Inform her local govt PHC (free) to do the following for her:
1) Get the report of urine ketone and serum urea creatinine
2) If the above is normal we can start her on Tablet Daonil (Glibenclamide) 5 mg once in the morning before breakfast and half before dinner (cheap at 50 paise per tablet but the problem is the drug companies have kicked this effective drug out of the market). ��
If we don't get Glibenclamide we can still go for Glimeperide 1 mg before breakfast and 1 mg before dinner to begin with and repeat the FBS and ppbs weekly and titrate the dose accordingly.
Bangla translated for the same advice above: (In winter 2017)
রোগীকে নিকটস্থ সরকারি চিকিৎসা কেন্দ্রে (যেখানে ফ্রি তে তিনি সেবা পাবেন) গিয়ে যা করতে হবে তা হলোঃ ১। উনার তিনটি পরীক্ষা করাতে হবে *urine ketone* *serum urea* এবং serum creatinine*। রিপোর্ট হয়ে যাওয়ার পর যদি সবগুলোর ফলাফল নরমাল বা স্বাভাবিক আসে তাহলে নিচের ওষুধ গুলো উনাকে নিতে হবেঃ
২। রিপোর্ট স্বাভাবিক আসলে তিনি প্রতিদিন Tablet Daonil (Glibenclamide) 5 mg সকালে খাবার আগে একটি এবং রাতে খাবার আগে অর্ধেক খাবে । (এই ট্যাবলেটের মুল্য মাত্র ৫০ পয়সা প্রতি ট্যাবলেট) কিন্তু এটি যদি পাওয়া না যায় তবে Glimeperide 1 mg সকালে একটা খাবার আগে এবং রাতে একটা খাবাড় আগে নিবেন। ৩। প্রতি সপ্তাহে উনার এই দুটি টেস্ট Fasting blood sugar (FBS) এবং PPBS করিয়ে নিতে হবে এবং সুগার কেমন থাকছে তার উপর ভিত্তি করে ডোজ ঠিক করে নিতে হবে। প্লিজ আপনি যদি বুঝতে না পারেন কোথাও আমাকে জিজ্ঞেস করেন আবার অথবা আমাকে ফোন দিবেন।
তাহলে সারমর্ম হলঃ প্রথমে পরীক্ষা করতে হবে *(urine ketone, serum urea, serum creatinine)* তিনটি, যদি স্বাভাবিক থাকে ওষুধটি (*Tablet Daonil (Glibenclamide) 5 mg* অথবা *Glimeperide 1 mg*) চালু করবেন এবং প্রতি সপ্তাহে পরীক্ষা দুটি * (Fasting blood sugar, PPBS)* করিয়ে ডোজ ঠিক করে নিতে হবে।
This is a case of a 48-year-old female with a history of hypothyrodisim for 4 years and since then taking levothyroxin 50mcg is complaining of dizziness and excessve sweating in the head. Occassionally she feels numbness in her hands and often she needs to use one hand to pull another hand. She is also complaining that she gets fatigue and falls down after a dizzy spells. She does have symptoms of hyperacidity, anorexia, polyuria, polydipsia, and (hotath koray daklay chomkay uthay). She had not problem in the childhood and at the age of 10 she had a chicken pox and had mumps in the throat (???) at the age of 11. Her period was started at 17 years of age and since then she used to have itchy sensation 15 days prior to the periods and used to be resolved after 5 days following periods. She got married at 18 years old and took birth to her first child after 1 year followed by second child after 2 years, followed by third child after 3 years (all were normal delivery). She was menopausal at the age 45. She is asking to sort out *polyuria, thyroid issue, and lowering blood sugar*
Her height is 5 7'', weight 62 Kg, waist circumferance 94 cm, chest circumference. Her Blood pressure is 140/90 mm Hg, pulse is 70/min. Lab reports show: HbA1C 12.3%, RBS 372 mg/dl, and PPBS 426 ,g/dl,TSH level 3.54 uIU/ml and +++ glucosuria.
Excellent Vivek. Since when is she Diabetic? Pritam do you now realize the cause of her weakness? Vivek what is the mechanism of increased weakness with increased blood sugars?
Vivek: Her cells are starving for energy where "keys" (insulin) are not unlocking the gates in the cells for the entry of glucose for ATP production.
Dr. Rakesh: So that would be our first question to Prodip babu?
Vivek: Her sugar very uncontrolled and most of her symptoms can be due to her high blood sugar and/or due to the complication of it such as neuropathy (dizzy spells can also be a part of autonomic neuropathy along with those numbness sensation?).
For patients presenting with severe hyperglycemia (fasting plasma glucose >250 mg/dL [13.9 mmol/L], random glucose consistently >300 mg/dL [16.7 mmol/L], A1C >9.5 [80.3 mmol/mol])but without ketonuria or spontaneous weight loss, *insulin remains the preferred initial therapy.*
However, *for patients who are insulin averse, initial therapy with high-dose sulfonylurea is an alternative option,* particularly for patients who have been quenching their thirst with sugar-sweetened beverages, in whom elimination of carbohydrates will cause a reduction in glucose within a couple of days. High-dose sulfonylureas are effective in rapidly reducing hyperglycemia in patients with severe hyperglycemia [36].
While starting treatment for this patient along with intense lifestyle modification and exercise, do we also need to evaluate for diabetic micro or macro complications that may result from the severe hyperglycemia? Given that the patient is very poor.
Dakthar babu Net Ar problam Ar Jono agar guli Tek
উত্তরমুছুনHoay Nai Aktuk dakhay Akta Reply Dela kub Valo hobay.
Patient bortomanay ke korbay Janaben
উত্তরমুছুনPatient bortomanay ke korbay Janaben
উত্তরমুছুনThe first advice for Prodip babu's patient
উত্তরমুছুনInform her local govt PHC (free) to do the following for her:
1) Get the report of urine ketone and serum urea creatinine
2) If the above is normal we can start her on Tablet Daonil (Glibenclamide) 5 mg once in the morning before breakfast and half before dinner (cheap at 50 paise per tablet but the problem is the drug companies have kicked this effective drug out of the market). ��
If we don't get Glibenclamide we can still go for Glimeperide 1 mg before breakfast and 1 mg before dinner to begin with and repeat the FBS and ppbs weekly and titrate the dose accordingly.
উত্তরমুছুনBangla translated for the same advice above: (In winter 2017)
রোগীকে নিকটস্থ সরকারি চিকিৎসা কেন্দ্রে (যেখানে ফ্রি তে তিনি সেবা পাবেন) গিয়ে যা করতে হবে তা হলোঃ
১। উনার তিনটি পরীক্ষা করাতে হবে *urine ketone* *serum urea* এবং serum creatinine*। রিপোর্ট হয়ে যাওয়ার পর যদি সবগুলোর ফলাফল নরমাল বা স্বাভাবিক আসে তাহলে নিচের ওষুধ গুলো উনাকে নিতে হবেঃ
২। রিপোর্ট স্বাভাবিক আসলে তিনি প্রতিদিন Tablet Daonil (Glibenclamide) 5 mg সকালে খাবার আগে একটি এবং রাতে খাবার আগে অর্ধেক খাবে । (এই ট্যাবলেটের মুল্য মাত্র ৫০ পয়সা প্রতি ট্যাবলেট) কিন্তু এটি যদি পাওয়া না যায় তবে Glimeperide 1 mg সকালে একটা খাবার আগে এবং রাতে একটা খাবাড় আগে নিবেন।
৩। প্রতি সপ্তাহে উনার এই দুটি টেস্ট Fasting blood sugar (FBS) এবং PPBS করিয়ে নিতে হবে এবং সুগার কেমন থাকছে তার উপর ভিত্তি করে ডোজ ঠিক করে নিতে হবে। প্লিজ আপনি যদি বুঝতে না পারেন কোথাও আমাকে জিজ্ঞেস করেন আবার অথবা আমাকে ফোন দিবেন।
তাহলে সারমর্ম হলঃ প্রথমে পরীক্ষা করতে হবে *(urine ketone, serum urea, serum creatinine)* তিনটি, যদি স্বাভাবিক থাকে ওষুধটি (*Tablet Daonil (Glibenclamide) 5 mg* অথবা *Glimeperide 1 mg*) চালু করবেন এবং প্রতি সপ্তাহে পরীক্ষা দুটি * (Fasting blood sugar, PPBS)* করিয়ে ডোজ ঠিক করে নিতে হবে।
This is a case of a 48-year-old female with a history of hypothyrodisim for 4 years and since then taking levothyroxin 50mcg is complaining of dizziness and excessve sweating in the head. Occassionally she feels numbness in her hands and often she needs to use one hand to pull another hand. She is also complaining that she gets fatigue and falls down after a dizzy spells. She does have symptoms of hyperacidity, anorexia, polyuria, polydipsia, and (hotath koray daklay chomkay uthay). She had not problem in the childhood and at the age of 10 she had a chicken pox and had mumps in the throat (???) at the age of 11. Her period was started at 17 years of age and since then she used to have itchy sensation 15 days prior to the periods and used to be resolved after 5 days following periods. She got married at 18 years old and took birth to her first child after 1 year followed by second child after 2 years, followed by third child after 3 years (all were normal delivery). She was menopausal at the age 45. She is asking to sort out *polyuria, thyroid issue, and lowering blood sugar*
উত্তরমুছুনHer height is 5 7'', weight 62 Kg, waist circumferance 94 cm, chest circumference. Her Blood pressure is 140/90 mm Hg, pulse is 70/min. Lab reports show: HbA1C 12.3%, RBS 372 mg/dl, and PPBS 426 ,g/dl,TSH level 3.54 uIU/ml and +++ glucosuria.
Excellent Vivek. Since when is she Diabetic? Pritam do you now realize the cause of her weakness? Vivek what is the mechanism of increased weakness with increased blood sugars?
Vivek: Her cells are starving for energy where "keys" (insulin) are not unlocking the gates in the cells for the entry of glucose for ATP production.
Dr. Rakesh: So that would be our first question to Prodip babu?
Vivek: Her sugar very uncontrolled and most of her symptoms can be due to her high blood sugar and/or due to the complication of it such as neuropathy (dizzy spells can also be a part of autonomic neuropathy along with those numbness sensation?).
For patients presenting with severe hyperglycemia (fasting plasma glucose >250 mg/dL [13.9 mmol/L], random glucose consistently >300 mg/dL [16.7 mmol/L], A1C >9.5 [80.3 mmol/mol])but without ketonuria or spontaneous weight loss, *insulin remains the preferred initial therapy.*
However, *for patients who are insulin averse, initial therapy with high-dose sulfonylurea is an alternative option,* particularly for patients who have been quenching their thirst with sugar-sweetened beverages, in whom elimination of carbohydrates will cause a reduction in glucose within a couple of days. High-dose sulfonylureas are effective in rapidly reducing hyperglycemia in patients with severe hyperglycemia [36].
While starting treatment for this patient along with intense lifestyle modification and exercise, do we also need to evaluate for diabetic micro or macro complications that may result from the severe hyperglycemia? Given that the patient is very poor.
However, we dont know if ketonuria is present.