Concluded Case

Fast Acting Insulin Aspart. as newer insulin analog .

Mr.X. 30 years ,taking Biphasic insulin two times day.He was brought to me in a semi conscious state .History not effectively able to elicit due to patients condition,and relatives illiterates .capillary blood glucose reveled HI ,it means his blood sugar was more than 600 mg per DL.. fast acting aspart ,insulin was started 10 units SC hourly basis .Pt is not willing for iv fluids management, in spite there is indication of dehydration which is warranted in this case. On third hour his CBG showed 540 mg of blood glucose by the blood glucose monitor.. 3 hours later he gained consciousness ,advised to go home. FAIS,Fast acting Insulin Aspart ,was advised for bolus insulin regime of 16 units for all meals .Plus NPH for BiD of 30/units for basal control. A week back reported to me.The photo was shot and published here.His Weight was 38 kg. He has altered bowel habits ,polys, ,fatigability, aggressive behaviour,poor sleep, mild cough,,Patient feel better. I remodified the insulin regime ,of Aspart of bolus regime ,and and multiple dose of basal regime . Advised rich proteins. Learned personnel can contribute ,and discuss widely..

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Concluded answer

This is the case of T1 DM on insulin therapy. Pt was on irregular insulin therapy. He had discontinued the insulin .He was ,malnourished, muscles are wasted ,emaciated, alcoholic, associated with amebic dysentery. He was put on Co formulation insulin for three meal bolus and basal. age was put on anti amebic .Patient is recovering. He gained weight. Dysentery well managed . But he is again drop out of the treatment . Hope he may win the T1DM if he is motivated.His family is supporting, he is adamant ,because of personality disorders with associated depression due to chronic illness .

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I tend to believe you managment is on point. Worry about sugar control. Especially diet. Also do routine CBC and Lipid profile on the client. You may pick some anomalies. Reassure the client that he can be treated and his sugars controlled. Teach him to trust you. Clarify that the goals of managing diabetes are to: =9Keep your blood glucose levels as near to normal as possible by balancing food intake with medication and activity. =9Maintain your blood cholesterol and triglyceride (lipid) levels as near the normal ranges as possible. =9Control blood pressure. Blood pressure should not go over 140/90. =9Decrease or possibly prevent the development of diabetes-related health problems. If possible printout this key factors to control DM for him: =9Meal Planning and following a balanced meal plan =9Exercising regularly =9Taking medication, if prescribed, and closely following the guidelines on how and when to take it =9Monitoring his blood glucose and blood pressure levels at home =9Keeping your appointments with the nearest healthcare providers and having laboratory tests completed as ordered by your doctor. NB. What you do at home every day affects your blood glucose more than what your doctor can do every few months during your check-up.

In this case there are so many points that we need to address - Age-30, Poor, Illiterate, Overt Hyperglycaemia even with biphasic insulin, Reluctant to Physicians advice, etc At this age we think of T1DM /LADA so investigations to be done accordingly (especially GAD65 Ab, Sr Insulin, C-Peptide) DKA should be treated with IV fluid & FIAsp with repeated monitoring of Ketone bodies & Sr Electrolytes with ABG, which is possible with Hospitalisation only & never on domiciliary treatment. Frequently monitor the BSL level with a good quality glucometer & SMBG should be advised & training of family members is crucial. Gradually shift the regimen to Basal Bolus Regimen of insulin with FIAsp & IGlar / IDeg. Later may be shifted to NovoMix / Ryzodeg. TB to be ruled out in such a cachectic person with DM.

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Reported in hyperglcemia proceeding in coma Timely action could revive and stabilise the situation Yes poor knowledge regarding diabetes the pt doesnot care He needs to be make aware of his disease and its life threatening complications

Thanx dr Dinesh Gupta
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Acanthosis nigricans Type 1 DM or MODY type2 DM Need to look for comorbidities like dyslipedemia, chronic calcific pancreatitis, CAD, PT, TB abdomen ,UTI

SUGGESTIVE OF ACANTHOSIS NIGRICANS AND . D. K. A SECONDARY. TO.... DIABETES. MELLITUS.... NEEDS. FURTHER. EVALUATION

You are treating DKA. So more active treatment is required. Good luck.

Hyperglycemia ,Coma Acanthosis nigricans Sec D.M

was in DKA RX aggressive sugar control

Went in hyperglycaemia & coma

This is the case of T1 DM on insulin therapy. Pt was on irregular insulin therapy. He had discontinued the insulin .He was ,malnourished, muscles are wasted ,emaciated, alcoholic, associated with amebic dysentery. He was put on Co formulation insulin for three meal bolus and basal. age was put on anti amebic .Patient is recovering. He gained weight. Dysentery well managed . But he is again drop out of the treatment . Hope he may win the T1DM if he is motivated.His family is supporting, he is adamant ,because of personality disorders with associated depression due to chronic illness .

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