25 year old female with SOB
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Name :- K Pranati
Roll no:- 168
Date :- 31/5/23
A 25yr old female came with chief complaints of SOB Grade II - III since 6 months
History of present illness :-
Patient was apparently asymptomatic until 2016 then developed headache, occipital region more, insidious in onset , gradually progressive, prominent with nausea and occasional vomitings, associated with photophobia, phonophobia, no lacrimation , no aggravating factors and relieved with medication.
She also had difficulty in writing ( associated with pain at tips ) and on investigation was found to have low hemoglobin (also had SOB, grade I - III ) jaundice and so, reports - Hb electrophoresis S/o HbE and mild iron deficiency anemia and was treated accordingly
In dec 2022 , patient had right hypochondric region pain , and on USG abdomen --> gallstones present and was operated for it.
Laproscopy cholecystectomy done.
In Feb 2022, patient experienced polyphagia, polydyspsia , nocturia present (3-4 times) and went for dental checkup , and on investigation , was found to have high sugars and was diagnosed to have diabetes, and since then she was on regular medication, presently using Tab.Lipoglobin HP BD and Tab. Vildamne 50 2 tabs (night).
Now SOB grade II - III increased since 6 months
Past history :-
Known case of diabetes mellitus since 1yr on medication Tab.Lipoglobin HP BD and Tab. Vildamne 50 2 tabs (night).
Not a known case of thyroid disorders , HTN , asthma
No chest pain and no orthopnea
Personal history:-
Diet- eggtarian
Appetite - decreased
Sleep - adequate
Bowel and bladder- regular
No allergies
Addiction - teetotaler
Tobacco - snuff
Family history:-
Grand father has diabetes mellitus II
Menstrual history:-
Aom- 13yrs
Menstrual cycle - 7/30-35days
General examination:-
Patient is conscious, coherent, co operative
Pallor present
No icterus, cyanosis, clubbing, lympadenopathy , edema
Vitals:-
Temp:- 98f
Pr- 96bpm
Rr- 16cpm
Bp- 120/80mm hg
Spo2- 96%
Grbs- 309 mg/dl
Systemic examination:-
Cvs- S1S2 heard , no murmurs
Rs- BAE present , NVBS present
P/A - soft , non tender
CNS- NAD
Investigation:-
FBS- 191mg/dl
PLBs:- 241mg/dl
HBA1C : 6.7
HEMOGLOBIN:- 6gm/dl
TLC- 7,800
PLT- 92,000
Provisional diagnosis:-
Metabolic syndrome with diabetes HbE thalassemia
Treatment:-
Tab.Lipoglobin HP BD
Tab. Vildamne 50
Tab. GLIMIPERIDE 0.5mg PO/BD
Tab. Metformin 1000mg PO/OD
Tab.folic acid 5mg PO/BD
Tab. Orofer XT PO/OD
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