A 25yr old female came with chief complaints of SOB Grade II - III since 6 months

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Name :- P. Sai Krupa Sri (intern) 

Roll no:- 113 

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