61/F with DM2 and oral sub mucosal fibrosis

 NOTE: THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT. 

PATIENT HISTORY: Pt is a 61 yr old female, homemaker.

First pregnancy in 1985 (normal delivery), uneventful.

In 1990, pt noticed white discharge during menstruation along with menstrual bleeding (normal, no pain). Dr. diagnosed it to be a uterine tumor and Sx done. Soon after she got pregnant, but her menstrual cycles did not stop, bleeding for 1-day per cycle, with no discharge. After 6 months into the pregnancy, Dr reported fetus had died and was aborted.

In 1993, got pregnant for 3rd time. This time also menstrual cycles did not stop. Bleeding for 1 day only per cycle. Normal delivery

In 2005, due to continuous extreme abd pain went to Dr who diagnosed it to be due to uterine cysts. Hysterectomy and bilateral salpingo-oophorectomy were done. 

In 2009 Feb, fell down from ladder almost 10 feet and#L1 vertebra. Recovery with medicine, bed rest, and physiotherapy. 

In 2010, c/o severe epigastric and hypogastric pain and agitation. Endoscopy and colonoscopy done. Medicine prescribed (Rabeprazole 20 mg, Levosulpiride, Omeprazole{continued till 2013, then since 2021 till date})

Since 2011 Jan, started Clonazepam 0.5mg , because at that time her husband had recently died and her daughter was still unmarried. Now,takes only when she c/o trouble sleeping or anxiety. Takes 2-3 times per month. 

In 2015, c/o continuous lower back pain and elbow pain lat epicondyle (?tennis elbow). Dr advised wearing a belt again (which provides relief) for back pain and gave injections(?steroid) in painful area of elbow, which resolved elbow pain. 

In 2016, while on a follow-up for the abd pain a lot of tests were done. TSH lvl was 6 mlU/L. Did not prescribe any medications.

In 2017 May, Due to a persistent high fever she was asked to do blood and urine tests which detected UTI and her TSH lvl was 8 mlU/L. Medicine Thyronorm 50 was prescribed.

In 2018, for 3 months c/o itchy red rash in the thigh and above elbow jt. Resolved with medicines and ointment. Around that time on a separate occasion c/o persistent fever, for which blood tests were done. DM was detected. Medicine prescribed Glycomate 500 SR.

In 2018, she c/o headache, dizziness, nausea and weakness in getting up from bed. After 1 month, she was taken to a Dr. who did an cervical X ray (report not available) and prescribed medications, taking which she recovered within days. Thinking the headache was due to eye problem she was also taken to Opthalmologist that time.

In 2020, again c/o abd pain in epigastric and hypogastric regions. Colonoscopy and endoscopy done. Erosive gastritis with gastric polyps were detected of which 2 polyps were removed later on 2021 via endoscopic polydectomy. Colonoscopy detected small internal piles.

While on a regular checkup for DM, Dr. prescribed he to take 

 For the past one month, c/o lower abd. pain, heartburn, throat burning constipation. Dr diagnosed it to be IBS. Prescribed medicine for 3 wks, taking which reduced her symptoms to certain extent.

Pt is diabetic and on medication. 

Addiction of eating Paan 3-4 times per day for the past 20 days.

CHIEF COMPLAINT AND Pt REQ.:

Pt wants a update about her gastric polyps and what further treatment can be done

c/o lower abd. pain, heartburn, throat burning constipation and an uneasy feeling in the epigastrium.

Wants to know if so many tablets are actually needed to treat her DM and also for cholesterol.

FAMILY HISTORY: 

Mother - similar c/o GI problems

Father - heavy smoker, used to cough a lot and also similar c/o GI problems

HER NORMAL ROUTINE: 

She wakes up between 5.30 and 6 am. Drink two glasses of  water .Then goes for a morning walk for 20 minutes. Then takes bath. Then eat 'red tea', two biscuits and does puja.

Does some cooking, eat some rice and vegetables, or sour curd, puffed rice and banana at 11 am.

After finishing household chores, eat lunch (rice, fish, vegetables, dal, sour curd) at 2.30pm.

Sleep from 3.30 pm to 5 pm.

Take a short walk in the evening.

Have red tea and biscuits at 6pm.

Then from 7 pm to 9 pm , lie down and watch TV.

Drink Diabatic Horliks at 8.30 pm.

Finished dinner by 10.30 pm.

Go to sleep at 11pm.

Eat 'JORDA PAAN' 4 or 5 times a day.

Loves to eat sweet or sour things like 'khurma', 'ROSHO GOLLA', NIMKI, CHANA CHUR, SINGARA.

Details of all the medicines that she takes every day.

1. Metformin 500mg +Sitagliptin 50mg( b.d before breakfast and dinner)

2.Metformin hydrochloride 500mg + glimepiride 2mg( o.d, before breakfast)

3. Rabeprazole 20 + Domperidone( o.d, empty stomach at morning)

4.Chlordiazepoxide(5.0 Mg) + Amitriptyline(12.5 Mg)( o.d ,after dinner)

5. Propanolol -10 mg( t.d, after breakfast, lunch, dinner)

REPORTS:

Hemogram:

    

Serum uric acid :        

   

     

Random blood sugar : 

     

Fasting blood glucose: 

     

Glycated hemoglobin: 

       

Serum creatinine: 

       

Blood urea nitrogen: 

   

Bleeding time , clotting time : 

    

LFT: 

     

Gastro referral was taken : 

 Endoscopy done : findings- multiple fundi gland polyps