48F OPD patient with Diabetes Mellitus type II since 10 years and neuropathy since 15 days
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Sanidha Singh
Roll no.- 98
A 48 year old female came to the OPD for regular health check up.
History of Presenting illness -
A 48 years old female came to OP for regular check up and is a K/C/O Diabetes Mellitus since 10 years and also complains of pins and needles sensation in B/L foot since 15 days which is aggravated on walking and relieved on resting.
Past history-
K/C/O Diabetes Mellitus since 10 years and is on Glimi-M1
H/O right leg cellulitis 1 month back.
H/O Hysterectomy 30 years ago.
N/K/C/O HTN, asthma, Tuberculosis, epilepsy, CAD, CVD
Family history- Not significant
Personal history-
Diet- mixed
Appetite- normal
Bowel and bladder movements- normal
Sleep- inadequate
No addictions
Vitals -
Temperature- afebrile
Pulse rate- 86 beats/min
Respiratory rate -18 cycles/min
Blood pressure- 130/80 mmHg
General examination:
Patient’s consent was taken
Patient was examined In a well lit room.
He was conscious, coherent , cooperative
No pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
Pitting type of pedal edema is present.
A 48 year old female came to the OPD for regular health check up.
History of Presenting illness -
A 48 years old female came to OP for regular check up and is a K/C/O Diabetes Mellitus since 10 years and also complains of pins and needles sensation in B/L foot since 15 days which is aggravated on walking and relieved on resting.
Past history-
K/C/O Diabetes Mellitus since 10 years and is on Glimi-M1
H/O right leg cellulitis 1 month back.
H/O Hysterectomy 30 years ago.
N/K/C/O HTN, asthma, Tuberculosis, epilepsy, CAD, CVD
Family history- Not significant
Personal history-
Diet- mixed
Appetite- normal
Bowel and bladder movements- normal
Sleep- inadequate
No addictions
Vitals -
Temperature- afebrile
Pulse rate- 86 beats/min
Respiratory rate -18 cycles/min
Blood pressure- 130/80 mmHg
General examination:
Patient’s consent was taken
Patient was examined In a well lit room.
He was conscious, coherent , cooperative
No pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
Pitting type of pedal edema is present.
Daily activity charting:
14/12/23 to 3/1/24:
Tab. Glimi- M1 PO/OD
1——X——X
14/12/23
28/12/23:
29/12/23:
[04/01/24, 1:54:29 PM] Sanidha: 
[04/01/24, 3:59:53 PM] Patient : This message was deleted by admin Rakesh Biswas Sir .
[04/01/24, 4:09:26 PM] Rakesh Biswas Sir : Creatinine 0.9
Deleting the previous image as patient identifiers are visible
[05/01/24, 10:40:17 AM] Sanidha:
Breakfast
[09/01/24, 8:28:00 AM] Rakesh Biswas Sir : Weekly 10 readings of home BP in 24 hours?
Weekly home Fbs, ppbs after every meal (4 values, one fasting, 3 two hour post meal, assuming three meals)
[09/01/24, 9:31:59 AM] Sanidha: Ok sir
[09/01/24, 9:55:12 AM] Sanidha: Patient complaining of pins and needle sensations in her legs
[09/01/24, 11:21:56 AM] Sanidha: image omitted
[09/01/24, 11:23:11 AM] Rakesh Biswas Sir : 10 readings expected today spaced out at random intervals over 24 hours
[09/01/24, 11:25:42 AM] Sanidha: Ok sir
[09/01/24, 11:37:50 AM] Sanidha:
[09/01/24, 11:38:19 AM] Sanidha:
Post breakfast GRBS
[09/01/24, 11:44:07 AM] Rakesh Biswas Sir : What tablet did she take before this?!! 🧐😳
[09/01/24, 11:48:00 AM] Sanidha: Sir she took Tab Glimi 1.5 mg + Tab Metformin 500 mg before breakfast
[09/01/24, 11:53:30 AM] Rakesh Biswas Sir : She needs to increase the dose of Glimeperide to 2 mg asap from tomorrow
What about her fasting today?
[09/01/24, 12:00:30 PM] Sanidha: Ok sir.
She’ll get it done tomorrow morning.
[09/01/24, 12:10:28 PM] Rakesh Biswas Sir : Ask her to report all her two hour post meal sugars today
[09/01/24, 12:13:40 PM] Sanidha: Ok sir
[09/01/24, 12:22:33 PM] Sanidha: 
[09/01/24, 12:58:08 PM] Sanidha: After 1 hour 
Dinner:
[10/01/24, 11:33:38 AM] Sanidha:
[10/01/24, 11:35:37 AM] Sanidha: 
[10/01/24, 11:51:42 AM] Sanidha:
FASTING GRBS:
[10/01/24, 2:25:56 PM] Rakesh Biswas Sir : Our hospital lab?
[10/01/24, 2:29:08 PM] Sanidha: Outside lab sir
[10/01/24, 2:31:05 PM] Rakesh Biswas Sir : Was the method used hplc or latex?
What method does our lab use?
[10/01/24, 2:35:40 PM] Sanidha: Sir our lab uses latex method
[10/01/24, 2:37:42 PM] Rakesh Biswas Sir : And their lab?
[10/01/24, 2:38:44 PM] Rakesh Biswas Sir : What are the comparative effectiveness results reported in terms of sensitivity specificity of both?
Lunch
[10/01/24, 4:25:16 PM] Sanidha:
Post lunch GRBS
[10/01/24, 4:33:34 PM] Rakesh Biswas Sir : The tablets in the image don't reduce pins and needle sensations
She needs to be put on Tablet Pregabalin 75 mg one hour before dinner regularly for that
[10/01/24, 4:54:46 PM] Sanidha:
Tab. Glimi 2.5 mg po/od before breakfast
Tab. Glimi 0.5mg po/od after dinner
Tab. Pregabalin 75mg po/od 1hr before dinner
Tab. Metformin 500mg po/bd after breakfast and after dinner
[10/01/24, 4:58:44 PM] Rakesh Biswas Sir : Also after lunch
[10/01/24, 5:00:24 PM] Sanidha: Ok sir
[10/01/24, 8:13:06 PM] Sanidha: 
[10/01/24, 8:13:06 PM] Sanidha: Pre dinner GRBS
[10/01/24, 8:14:02 PM] Rakesh Biswas Sir : Let her take Glimeperide 0.5mg
[10/01/24, 8:21:07 PM] Sanidha: Ok sir
[10/01/24, 8:52:14 PM] Sanidha:
Dinner
[11/01/24, 8:44:13 AM] Sanidha:
Fasting GRBS
Breakfast:
Post breakfast GRBS:
Pre lunch GRBS:
Lunch:
Dinner:
[12/01/24, 7:48:36 AM] Sanidha:
Fasting GRBS:
Pre lunch GRBS:
Post lunch GRBS:
Breakfast:
Post breakfast GRBS:
Lunch:
Pre dinner GRBS:
Dinner:
Post dinner GRBS:
[13/01/24, 9:19:34 AM] Sanidha:
Fasting GRBS:
Breakfast:
Post breakfast GRBS:
Lunch:
[14/01/24, 8:55:43 PM] Sanidha:
Tab. Glimi 3mg po/od before breakfast
Tab. Glimi 1.5mg po/od after dinner
Tab. Pregabalin 75mg po/od 1hr before dinner
Tab. Metformin 500mg po/bd after breakfast, after lunch and after dinner
Pre dinner GRBS:
Dinner:
Post dinner GRBS:
[15/01/24, 12:08:51 AM] Sanidha: 
Post lunch GRBS:
Lunch:
[16/01/24, 11:51:01 AM] Sanidha: 
Fasting GRBS:
Breakfast:
Pre dinner GRBS:
[17/01/24, 1:11:01 PM] Sanidha: 
Pre lunch GRBS:
Lunch:
Post lunch GRBS:
[18/01/24, 7:51:19 PM] Rakesh Biswas Sir : Try to explain to her that the two hour post meal can tell us best about the effect of the drug rather than just a pre meal sugar as the timing of the pre meal is likely to change everytime with whenever the patient wants to have the meal whereas two hour post meal will always be two hour post meal
[18/01/24, 8:06:11 PM] Sanidha: Ok Sir
[18/01/24, 8:06:21 PM] Sanidha:
Tab. Glimi 3.5 mg po/od before breakfast
Tab. Glimi 2.5mg po/od after dinner
Tab. Pregabalin 75mg po/od 1hr before dinner
Tab. Metformin 500mg po/bd after breakfast, after lunch and after dinner
Pre dinner GRBS:
Dinner:
Post dinner GRBS:
[19/01/24, 8:26:39 AM] Sanidha:
Tab. Glimi 3.5 mg po/od before breakfast
Tab. Glimi 2.5mg po/od after dinner
Tab. Pregabalin 75mg po/od 1hr before dinner
Tab. Metformin 500mg po/bd after breakfast, after lunch and after dinner
Fasting GRBS:
Breakfast:
Pre lunch GRBS:
Lunch:
Post lunch GRBS:
Pre dinner GRBS:
Dinner:
[20/01/24, 8:51:09 AM] Sanidha:
Tab. Glimi 3.5 mg po/od before breakfast
Tab. Glimi 2.5mg po/od after dinner
Tab. Pregabalin 75mg po/od 1hr before dinner
Tab. Metformin 500mg po/bd after breakfast, after lunch and after dinner
Fasting GRBS:
Breakfast:
Post breakfast GRBS:
Pre lunch GRBS :
Lunch:
Post lunch GRBS:
Dinner:
Post Dinner GRBS:
[20/01/24, 11:43:40 PM] Rakesh Biswas Sir : 👍
[21/01/24, 1:10:04 PM] Sanidha: 
Fasting GRBS:
Breakfast:
Lunch:
Post lunch GRBS:
Dinner:
[22/01/24, 9:21:17 AM] Sanidha:
Tab. Glimi 4 mg po/od before breakfast
Tab. Glimi 3 mg po/od after dinner
Tab. Pregabalin 75mg po/od 1hr before dinner
Tab. Metformin 500mg po/bd after breakfast, after lunch and after dinner
Fasting GRBS:
Breakfast:
Lunch:
Post lunch GRBS:
[23/01/24, 11:11:26 AM] Sanidha:
Tab. Glimi 4 mg po/od before breakfast
Tab. Glimi 3 mg po/od after dinner
Tab. Pregabalin 75mg po/od 1hr before dinner
Tab. Metformin 500mg po/bd after breakfast, after lunch and after dinner
Fasting GRBS:
Breakfast:
[24/01/24, 12:39:36 PM] Sanidha:
Tab. Glimi 4 mg po/od before breakfast
Tab. Glimi 3 mg po/od before dinner
Tab. Pregabalin 75mg po/od 1hr before dinner
Tab. Metformin 500mg po/bd after breakfast, after lunch and after dinner
Breakfast:
Lunch:
Post lunch GRBS:
25/01/24:
Tab. Glimi 4 mg po/od before breakfast
Tab. Glimi 3 mg po/od before dinner
Tab. Pregabalin 75mg po/od 1hr before dinner
Tab. Metformin 500mg po/bd after breakfast, after lunch and after dinner
Fasting GRBS:
Breakfast:
Lunch:
Post lunch GRBS:
Dinner :
Post dinner GRBS:
[26/01/24, 3:01:31 AM] Sanidha:
Tab. Glimi 4 mg po/od before breakfast
Tab. Glimi 3 mg po/od before dinner
Tab. Pregabalin 75mg po/od 1hr before dinner
Tab. Metformin 500mg po/bd after breakfast, after lunch and after dinner
Fasting GRBS:
Breakfast:
Lunch:
Post lunch GRBS:
Dinner:
Post dinner GRBS:
[27/01/24, 12:08:26 AM] Sanidha: 
Fasting GRBS:
Breakfast:
Dinner:
Post dinner GRBS:
[28/01/24, 11:23:33 AM] Sanidha:
Tab. Glimi 4 mg po/od before breakfast
Tab. Glimi 3.5 mg po/od before dinner
Tab. Metformin 500mg po/bd after breakfast, after lunch and after dinner
Fasting GRBS:
Lunch:
Post lunch GRBS:
Dinner:
Post dinner GRBS:
[29/01/24, 2:51:48 AM] Sanidha:
Tab. Glimi 4 mg po/od before breakfast
Tab. Glimi 3.5 mg po/od before dinner
Tab. Metformin 500mg po/bd after breakfast, after lunch and after dinner
[29/01/24, 8:26:43 AM] Rakesh Biswas Sir : How did it come down to ideal levels of control all of a sudden with current maximal doses of Glimeperide 4 mg before breakfast and 3.5mg before dinner?
How much metformin is she taking and when?
[29/01/24, 1:07:21 PM] Sanidha: Sir might be she is restricting her diet may be that’s why her post meal GRBS is coming down.
[29/01/24, 1:10:12 PM] Sanidha: Sir also here she only had a glass of milk in the dinner hence the post meal GRBS value 193 and also the next day fasting GRBS was 177
Fasting GRBS:
Breakfast:
Lunch:
Post lunch GRBS:
Dinner:
Post dinner GRBS:
Learning point:
P(Population):
A total of 154 samples from patients with diabetes type 2 with HbA1c concentration covering the whole clinical range were analyzed by four commercially methods
I (Intervention):
A total of 154 samples from diabetic patients with HbA1c concentration covering the whole clinical range, were obtained through venipuncture into sterile tubes containing the EDTA K2 and tested with 4 assays ( 1.Ion exchange HPLC method , 2.Immunoassay , 3.Boronate affinity chromatography , 4.Ion exchange chromatography )within 2 days
C ( Comparison):
HbA1c measurement was performed concurrently in all cases by four commercially available assays:
1.D-10 Hb A1c (Bio-Rad Laboratories, Hercules, CA), Ion exchange HPLC method
2.Cobas Integra 400 (Roche Diagnostics, Mannheim, Germany), Immunoassay
3.NycoCard Reader II, (Axis-Shield, Oslo, Norway), Boronate affinity chromatography
4.DS5, (Drew Scientific, Le Rheu, France), Ion exchange chromatography
O ( Outcome) :
Total precision (in term of CV%) were less than 1.6 %, 1.0 %, 3.1 % and 3.3 % for D10, cobas integra 400, Nycocard reader II and DS5 respectively. The mean ± SD value of HbA1c was significantly higher when measured by D10 (7.59 % ± 1.43 %) than when estimated with the Nycocard reader II (6.87 % ± 1.17 %, r: 0.937, P < 0.05) and DS5 (6.69 ± 1.47 %, r: 0945, P < 0.05) and almost same compared to cobas integra 400 (7.66 ± 1.45, r: 0.944, P: 0.06).
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