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




Discharge summary










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