General medicine

A 49 YEAR OLD P2L2 WITH MULTIPLE COMORBIDITIES 

A.nikhil

Roll No - 09

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT

A 49 year old P2L2 came to the hospital with complaints of 

Hypertension at 160/90 since 20 years for which she was on Telma-H (40/12-5) 

Diabetes since 10 years (at 426 mg/dl) which got diagnosed when she went to a local hospital with c/o tooth ache for which she was started on Sitagliptin and Glimiperide.

Menorrhagia since 5 years for which she went to local hospital but the patient was not compliant to the prescribed medication, after one year in 2017, she underwent an ultrasound I/v/o similar complaints where a small fibroid was diagnosed, for which surgery was not adviced but the patient was again put on medication . Patient was alright for 2 years after which she again complained of menorrhagia on and off for which she was started on tranexamic acid which she used for one year.

Left wrist pain 2 years back for which Orthopedic opinion was adviced

Difficulty in breathing since 2 years , occasional, grade 1, complaints resemble paroxysmal nocturnal dyspnea.

In 2020, she was diagnosed with bulky uterus (size 98x53x47mm) with small myomas (18X16 mm). Thyroid profile was done in 2020 with T3 - 1.51 , T4- 7.98, TSH- 2.32 

C/o right sided supra clavicular swelling 6 months back, which was hard in consistency, not associated with weight loss, fever, decreased appetite.

C/o loss of vision in left eye one month back, upon fundoscopy, retinal hemorrhages were seen in left eye , diagnosed as Non Progressive Diabetic Retinopathy (NPDR) for which Pars plana vitrectomy was done.

ON EXAMINATION -

PATIENT IS CONCIOUS , COHERENT COOPERATIVENo signs of PALLOR, ICTERUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY, EDEMA

VITALS - 

TEMPERATURE - 97' F

PULSE RATE - 90 BPM

BLOOD PRESSURE - 110/70 MM OF HG 

RESPIRATORY RATE - 26

SPO2 - 99 % AT ROOM AIR

SYSTEMIC EXAMINATION - 

CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS 

RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS

CENTRAL NERVOUS SYSTEM : NAD

P/A - SOFT, NON TENDER, NO ORGANOMEGALY.

Investigations:-

ECG was done.

USG abdomen and pelvis, FBS, PLBS, HbA1c, CBP, CUE  , serum creatinine were advised

Gynaecology opinion was adviced.

Treatment:-

Patient is currently on

1) SYSTAFLAM GEL

2) TAB GLIMIPERIDE 2MG 8 AM BEFORE FOOD

3) TAB. TELMA-H (40/12-5) PO/OD 

4) TAB BISOPROLOL 5MG PO/OD 

5) TAB PANTOP + DOMPERIDONE (40/30) PO/OD BBF

6)TAB. GLIMIPERIDE 1MG (8PM) BEFORE FOOD.

7) TAB. METFORMIN 500 MG BD AFTER FOOD

02/02/2022

Ortho referral done for right sided supraclavicular swelling which was diagnosed to be sternoclavicular joint synovitis.

Ophthalmology opinion was taken.

03/02/2022

Gynaecology referral done

Ophthalmology opinion taken and patient is diagnosed to have proliferative diabetic retinopathy in both eyes

7 point profile:- (4/2/22)

8am- 245 mg/dl

1pm - 158 mg/dl

3pm- 276 mg/dl

8pm - 296 mg/dl

10pm- 295 mg/dl

8am - 273 mg/dl(5/2/22)