Concluded Case

A 45 yr female pt present with c/o uncontrol dm since 1 month rt hypochondriac region back headache gen weakness recently rbs 600mg/dl bp 160/90 mmHg k/C/O type 2 dm since 15 yrs Htn since 7 yrs ckd since 1 yrs diabetic retinopathy since 2 yrs please suggestions best opinion & Rx

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What is the chief complaint here?? If it’s right hypochondriac abdominal pain ,, find out whether gall stones?? Acute cholelithiasis?? Uncontorlled diabetes with eGFR < 45,, Glimeperide is not safe,, switch to intensive insulin therapy as Gliptins and Glifozins have no proven renal Saftey profile.. First check urine and blood ketones and frequent monitoring of blood glucose is absolutely essential at least 4 times a day... start Glargine+ Aspart/Regular insulin at 1u/Kg body weight and adjust the dose of insulin further based on FBS&PPBS.... Target FBS<120, HBA1C <7.5 in 3 months... Cilindipine max effective dose is 20mg OD but the patient is now taking 30mg that too in split doses.. change to cilacar 20 mg at night plus nebistar 5mg bd(if HTN uncontrolled try Arkamin 0.1mg Tid and gradually increase the dose of arkamin up to 0.6mg per da y Continue anti lipid and anti platelet medication (Avoid Asprin as patient is stage 3 CKD,,better switch to Atorvastatin) First rule out DKA and gall stones, then control HBA1C only then think about Retinopathy unless the patient is having acute loss of vison/painful eye/severe loss of visual acuity Refer to nephrologist for management decision anouut CKD

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UNCONTROLLED D M = RX INJ SHORT ACTING INSULIN ( PT MAY BE HAVING DIABETIC KETOACIDOSIS ) BY TRIAL & ERROR METHOD 16 UNITS 3 - 4 TIMES 1/ 2 HR BEFORE FOOD GET URINE = KETONE BODIES C & S ----------------------------------- RT HYPOCHINDROPIC PAIN AND BACKPAIN ?RX USG = FATTY LIVER / CHOLELITHIASIS --------------------------------------------- FOR HTN = NO TO ACE I ARB AS HE HAS CKD A CCB CILNIDIPINE MAY BE CHOSEN -------------------------------------------- WEAKNESS = DUE TO UNCONTROLLED D M ----------------------------------- HEADACHE = HTN INFECTION / FEVER ( UTI) KETOACIDOSIS ------------------------------------------------ DIABETIC RETINOPATHY CONTROL DM OPHTHALMOLOGICAL CONSULTATION ---------------------------------------------- CKD = CONTROL DM AVOID ARB ACE FOR HTN PROTEIN RESTN TO 40 GM BLOOD Ca ++ PO 3/4 PARA THORMONE VIT D CTEATININE GFR NEPHROLOGIST CONSULTATION Rx VIT D & Ca SUPPLEMENT

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Uncontrolled diabetes Fbs is 176 Hba1c 10% Hypertensive Ckd Dieabetic retinopathy with cataract Needs further workout Ecg 2decho sr creatinine and bul Urgent control of bsl Needs to shift on basal bolus insulin After control of sugar pt need to be operated for cataract if opthamologist opinion is so. Retinopathy may be corrected by laser Since multiple comorbidies hence high risk pt

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IT'S A..CASE OF.. UNCONTROLLED DM..& ..HT..WITH.. RETINOPATHY.. * NEED'S STRICT GLYCEMIC CONTROL WITH ANTIDIABETIC MANAGEMENT WITH EXPERTS OPINION.. * NEED'S CLINICOPATHOLOGICAL EVALUATION TO CONCLUDE DIAGNOSIS AND TREATMENT.. ECG..2DECHO STUDY.. KFT.. OPHTHALMIC EXAMINATION..

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First of all random blood sugar is very high consult endocrinologist for control of blood sugar For pain you need to consult gastroenterologist Once the things are resolved fundus examination and possible treatment can be decided

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,FROM THE.HISTORY.AND FINDING S THIS PT HAS LONG STANDING UNVONTROLLED D M HYPERTENSION WITH C K D SO HE IS IN GROUP OF MULTIORGAN DISORDER NEEDS YO VONTROLL HIS D M PERIODIC RETINAL.EXAMNINATION TO LOOK FOT RETINOPATHY

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As per OPHTHALMOLOGY diabetic retinopathy is not a simple diagnosis it has definitive stages like NPDR,PDR. In NPDR mild.moderate,severe and very severe NPDR. it gives the ophthalmological status becoz each stage has its own way of progression

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What is the chief complaint here?? If it’s right hypochondriac abdominal pain ,, find out whether gall stones?? Acute cholelithiasis?? Uncontorlled diabetes with eGFR < 45,, Glimeperide is not safe,, switch to intensive insulin therapy as Gliptins and Glifozins have no proven renal Saftey profile.. First check urine and blood ketones and frequent monitoring of blood glucose is absolutely essential at least 4 times a day... start Glargine+ Aspart/Regular insulin at 1u/Kg body weight and adjust the dose of insulin further based on FBS&PPBS.... Target FBS<120, HBA1C <7.5 in 3 months... Cilindipine max effective dose is 20mg OD but the patient is now taking 30mg that too in split doses.. change to cilacar 20 mg at night plus nebistar 5mg bd(if HTN uncontrolled try Arkamin 0.1mg Tid and gradually increase the dose of arkamin up to 0.6mg per da y Continue anti lipid and anti platelet medication (Avoid Asprin as patient is stage 3 CKD,,better switch to Atorvastatin) First rule out DKA and gall stones, then control HBA1C only then think about Retinopathy unless the patient is having acute loss of vison/painful eye/severe loss of visual acuity Refer to nephrologist for management decision anouut CKD

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1

Diagnosis : uncontrol DM with retinopathy and nephropath With uncontroll HTN , CKD Prompt control DM

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Uncontrolled Diabetes Mange with insulin & ringer soln Mange diabetic ketoacidosis

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renal creatinine general management in high levels of serum creatinine look for corresponding rise in blood urea also and then decide the treatment. such cases are usually hypertensive anaemic or having congenital shrunken kidney even. the treatment part in all such cases is to control hypertension avoid heavy metals use punarnava kshar mooli kshar yav kshar sat giloya punarnava mandur gokshur guggul and there is one sharbat bazoori . if you patient is non diabetic use this sharbat Headache prawal pishti 10 gm, + godanti bhasma 10 gm+ mukta pishti 2 gm + swarna makshik bhasma 10 gm mixed and divided in 60 doses than 1 dose tice daily\ sarstwarishta 20 ml twice daily with water

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