=10.1371/journal.pone.0237365.g002
[4/1, 7:30 PM] pt Advocate : Short treatment group means like my mothers case now ...n chaces r 8.6 ..which r lower than long or complete ( i.e,complete 10 or 14 doses)group?...
[4/1, 7:47 PM] Rakesh Biswas: It means the chances of reinfection are the same regardless of shorter or longer duration of treatment
[4/1, 7:51 PM] pt Advocate : Then y in general prescription made for 3 ,5 ,7 ,9 days
[4/1, 8:44 PM] Rakesh Biswas: Empirical
[4/1, 8:51 PM] Rakesh Biswas: But we need to repeat culture and see if the infection has been eradicated
[4/1, 8:56 PM] pt Advocate : As per previous record what i found that even after one dose also the culture report was nil like " no organisam isolated "or not found
[4/1, 9:08 PM] Rakesh Biswas: So it must have been eradicated and then she got a fresh infection again
[4/1, 11:05 PM] pt Advocate : Yes but after 3 to 5 months it recurring
[4/2, 7:26 AM] Rakesh Biswas: Yes
AUGUST 2022:
[8/29, 6:54 PM] Pt 72F Advocate NLG: In case of high bp
[8/29, 6:55 PM] Pt 72F Advocate NLG: Can sorbitrate be given ??
[8/29, 6:55 PM] Pt 72F Advocate NLG: For high bp relief
[8/29, 6:56 PM] Pt 72F Advocate NLG: Mother having 180 /90 bp
[8/29, 6:59 PM] Pt 72F Advocate NLG: She was complaining weakness ,drowsiness, abdominal pain ...loss of appetite
[8/29, 7:05 PM] Rakesh Biswas: High BP is not a symptom. Relief is only for symptoms.
Please monitor her BP every hourly at random intervals at least ten times and let us know
[8/29, 7:05 PM] Pt 72F Advocate NLG: Ok
[8/29, 7:05 PM] Rakesh Biswas: Check out the conversations around this we had in the morning in her PaJR group
[8/29, 7:06 PM] Pt 72F Advocate NLG: But if its high even after giving regular medicines...then what can be given to relief
[8/29, 7:07 PM] Rakesh Biswas: Share the BP chart
[8/29, 7:07 PM] Pt 72F Advocate NLG: For time being what to give to relief bp...like angistat 2.5 is good
[8/29, 7:07 PM] Pt 72F Advocate NLG: Right now its 190
[8/29, 7:07 PM] Pt 72F Advocate NLG: 190/ 90
[8/29, 7:18 PM] Rakesh Biswas: BP is not treated like that.
What BP medication is she currently treating?
Let's take this discussion to the group so that others can also help
"Post-menopausal women have higher rates of recurring UTIs because of pelvic prolapse, lack of oestrogen, loss of lactobacilli in the vaginal flora, increased periurethral colonisation by Escherichia coli (E. coli), and a higher incidence of medical illnesses such as diabetes mellitus (DM).
The microorganism that causes recurrent UTIs is similar, in most cases, to the sporadic infection.
Most uropathogens from the rectal flora ascend to the bladder after colonising the periurethral area and urethra.
Despite the fact that most E. coli are eradicated by the host defence mechanisms within days, only small clusters of intracellular E. coli are observed to persist for several months in an antibiotic-resistant state.
Reactivation of uropathogenic E. coli (UPEC), an intracellular bacteria, could cause recurrent UTIs."
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3749018/
[4/2, 7:52 AM] pt Advocate : Excellent
[4/2, 7:53 AM] pt Advocate : How to correct pelvic prolapse (any exercise)lack of oestrogen ,,lack of lactobacilli ....
[4/2, 7:55 AM] pt Advocate : By using effective cleansing agents like dettol etc can one reduce periurethral colinisation??
[4/2, 8:05 AM] Rakesh Biswas: Look up Kegel's pelvic strengthening exercises in Google Images
[4/2, 8:06 AM] Rakesh Biswas: None of them have any proper scientific trials done so the answers are all speculative
[4/9, 3:40 PM] Pt 54F Advocate NLG: Mother complains burning micturation..
[4/9, 3:51 PM] Pt 54F Advocate NLG: Citralka ??or any other better than this
[4/9, 8:02 PM] Rakesh Biswas: All urinary alkalizers are more or less same and sometimes the urinary burning may not be due to acidity of the urine
[4/9, 11:04 PM] Pt 54F Advocate NLG: Then ?
[4/9, 11:05 PM] Rakesh Biswas: Inflammation
Neural
[4/9, 11:08 PM] Pt 54F Advocate NLG: Bcoz of what etiology
N
Treatment?
[4/10, 7:02 AM] Rakesh Biswas: UTI producing inflammation leading to frayed nerve endings that continue to persistently evoke the same burning sensations although the organisms are cleared and there is no fever or sepsis.
There is treatment only for UTI
For any kind of neural burning one may use Pregabalin.
However all my assumptions above are based on very limited data about the patient that has been shared by you and she may have a totally different problem
[4/10, 8:51 AM] Pt 54F Advocate NLG: What else i can share with you...so that can reach to exact conclusion
[4/10, 9:32 AM] Rakesh Biswas: When did she first notice the urinary burning? What was her daily 24x7 routine activity (please mention hour by hour) and when the problem started how did it change the daily routine?
[4/11, 4:33 PM] Pt 54F Advocate NLG: First complained long ago ,may be 2,3 yrs ago
[4/11, 4:35 PM] Pt 54F Advocate NLG: N now this time ..she noticed 15, 20 days before
[4/11, 4:36 PM] Pt 54F Advocate NLG: After taking antibiotics, got subsided little bit ....now again developed mild to moderate
[4/11, 4:38 PM] Pt 54F Advocate NLG: So whatever may be the reason sir ,,,at this moment of time ,,considering the commom reason ...can give citralka ??
[4/11, 4:41 PM] Pt 54F Advocate NLG: Sir plz mention pregabalin dose or a common good results brand
[4/11, 4:44 PM] Rakesh Biswas: I'm not sure it will help. Need a better detailed history and discussion
[4/11, 4:44 PM] Pt 54F Advocate NLG: Will discuss all details
[4/11, 4:57 PM] Pt 54F Advocate NLG: She wakes up every morning around 9 to 10 in past (after waking up for morning prayers at 5 am ,again she sleeps.,,,n wakesup at 9 or 10 am.)..n since few yrs waking up at 8 am bcoz of weakness...after that ,face wash n takes tea without sugar ..then after an hour (varies ....some time an hour or 2 hrs or half an hour...may be bcoz of delay in cooking or some time bcoz of no appetite)....taking insulin humalog mix 50, 20 units ....before ,almost since 1to 2 yrs,,,insulin dose varies between 20 to 24(depending upon yesterday nights sugar levels readings)...after taking insulin ,,,takes breakfast like idli or oats or rice or some time roti...then regular medications like for bp n for heart n etc....takes lunch including rice n veg curries around 2 or 3 pm ....then dinner around in between 9 to 11 pm after taking insulin dose of 10 to 14 units...sleeps around 12 to 1pm ....some times sleeps around 11 pm
[4/11, 6:36 PM] Rakesh Biswas: Is this schedule before her urinary symptoms?
What was her schedule before she developed diabetes?
[4/11, 7:18 PM] Pt 54F Advocate NLG: This is her regular schedule ...till now
Diabetic since 30 yrs ...no idea ...
[4/11, 7:28 PM] Rakesh Biswas: Before burning symptoms developed?
How did her schedule change after the symptoms started?
[4/11, 7:40 PM] Pt 54F Advocate NLG: No change in schedule
[4/11, 7:40 PM] Pt 54F Advocate NLG: As usual
[4/11, 7:41 PM] Pt 54F Advocate NLG: After some days of burning symptoms...she use to take medications like citralka n if symptoms persist ,antibiotics
[4/11, 7:42 PM] Pt 54F Advocate NLG: Then checking blood glucose n setting insulin dose according
[4/11, 7:46 PM] Pt 54F Advocate NLG: N gets subsides on taking simple medications
[4/11, 7:47 PM] Rakesh Biswas: Such as citralka?
[4/11, 7:53 PM] Pt 54F Advocate NLG: Yesyes
[4/11, 7:53 PM] Pt 54F Advocate NLG: Some supportive medications as well
[4/11, 7:57 PM] Rakesh Biswas: Such as?
[4/11, 8:01 PM] Pt 54F Advocate NLG: Like for improvement in blood count, hb.
Multivitamins,
[4/11, 8:01 PM] Pt 54F Advocate NLG: Antioxidants
[4/12, 12:58 AM] Pt 54F Advocate NLG: So wht to do now
[4/12, 8:25 AM] Rakesh Biswas: Continue previous support.
[4/20, 9:57 PM] Pt 54F Advocate NLG: Whts reason for abdominal discomfort?
[4/20, 10:07 PM] Rakesh Biswas: Who's?
[5/3, 6:32 AM] Pt 54F Advocate NLG: Again mother developed multiple spikes of fever with chills subsiding with dolo after few hours again raising since 2 days
[5/3, 6:34 AM] Pt 54F Advocate NLG: Just last month only given iv merupinam 500 mg ..missing some doses ...i was expecting the recurrence in a month bcoz of missing doses ...see again same issues ....
[5/3, 8:07 AM] Rakesh Biswas: It's not because of missing doses.
It's because of the bacteria that couldn't be killed because they were resistant anyways and once the weaker bacteria died due to the antibiotics now the resistant ones have increased in number and we may probably need antibiotics higher than meropenem.
Antibiotic therapy in UTI is a vicious cycle
[5/5, 2:52 PM] Pt 54F Advocate NLG: They came
[5/5, 2:53 PM] Pt 54F Advocate NLG: To meet u
[5/5, 4:18 PM] Rakesh Biswas: Yes it was good to meet her and get clarity on her issues
I feel her blood sugars are not getting controlled well and that is the main reason for her recurrent UTI.
Unless we control her blood sugars properly just giving antibiotics for UTI will not help much.
Can you share the last Hba1c?
We need to admit her and adjust her insulin to ensure proper control
[5/5, 4:19 PM] Pt 54F Advocate NLG: Oook sir
[5/5, 4:20 PM] Pt 54F Advocate NLG: Last hba1c was 10
[5/5, 4:24 PM] Rakesh Biswas: When was that?
[5/5, 4:35 PM] Pt 54F Advocate NLG: Almost 2 ,3 yrs before
[5/5, 4:36 PM] Rakesh Biswas: 😳
[5/5, 4:36 PM] Rakesh Biswas: Please get another one asap
[5/7, 6:42 PM] Rakesh Biswas: Recurrent UTIs linked to gut microbiome: A study suggests that women who get recurrent urinary tract infections (UTIs) may be caught in a vicious cycle in which antibiotics given to eradicate one infection predispose them to develop another.
https://www.frontiersin.org/articles/10.3389/fcimb.2021.562525/full
[5/11, 3:24 AM] Pt 54F Advocate NLG: Sir ,have a look ...
Now under which category of infection ..mothers case considers
[5/11, 7:25 AM] Rakesh Biswas: Asymptomatic bacteriuria
[5/11, 7:25 AM] Rakesh Biswas: Share her blood sugar trends daily with me
[5/11, 7:25 AM] Rakesh Biswas: And let her meet us weekly
[5/11, 7:32 AM] Rakesh Biswas: Read this article relevant to your patient's problem and let me know if there are any passages from which you may have inputs in the form of questions related to your patient 👇
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5802407/
[5/21, 8:50 PM] Pt 54F Advocate NLG: This is 7 days report
[5/21, 8:50 PM] Pt 54F Advocate NLG: Of blood sugar levels
[5/21, 9:02 PM] Rakesh Biswas: Insulin Mixtard?
The dose needs to be adjusted.
Please share her Hba1c every three months
[5/21, 9:06 PM] Pt 54F Advocate NLG: Humalog mix 50 lilly brand she using now since 15 yrs
[5/21, 9:13 PM] Rakesh Biswas: Let me know yesterday and todays profile
[5/21, 9:17 PM] Pt 54F Advocate NLG: As like this only yesterday .....
Yesterday morning she she took 22 units n took food as usual but at night after taking 121 units ate mango or normal size only without any other food
Today morning insulin 22 units took then took brkfast then lunch little quantity ...but sugar now one hour before was 471 ..i told to take atleast 14 units before dinner
[5/21, 9:18 PM] Pt 54F Advocate NLG: 12 units not 121*
[5/23, 7:02 PM] Rakesh Biswas: 👆
Need to know her entire sugar profile
Pre and post meal for three meals per day
[5/23, 7:12 PM] Rakesh Biswas: Can add 6U of plain insulin (it looks like water) before lunch.
Also share the recent values at least do it once a week
[5/23, 7:23 PM] Rakesh Biswas: Soluble insulin
[5/23, 7:23 PM] Rakesh Biswas: Regular insulin
[5/23, 7:35 PM] Rakesh Biswas: It's the cheaper short acting insulin.
The Insulin IN Humalog mix is a mixture of an expensive short acting insulin lispro with longer acting protamine Insulin.
Regular insulin is like insulin lispro but more cheaper. The pharmacokinetics of insulin lispro is supposed to be better than regular insulin and if you want you can also give her 6U of the lispro insulin (instead of the cheaper regular insulin). Lispro is available by the name Humalog (only).
Either of them, lispro or regular can be added 6U before lunch and initially we need strict monitoring regularly to up or down regulate the dose as per the current requirement of her body
[6/3, 3:36 PM] Pt 54F Advocate NLG: R u there ir
[6/3, 3:37 PM] Rakesh Biswas: Where are they? Ask them to meet Dr Vamsi in the OPD and he will bring them to me
[6/3, 4:33 PM] Rakesh Biswas: I met them
[6/3, 4:34 PM] Rakesh Biswas: She needs good blood sugar monitoring and control.
[6/3, 4:36 PM] Pt 54F Advocate NLG: What next sir
[6/3, 4:41 PM] Rakesh Biswas: We need to monitor her blood sugars closely such that we can adjust the insulin dose. They did share a chart till 17th on the 25th. We need them to share the blood sugars daily so that we can adjust the insulin dose right on that day
[6/16, 6:07 PM] Pt 54F Advocate NLG: Sir plz have a look
[6/16, 6:35 PM] Rakesh Biswas: We will need to get her serum ferritin and if possible entire iron profile.
Is she on any oral iron medications?
Does she have any symptoms currently?
[6/16, 6:43 PM] Pt 54F Advocate NLG: Yes she was on oral iron medication like feronia n ferrinject inj iv n some other iron suppliments
[6/16, 6:44 PM] Pt 54F Advocate NLG: Symptoms are weakness lack of appetite
[6/17, 10:23 PM] Pt 54F Advocate NLG: Sir i told you about all symptoms...will get those serum ferritin test...for time being advice some medication for relief
[6/17, 10:28 PM] Pt 54F Advocate NLG: Sir why it was not adviced to get serum ferrritin also during last visit ...bcoz in proper nalgonda labs are not good to trust ..actually bcoz of weakness n lsummer she facing difficulty to visit more time to kamineni for tests n treatment ...n some times brother also not available to bring her ...
[6/17, 10:30 PM] Rakesh Biswas: Her symptoms are due to anemia. If we want to treat her as iron deficiency anemia without further investigations we can start her again on oral iron. The commonest cause of iron deficiency anemia is blood loss and even occult blood loss needs to be ruled out
[6/18, 3:51 AM] Pt 54F Advocate NLG: Sir ,what oral iron medication she can take till she gets that test reports ...bcoz mother complaining weakness n illness
[6/18, 7:49 AM] Rakesh Biswas: What oral medication was she on before this? What was the duration she took it for? What was her hemoglobin before she started taking it and what was her hemoglobin after three months of taking it? What were her symptoms before she started taking it?
[6/18, 7:53 AM] Rakesh Biswas: Serum ferritin can only be adviced after seeing the CBC report only if it's suggestive of iron deficiency anemia.
We are seeing this CBC report done on 3/6/2022 only on 16/6/2022 so we asked for the serum ferritin test once we saw the CBC
[6/19, 11:50 AM] Pt 54F Advocate NLG: Ok sir ,in general what i was thinking that commonly at this age a person with all such medical history and also the clinical presentation n pale yellow skin ,lack of appetite n generalised weakness,( in general what all these can suggest most probably )bcoz majority of such cases belongs to iron deficiency most of time in general in our country...this is what i am thinking ,plz corrrect me sir
[6/19, 11:53 AM] Rakesh Biswas: And in this age that iron deficiency anemia can be due to blood loss (blood loss is the commonest cause of iron deficiency anemia) and her blood loss could be occult and hopefully not due to an occult malignancy (with increasing age there is increased chances of malignancy).
Anyways without going into the above we just need to focus on giving her symptomatic relief and perhaps restart the oral iron she was previously on
[6/19, 12:08 PM] Pt 54F Advocate NLG: Yes yes...no wastage of blood in the form of occult blood ...all this bcoz of malnutrition loss of appetite insufficient food intake like not taking fruits bcoz of fear of increasing sugar levels not taking meat bcoz of fear of increasing creatinine ...all if we correct her appetite n suggest the best possible diet in long term ,we can improve her general over health...ok as per her condition ryt now ,can she go for blood transfusion ??
[6/19, 12:15 PM] Rakesh Biswas: Was she helped by the blood transfusion she received last time?
[6/19, 12:43 PM] Pt 54F Advocate NLG: Yes yes
[8/15, 5:03 PM] Pt 54F Advocate NLG: Sir ,mother want to admit in hospital for 3,4 days bcoz of weakness ,vomiting n generalised illness ..so that she will recover n well being
[8/15, 5:28 PM] Pt 54F Advocate NLG: As per previous records. She just need iv with multivitamin n general care...she will recover
[8/18, 9:05 PM] Pt 54F Advocate NLG: Sir 2 days before usg abdomen done ...
[8/18, 9:06 PM] Pt 54F Advocate NLG: It is said that again asking for some test to detect stone .,,test costing 5000
[8/18, 9:29 PM] Rakesh Biswas: The urology have asked for a CT scan as the ultrasound is unable to visualize what is causing the moderate hydroureteronephrosis
[8/18, 9:30 PM] Rakesh Biswas: Maybe worthwhile as this may be causing her recurrent UTI and is most likely a stone
[8/18, 9:59 PM] Pt 54F Advocate NLG: Ok got it
[8/18, 10:49 PM] Pt 54F Advocate NLG: But in usg abdomen study ...no stone found sir
[8/19, 7:28 AM] Rakesh Biswas: Exactly the reason why they need the CT to find it. They found an obstruction in the middle of the ureter which they suspect is likely due to a stone
[8/19, 10:52 AM] Rakesh Biswas: We will make a separate group for her to discuss her daily along with our team
[8/19, 10:55 AM] Pt 54F Advocate NLG: Thats great sir
[8/19, 3:49 PM] Pt 54F Advocate NLG: She has no complain of gastro ....except usual constipation ,which releives on taking laxatives which u have suggested since long
[8/19, 4:07 PM] Rakesh Biswas: Yes she is most likely having diabetic autonomic neuropathy causing intestinal hypomotility
[8/30, 10:40 AM] Pt 72F Advocate NLG: Hi sir...if patients bp is high ...regular medicines not working ....what to do ....shd leave the pateint to be with bp remains ...??? Or shd change the tablet ??or shd increase the medicine dose ???
[8/30, 10:45 AM] Pt 72F Advocate NLG: I told many times n i we shared that info many times about her medicines what she is taking regularly ...i was thinking group is aware of this ......yesterday the situation of patient was to give proper medication to control the bp ...rather than discussion in grp ..which takes again much time ...instead of giving immediate relief
[8/30, 1:09 PM] Rakesh Biswas: Since how many years is she having increased BP?
[8/30, 1:11 PM] Pt 72F Advocate NLG: Since 20 yrs she using bp medicines
[8/30, 1:12 PM] Rakesh Biswas: How many times has her BP needed such emergency measures to be controlled sos inspite of her regular medications?
SEPT 2022:
[9/4, 2:34 PM] 72F Pt Advocate NLG: Hi sir ...in this paper ..nephrologist adviced inj renocel weekly once ..bcoz of her anaemic condition n pale yellow skin ....she want to take this inj...
[9/4, 2:35 PM] 72F Pt Advocate NLG: Is it beter to take this at home or hosp
[9/4, 7:19 PM] Rakesh Biswas: Any qualified nurse can perhaps administer it at home as it's subcutaneous
[9/4, 7:30 PM] 72F Pt Advocate NLG: Ok its a subcutaneous...not iv ??
[9/4, 7:43 PM] Rakesh Biswas: It can be administered by both routes and both are equally effective
https://pubmed.ncbi.nlm.nih.gov/1574961/
[9/4, 8:47 PM] 72F Pt Advocate NLG: Previously when she was given a multivitamin inj im ,she got syncope after some time
[9/4, 8:48 PM] 72F Pt Advocate NLG: After that ,,any such injection i gave iv only for her fear satisfaction
[9/4, 8:50 PM] Rakesh Biswas: Subcutaneous is different from im but yes any injection can have it's complications
[9/4, 8:51 PM] 72F Pt Advocate NLG: I think the safe is subcutaneous
[9/4, 8:51 PM] 72F Pt Advocate NLG: Am i ryt
[9/4, 8:52 PM] 72F Pt Advocate NLG: Bcoz of slow absorption
[9/4, 8:52 PM] 72F Pt Advocate NLG: Compare to iv
[9/4, 9:04 PM] Rakesh Biswas: Yes
[9/6, 4:56 PM] 72F Pt Advocate NLG: Sir ,can it be given with ns
[9/6, 5:01 PM] 72F Pt Advocate NLG: Will give in iv with ns ...100 ml ns
[9/6, 5:01 PM] 72F Pt Advocate NLG: Instead of direct iv
[9/6, 7:36 PM] Rakesh Biswas: See directions here 👇
"Do not dilute. Do not mix with other drug solutions except for admixing as described below:
Preservative-free Epogen from single-dose vials may be admixed in a syringe with bacteriostatic 0.9% sodium chloride injection, USP, with benzyl alcohol 0.9% (bacteriostatic saline) in a 1:1 ratio using aseptic technique at the time of administration"
[9/7, 7:30 PM] 2019 KIMS UG: Sir , i could identify monoblasts , monocytes and promonocytes and a few dysplastic neutrophils in the above peripheral smears sir
[9/7, 7:34 PM] 2019 KIMS UG: The hallmark of CMML is dysplastic change in myeloid lineage cells in bonemarrow with persistent increase in monocytes in peripheral blood
[9/7, 8:31 PM] 2019 KIMS UG: Also sir , in today's class question about mechanism of albuminuria in minimal change disease kidney...
It has been found by electron microscopy that there is effacement of foot process of podocytes in glomerular basement membrane and
FcRn-dependent albumin transcytosis is increased in minimal change nephrotic syndrome. The numbers of endocytosed vesicles are increased under conditions of nephrotic syndrome, and these vesicles may be transported by motor proteins, including cytoplasmic dynein 1 and myosin IXa, whose expression is increased in glomeruli in cases of minimal change nephrotic syndrome.
[9/7, 8:31 PM] 2019 KIMS UG:
[9/7, 9:00 PM] 2019 KIMS UG: Sir , what could be the cause of resting coarse tremors in this case sir..
[9/7, 9:03 PM] Rakesh Biswas: Very good question. We had forgotten about that in our pursuance of his CMML. Can you review the literature to see any case reports of cerebral involvement in CMML? That way we can explain all his symptoms with one etiology
[9/7, 9:04 PM] 2019 KIMS UG: Yes sir . I will find out sir
[9/7, 9:14 PM] 2019 KIMS UG: Sir , there was a case report showing uncommon cerebral involvement in CMML sir
[9/7, 9:14 PM] Rakesh Biswas: Please share the link
[9/7, 9:15 PM] 2019 KIMS UG: Cerebral CT showed multiple hemorrhagic nodular lesions
[9/7, 9:15 PM] 2019 KIMS UG: MRI also showed multiple supra-
and infratentorial hemorrhagic lesions of varying age,
in favor of leukemic infltration as well as the beginning
of left temporal engagement
[9/7, 9:15 PM] Rakesh Biswas: Were his cerebral symptoms and signs similar to our patient?
[9/7, 9:22 PM] Rakesh Biswas: "occurrence of severe problems of alertness and aphasia. At this time, clinical examination showed a Glasgow score of 11 (M6V2E3), with bilateral nonreactive myosis and right central facial paralysis. There was no motor or sensory deficit of the limbs within the limits of clinical examination in such a state of consciousness."
[9/28, 12:52 PM] 72F Pt Advocate NLG: Is aristozyme advisble for loss of appetite to mother
[9/28, 2:22 PM] Rakesh Biswas: Too sweet
[9/28, 2:42 PM] 72F Pt Advocate NLG: Kindly tell alternate sir
[9/28, 2:43 PM] 72F Pt Advocate NLG: For loss of appetite
[9/28, 2:46 PM] 72F Pt Advocate NLG: Which can be given sir
[9/28, 2:46 PM] 72F Pt Advocate NLG: Digestin??
[9/28, 2:47 PM] Rakesh Biswas: I think we had a long discussion this earlier?
[9/28, 2:47 PM] 72F Pt Advocate NLG: Yes sir
[9/28, 2:47 PM] 72F Pt Advocate NLG: But as a syrup
[9/28, 2:48 PM] 72F Pt Advocate NLG: What to give for patient relief
[9/28, 2:48 PM] Rakesh Biswas: Find out the cause first
[9/28, 2:49 PM] 72F Pt Advocate NLG: Every thing in front of u sir
[9/28, 2:49 PM] 72F Pt Advocate NLG: Nothing new
[9/28, 2:49 PM] 72F Pt Advocate NLG: As usual
[9/28, 2:50 PM] 72F Pt Advocate NLG: Just feeling little less hunger
[9/28, 2:53 PM] Rakesh Biswas: Since when? If it's not unusual then it must be there for quite some time?
[9/28, 3:10 PM] 72F Pt Advocate NLG: Its intermittently
[9/28, 3:11 PM] Rakesh Biswas: Let's continue this conversation in the PaJR group
[9/28, 3:17 PM] 72F Pt Advocate NLG: Sir jiii ...koi syrup boliye
UROLOGY REFERRAL
NEPHROLOGY REFERRAL
GRBS CHARTING AUG 2022
15/08/22
10pm - 320
16/08/22
12am- 192
8am- 103
1pm- 230
3pm- 208
7pm- 203 given 6 units of INSULIN
17/08/22
12am- 177
8am- 157 given 6units of INSULIN
10am- 189 given 6UNITS OF INSULIN.
2pm- 124 4UHAI
7pm - 267 8U HAI
10pm- 179
18/08
8am - 273 8U HAI
2pm- 248 10U HAI
7pm - 319 12U HAI.
TREATMENT:
1) Normal soft diabetic diet
2) IVF - NS + RL - 75ml/hr
3) inj. HAI according to GRBS
4) inj. OPTINEURON 1amp in 100ml NS
5) inj. ZOFER 4mg/IV/BD
6) inj. LASIX 20mg/IV/BD
7) tab. MET-XL 25mg/PO/OD
GRBS monitoring
PROVISIONAL DIAGNOSIS:
UNCONTROLLED SUGARS SECONDARY TO TYPE 2 DIABETES MELLITUS.
February 7 2023
A 72 Years Old Female Came With Complaints of
Involuntary Movements in Left Upperlimb Since Today Morning
Generalized Body Weakness Since 1 Week
HOPI :
Patient Usually Stays at Her Elder Son & Usually Takes 20Units of INSULIN LISPRO 2 Times in the Morning & Night. The Dose Usually Modified by His Son according her Food Needs.As the Patient Decreased Intake of Food The Insulin Dose Was also Decreased by His Son Gradually Where He Fixed the Dose of Insulin to 6Units since 4 Months. 1 Week Back Patient had a fall from Bed & Was Complaining of Generalized Body Weakness.When His Younger Son who is Dental Surgeon by Occupation Came to See her he Noticed that she had Generalized Weakness & He Personally Started Monitering Her Glucose Levels Since 3 Days & He Noticed she was having abnormally High GRBS Values But Managed to Give Lower Doses of Insulin Because of Fear of Hypoglycemia
Day Before Yesterday Her GRBS 720 - 8 Units
Yesterday - 650 - 10 Units
Today -
Between 9Am to 11Am - 650 .....16Units in The Morning
4PM - 530 ... 6 Units
At Presentation Vitals :
BP - 110/70mmHg
PR - 76/min
Spo2 - 98% at Room Air
GRBS - 315
Management
UKB-Negative sir
Starting on Algorithm 1
Usg abdomen :
B/l grade 1-2 RPD changes with raised echogenecity
GRBS TRENDS - 7/2/2023
Involuntary movements on 8/02/2023
On 09/02/2023
Quasi purposive chorea with minimal ballismus
At 12:30am :
saturations dropped to 60 at room air
bp -170/90 mm of hg
B/l basal crepts present
Pt complained of sob
ECG ON 13/2/23
CXR ON 13/2/23
CXR ON DAY OF ADMISSION -7/2/23
Diagnosis at this visit:
Fever chart
Culture and sensitivity report on 7/2/23
Hyperglycemia with hemiballismus K/C/o type 2 DM with HTN since 20 yrs
K/c/o hypothyroidism since 15 yrs
K/c/o CKD since 2 yrs
Diabetic nephropathy with recurrent UTI with iron deficiency anemia.
Treatment:
1)Inj.LASIX 80MG IV STAT
2)Tab.NICARDIA 10MG PO STAT
For acute pulmonary edema
3)Inj.AUGMENTIN 1.2G IV TID
For Fever Spike & Cough with Expectoration
Cough with sputum on 13/02/23
Study on this patient
By k.santhosh kumar
The Pneumonia Patient Outcome Research (PORT) study conducted more than 2 decades ago reported that Escherichia coli was the fourth most common causative pathogen and the second most common cause of “bacteremic” CAP [6].
There is evidence to suggest that certain virulence factors such as alpha-hemolysin and cytotoxic necrotizing factor type–1 are often associated with bloodstream infection and sepsis due to E. coli [26].Although expression of these virulence factors is more common in uropathogenic E. coli, other nonurosepsis strains are also capable of producing these factors [26].
Although fluoroquinolones are considered antipseudomonal drugs and can be used as part of a broad-spectrum approach to patients at risk for MDROs, our data suggest that ceftriaxone and other higher-generation cephalosporins might be a better choice for empiric treatment of patients at risk for gram-negative infections, especially pa- tients over the age of 80, for whom E. coli was the second most commonly isolated organism
Limitation of the study:-
By excluding patients with diagnosis codes for urinary tract infection and gastrointestinal/intra-abdominal infection, we attempted to identify patients with primary pneumonia with no other explanation for having E. coli in their blood or respira- tory secretions.
In summary, it appears that E. coli is a relatively common cause of severe pneumonia. It is often severe and associated with higher case fatality than pneumococcal pneumonia but similar to other gram-negative pneumonias.
There is evidence to suggest that certain viru- lence factors such as alpha-hemolysin and cytotoxic necrotizing factor type–1 are often associated with bloodstream infection and sepsis due to E. coli [26]. Although expression of these vir- ulence factors is more common in uropathogenic E. coli, other nonurosepsis strains are also capable of producing these factors.
Discharge summary on 16/02/2023
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