25 year old female with Diabetes mellitus
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
A 25 year old female student , resident of coochbehar (West Bengal) came to GM OPD with chief complaints:-
✓ swelling in right and left lower limbs since 2017
✓ Headache since 2017
History of presenting Illness:-
Patient was apparently asymptomatic 6 years ago.On one fine day after she woke up , she noticed swellings in the both limbs below knee level.It was insidious in onset, progressive,has no aggravating factors, relieved on massage. It is not associated with pain.
H/o headache since 2017 in the back of head (occipital region) which is intermittent in nature, associated with nausea,photophobia and phonophobia.When she was asleep and suddenly wakes up then she will experience severe headache but then temporarily relieves on its own.
Later ,she consulted a general physician after thorough examination she was diagnosed with migraine.Later ,she went through few routine blood investigations and was diagnosed with Anemia . When she was found anemic , they adviced her to get Hb electrophoresis , result shown that her Hb E levels are high .
In April 2023
Serum iron : 47.62 g/dL
TIBC : 401.13 g/dL
She was prescribed with GRENIL for headache and Folic Acid tablets for anemia .
She complained of pain while writing since 2016 which used to start after writing a paragraph (20-30 lines) relieved on rest. It is non radiating, intermittent in nature .(Type - cramp like pain?)
Past history:-
In the year of 2022, around june- July She had severe tooth pain ,consulted a dentist , after routine investigations she got to know about high blood sugar levels . So , dentist treated her conservatively until blood sugars are normal and treated her accordingly.(RCT)
In the month of Aug , She had pain in left upper quadrant, consulted a physician , after a thorough investigations, she was diagnosed with gall bladder stones on USG . She got treated conservatively, on pioglitazone for diabetes .Later she underwent laparoscopic cholecystectomy in December 2022.
Daily routine:-
Previously patient wakes up around 7-8 am in the morning, goes for walking occasionally for an hour , returns home drinks tea and eat biscuit s and eats breakfast after an hour .
Present - She couldn't go for walk , because she became weak ( because of anemia??) .At a times she also feels dizzy while walking.
After brisk walking for a while, she will have difficult in breathing, palpitations and sweating which relieved on taking rest. (6 months)
Previously,at 11 Am goes to college and returns home by 3 for lunch ,takes rest for sometime while watching or TV or phone .Around 6 pm , she will snacks and do her work . Around she will have her dinner have a chat with family, goes to sleep while using her phone by 12 pm .
Present - Since 3 months she gets tired easily unable to do her work ,sleeps a lot than her usual time .
Personal History:-
Diet - Mixed
Sleep - Adequate
Appetite - normal
B&B - regular
No addictions .
Menstrual history:-
Menarche - 13 years
5/30 - 3 pads / day
Family history:-
Her paternal grand father have diabetes mellitus
Treatment History:-
Tab.Lipoglobin HP
Tab.DIAPRIDE M1 Forte
Tab.VALDIMAC 50
Tab.FOLIC ACID 5 mg
Conservative treatment for Gall stones -
ZERODOL SP
General Examination:
Patient was conscious coherent co-operative
Pallor - present
No icterus, cyanosis, clubbing, lymphadenopathy, edema.
FBS - 191 mg/dl
PLBS - 241 mg/dl
Systemic examination:
CVS: S1 S2 heard , no murmurs
RS: BAE present ,NVBS heard
CNS: No focal neurological deficits found
P/A: Non tender,no organomegaly
PROVISIONAL DIAGNOSIS :-
Metabolic syndrome with Diabetes and HbE thalassemia.
Prev USG report:-
Investigations
HbA1c - 6.7%
Complete Blood picture -
On 4/6/2023
Serum ferritin - 4.3 ng/mL
Discharge Summary
25 year old female resident of coochbehar, West Bengal came with chief complaints of swelling in both lower limbs, headache since 2017( ass with nausea and dizziness) difficulty in breathing (6 months) . Patient is severe anemic since 2017 , diagnosed with diabetes mellitus 1 year ago ,had laparoscopic cholecystectomy (6months ago) .
FBS - 191 mg/dl
PLBS - 241 mg/dl
HbA1c - 6.7%
Hemoglobin - 6 %
MCV,MCH,MCHC - decreased
Serum ferritin - 4.3 ng/mL
Treatment advised :-
Tab . Glimipride 1.5mg before breakfast
Tab . metformin 1000mg after breakfast
Tab . Glimipride O.5mg before food @8pm
Tab . OROFER XT PO/OD
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