Thursday, December 23, 2021

CASE OF 44 YEAR OLD FEMALE with dm,htn and hypothyroidism

"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 patient's clinical problems with collective current best evidence based inputs.This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment"

A CASE OF 44 YEAR OLD FEMALE PATIENT WITH HYPOTHYROIDISM, HYPERTENSION, DIABETES.


A 44 year old female came to gm opd for regular check up.
K/c/o dm,htn and hypothyroidism 

History of presenting illness:

Patient was apparently normal before 2004 and then she developed irregular menses for which she went to a local hospital where investigations were sent and treatment was done. The USG reports showed normal ovaries and uterus but presence of gall badder stones (asymptomatic) for which she was operated the same year.
After 2 years she went for a regular checkup and investigations showed e/o hypothyroidism and she's on medication (thyroxine 125mg) Since then.
Next year she was diagnosed as hypertensive (14 years back).
Then after 5 years she went to the hospital as she was feeling very tired and they took her samples and diagnosed her as diabetic 
She is on medication for diabetes and hypertension.

She also c/o of back pain since 12 years I.e; since the birth of the second child (c section I/v/o pre-eclampsia).

In 2019 she went to the hospital again for regular check up and was said to have liver problem
She is also having talengectasia on both legs in the popliteal fossa since 1 year.

Past history:
She is a k/c/o dm,htn, hypothyroidism 

Personal history:
Sleep: disturbed from all the health issue stresses.
Diet: mixed
Appetite: normal
Addictions: none

OBS history:
ML: 23 years
1 st delivery: FTNVD
2 nd delivery: C section i/v/o HTN.
Tubectomised 12 years back.

Family history:
Mother is a k/c/o DM, HTN, arthritis.
And father, k/c/o DM, HTN.

General examination:

Patient consious, coherent, cooperative.
No pallor, icterus, clubbing, lymphadenopathy, edema

Vitals: 
Temp: afebrile
Pr: 94 bpm
Rr: 18 cpm
Bp: 120/60
Spo2: 99% at RA 

Systematic examination:
CVS: S1 and S2 heard
RS: B/L crepts present, IAA
P/A: soft , non tender.
CNS: NAD.



Investigations:
2019

Colour doppler scan report in 2019

Outside usg 
2019
2021
Recent usg:

On admission:
Provisional diagnosis:
DM, HTN, Hypothyroidism.


Treatment:
1. T. GIBTULO-MET 12.5/500 MG
2. T. PROPANOLOL 20 MG OD
3. T. OLMEZEST-AM 40/5 MG OD
4. T. THYRONOM 112 MG OD
5. T. HEPTAGON 1 tab BD