Post CABG with stools after every meals (Sorry for a lengthy one)

A 55 years old female housewife presented to OPD Chief Complaints She complaints of weakness, ghabrahat, and increased frequency of stools after every meals, and decreased consistency but not watery, as well as epigastric discomfort/gas problem Her fasting sugars are like 85/90/100 PPBS is 222/232 History History of CABG done in December 2020 and she was on following medications - Tab Telma 40 OD, Tab Aspirin 150 + Clopidogerol 75 HS, Tab Cardivas 12.5 BD, Tab Rosuvas 10 HS, Human Mixtard 30/70 22 units morning and 12 units at night She was also given a brief course of Norflox TZ BD for 5 days in December for her stool issues Vitals Her vitals are - Pulse - 89/min BP - 150/98mmHg RBS - 232 mg/dl Management My concerns for this patient are - 1) I would like to switch her to basal insulin like glargine 10 units at night and Gluconorm Z XR Mex 60/500 in morning in place of Human Mixtard 30/70? Your views 2) In Beta-Blockers, I think Bisoprolol would have been a better choice or Metoprolol too? Bisoprolol > Metoprolol as it offers OD dose advantage, though all are cardioselective? Your views 3) Being on beta blocker Carvedilol 12.5 BD and Telma 40, still her BP is on a higher side, what do u recommend adding to Telmisartan 40, diuretic like Chlorthiadone or Cilnidipine? Your views 4) For her stool issues, I have advised her to take rifaximin 400mg TDS for 7 days, Redotil 100mg BD for 3 days? Your views 5) Regarding anti-platelets, as she is on 150mg aspirin and 75mg Clopidogerol, do u recommend stepping down to dual antiplatelet 75 plus 75 ? Your views

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For control of diabetes. U can go for glargine( Lantus 10- 12 units at night. If her egfr is more than 47/50.u can go with combination of empa+ linagliptin 5+10mg at breakfast. u can add metformin 500.mg bd & glicazide 60 mg bid.pl have a check on bsl level. For blood pressure u can have tab metaprolo 50mg at 8am & telmisartan ch.401+ 12.5 mg at bed time Pl go ahead with rifaxikim 400mg bid for gut disturbances

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Continue rifaximin and folic acid, antimotility drugs. Avoid milk and gluten containing food consumption. See any drug causing symptoms. See for hyperthyroidism.

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Syp Pankreoflat 5ml with meals. Tab Rifagut 550 BD. Tab Pantoprazole 40 Before breakfast. Tab Colirid 40 tds an hour before meals. Tab Bisoprolol + Telmisartan + cilnidipine or Azelnidipine may be better tolerated than chlorthalidone as she is diabetic. Lantus for FBS check + Vildamac/Dapagliflozin/Voglibose/Gliclazide for PPBS check, many options, voglibose may be tried once the gut motility improves. Aspirin 150 may cause some gastritis leading to an exaggerated gastrocolic reflex. May get covered with a PPI as it's less than a year since her CABG.

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NEED'S.. * GLARGINE INSULIN..WITH ..OHA .. * CONTINUE.. RIFAMAX.. * PROBIOTICS.. * METOPROLOL .. TELMISARTAN.. * ENDOCRINOLOGIST OPINION..

Tnx Dr Anil Gangani
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If stool problem which much looks like giardiasis ,stool culture must b done. She may need colonoscopy. Still go deep inquiry about her diat regime. Sugar controll should b as advised above with insulin rather OHA

Start tab Zomatril 30 mg tds Start mixtard Metprolol should be given

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Ibs

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?IBS... ?IBD... SOS colonoscopy...,stool r/m Tab rifagut 400 mg TDs Tab vibact Ds bd Tab mesocol bd Econorm sachet bd Tab normaxin bd*5 days Tab roko 1tab od

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Rx Abhyadi qwath BD. Galo ghan tab 1bd Panchsakar powder HS for 2 to 3 week

Thanks for sharing this case

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