This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians sign informed consent
Here we discuss our individual patient problems through series of inputs from available Global online community of experts with n aim to solve those patient clinical problem with collect current best evidence based input
This Elog also reflects my patient centered online learning portfolio.
I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan
Thankyou Dr Stimita for helping in History
53 year old female housewife by occupation resident of coochbihar admitted with complains of generalised weakness since 6 years
The patient's medical history reveals that she was asymptomatic until six years ago when she presented with weight loss, xerostomia, and anorexia. She sought medical attention at a local medical facility, where she was diagnosed with Diabetes mellitus and subsequently initiated on oral hypoglycemic agents.
Around four years ago, the patient began experiencing generalized asthenia and easy fatigability, leading to the diagnosis of both Hypertension and hypothyroidism.
Approximately four years ago, the patient complained of cervical discomfort, prompting a diagnostic consideration of cervical spondylosis. This condition was managed with a course of physiotherapy.
Currently, the patient reports intermittent occurrences of generalized asthenia, easy fatigability, and xerostomia. She also experiences sporadic episodes of lumbosacral discomfort and bilateral coxalgia, which intensify during prolonged periods of sitting.
Furthermore, the patient describes sporadic episodes of burning epigastric discomfort, which is alleviated by food ingestion or resolves spontaneously after a certain period. She occasionally experiences early morning nausea that subsides after breakfast.
Sleep disturbances are also reported, with frequent nocturnal awakenings disrupting the patient's sleep pattern.
Lastly, the patient presents with sporadic bilateral lower limb paresthesias, without specific exacerbating or relieving factors.
PSYCHOSOCIAL HISTORY
Raised in a rural environment as part of a nuclear family, she pursued her education up to the 10th grade. However, societal norms prevalent in her village led her to discontinue her studies thereafter.
Subsequently, she immersed herself in domestic duties. At 26, she married a businessman. Following their union, she conceived naturally and gave birth to a son within the first year. Opting to concentrate fully on her young child, she elected to terminate her pregnancy a year later.
Around 6 to 7 years later, she conceived once again, only to experience a miscarriage. This incident weighed on her for months, yet the support of her family aided in her recovery.
Currently, she enjoys a harmonious nuclear family life with her husband, son, and daughter-in-law. Her son actively participates in their hardware store business, while her daughter-in-law works as a school teacher.
Initially, she managed household duties independently. However, in recent years, she has faced increasing fatigue and weakness. With her daughter-in-law's teaching commitments, she sought the help of a maid for household tasks.
Her daily routine involves waking up at 6:30 am, engaging in chores, enjoying tea with biscuits, preparing meals, and spending quality time with family. Due to her diabetes diagnosis, she shifted from consuming rice for dinner to eating chapati.
Despite her talkative and proactive nature, she's been battling fatigue for 4-5 years, which has left her dissatisfied. Health issues in her husband and daughter-in-law, alongside her own medical regimen, have become a concern despite financial stability.
She experiences heightened anxiety over minor matters and constantly worries about her health. Her sleep patterns are erratic, with occasional full-night sleep but often interrupted rest.
PAST HISTORY
Known case of Diabetes since 6 years
Initially on tab glycomet 500mg now changed to tab vildgliptin and metformin 50/500mg po/Od
Known case of Hypertension since 4 years
On tab telmasartan 40mg but doesn’t take it regularly
Known case of Hypothyroidism
Initially on T Thyroxine 25mcg for 2 years and increased to 50mcg
Now on T thyroxine 32.5mcg
Had cataract surgery to right eye
PERSONAL HISTORY
no smoking/alcohol history
Consumes Areca nut/ pan two per day
General examination
Height : 5’4
Body weight: 67kgs
Mid arm circumference: 25cms
Abdominal circumference: 90cms
BP : 130/80mmhg
PR : 75bpm
GRBS :
Temp: afebrile
No pallor, icterus,cyanosis, clubbing, lymphadenopathy, edema
SYSTEMIC EXAMINATION
Cardiovascular system:
S1 and S2 heard no murmurs heard
Central nervous system:
No focal neurological deficit, cranial nerve intact
Respiratory system:Bilateral air entry-present ,Normal vesicular breath sounds-heard
Abdominal examination: soft and non tender, No Hepatomegaly, spleen is not palpable.
Clinical images
PROVISIONAL DIAGNOSIS
Metabolic syndrome with known case of DM,HTN and Hypothyroidism
INVESTIGATIONS
GRADE 2 fatty liver
HEMOGRAM
HB - 10.9gm/dl
TLC- 8000 cells/cumm
N/L/E/B- 57/34/7/0
PCV - 33.4 vol%
MCV- 91.0 fl
MCH- 29.7 pg
MCHC- 32.6 %
RDW-CV - 14.1%
RDW-SD - 47.8 fl
RBC- 3.67 millions/cumm
PLATELETS- 2.5lakhs/cumm
CUR
COLOUR- pale yellow
Appearance- clear
Reaction- acidic
SP gravity- 1.010
ALBUMIN- NIL
SUGAR- NIL
BILE SALTS- NIL
BILE PUGMENTS- NIL
PUS CELLS - 2-4
EPITHELIAL CELLS- 2-3
RBC - NIL
CRYSTALS- NIL
CASTS- NIL
AMORPHOUS DEPOSITS - NIL
THYROID PROFILE
T3 - 1.25 ng/ml
T4 - 11.68 micro g/dl
TSH - 7.35 micro iu/ml
FBS 135mg/dl
PPBS
HBA1C
LIPID PROFILE
Total cholesterol - 211mg/dl
Triglycerides- 106mg/dl
HDL- 43.1mg/dl
LDL-113 mg/dl
VLDL-21.2mg/dl
RFT
UREA - 31mg/dl
CREATININE- 0.8mg/dl
URIC ACID-5.7mg/dl
CALCIUM- 10.0mg/dl
PHOSPHORUS-3.1mg/dl
SODIUM- 144meq/L
POTASSIUM - 4.4 mEq/L
CHLORIDE- 99 mEq/L
DVL referal in view of allergic contact dermatitis
Opthalomology referal in view of DOV
OMFS Referal in view of tooth extraction
ENT Referal in view of ear pain
METABOLIC SYNDROME
ALLERGIC CONTACT DERMATITIS
IMMATURE SENILE CATARACT IN BOTH EYES
OTITIS EXTERNA in right ear
Treatment
Adviced cataract surgery by Opthal dept
Mupirocin ointment for application in external ear - adviced by ENT for otitis externa
Treatment adviced by DVL for allergic contact dermatitis
Tab Teczine po/Od for one week
Momate F cream for local application for one week
Venusa max lotion for local application for two weeks
Lifestyle modifications
Physical activity 30mins everyday
Tab vildagliptin and metformin 50/500mg po/Od
Tab telmasartan 40mg po/Od
Tab thyroxine 32.5mcg po/od
Follow up in PaJR
After going home
Case 1
### Thematic Analysis of the Case
#### 1. **Coding:**
- **Chronic Conditions:** Diabetes mellitus (6 years), hypertension (4 years), hypothyroidism (4 years), metabolic syndrome, cervical spondylosis.
- **Musculoskeletal Issues:** Bilateral coxalgia, cervical discomfort, lumbosacral pain.
- **Psychosocial Stress:** Anxiety about health, family responsibilities, disrupted sleep.
- **Lifestyle Factors:** Areca nut consumption, household work limitations due to fatigue.
#### 2. **Categorization:**
- **Metabolic Dysregulation:** Diabetes, hypertension, and hypothyroidism suggest poor metabolic control leading to metabolic syndrome.
- **Musculoskeletal Pain:** Chronic cervical and lumbar discomfort due to age-related degeneration.
- **Psychosocial Impact:** Health-related anxiety and the burden of managing family duties.
#### 3. **Theme Identification:**
- **Multisystem Degeneration in Middle Age:** This case illustrates how metabolic disorders combined with musculoskeletal and mental health issues affect middle-aged women.
- **Need for Lifestyle Adjustments:** Her management plan highlights the importance of physical activity and consistent medication adherence.
- **Mental Health Strain on Chronic Disease Management:** Anxiety about health further complicates her condition management and requires addressing alongside physical symptoms.
#### 4. **Theme Representation (Learning Points):**
- **Interdisciplinary Approach to Metabolic Syndrome:** The patient requires coordinated care to address diabetes, hypertension, and hypothyroidism while managing lifestyle modifications and mental health.
- **Impact of Family Dynamics on Health:** The psychosocial context (family responsibilities, health anxieties) influences her health behaviors and condition management, warranting psychological support.
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