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A CASE OF 44 YEAR OLD FEMALE PATIENT WITH HYPOTHYROIDISM, HYPERTENSION, DIABETES.
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
Outside usg
2019
2021
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