Patient name: Deena Gender: Female Age: 50 Weight: 90 kg
Date: 29 September 2021
th
Chief compliant: Loose Stools and Unintentional weight gain, and
fatigue Height: 160cm
Dr. Traik
Subjective: Mrs. Deena is a 50-year-old woman who has suffered from diabetes and high blood
pressure in the past two years. She is on controlled medications and is seen by her doctor for her
diabetes and hypertension. Her mother has diabetes, while her father has hypertension, according
to her family's medical history. She takes her medication consistently, and her high blood
pressure is under control. She does not smoke or drink alcohol in her social life, but she did
smoke a couple of years ago. Every day, she has two cups of coffee with sugar. She eats three
meals a day, along with rice bread, snacks, soda, and adequate amounts of water. According to
Mrs. Deena, she put on 10 kg in 3 weeks. She frequently feels dizzy and fatigued, has
uncontrolled hyperglycemia, and is cold. She frequently measures her blood glucose but doesn't
regularly check her blood pressure. She wants to use Xenical (Orlistat) on her own to loose
weight. Ginseng is what she is taking for fatigue, but it isn't relieving her symptoms.
Objective: Mrs. Deena is taking 1000 mg of Metformin PO twice daily with breakfast and
dinner for last 2 years. She is taking hypertensive medicine for her hypertension and her
hypertension is controlled but as stated before she is not monitoring it regularly. Moreover she is
taking Ginseng supplement for her fatigue OTC with dinner for last one week. She does not have
any known allergies for any medication or substance and her vaccination in up to date. Her
weight is 90 kg and height is 160 cm, BMI is 35.2 (Obese), HR 88 BPM, and her blood pressure
is 150/94 mm Hg. Moreover her lab data readings are as follows:
HbA1c: 9.2%
Fasting Blood Glucose: Not done
Random Blood Glucose: Not done
HDL: 1 mmol/L
LDL: 3.3 mmol.L
ALT: 23
AST: 20
Cholesterol Level: Not done
TG: 2.3 mmol/L
TSH: 10 mIU/L (Elevated)
Free T4: 0.2 ng/dl
T3: 50 ng/dl
SCr: 155 micromoles/L
UACr: 18 mg/mmol
Vitamin B12: Not done
Ca: Not done
Assessment: Mrs. Deena is experiencing several health related issues. The first issue is that she
is suffering from uncontrolled diabetes as her lab data shows an elevated HbA1c of 9.2% and
thus elevated random glucose and fasting glucose. Second issue is that she is having an
unintentional weight gain in last one month in which she has gain 10 kg as her BMI is 35.2
indicating that she is obese. Her T3 and T4 levels are low which indicates that she is suffering
from hypothyroidism which is also contributing to her weight gain and need a therapy. The
patient’s TG, and LDL level is high which indicates hyperlipidemia. Her hypertension is also
uncontrolled as her last recorded BP is 150/94. As there is no proper medication history of Mrs.
Deena then it is suggested that the drugs that are causing weight gain should be stopped.
Moreover she is taking Hydrochlorothiazide which should be stopped immediately as it results in
hyperglycemia by interacting with Metformin (decreasing the activity of Metformin). This drug
also interacts with Metformin so instead of this a combination of Losartan/Amlodipine can be
started. The Ginseng she is using is helpful in treating fatigue but is causing hypoglycemia so
this should be discontinued (1). For her high cholesterol level, statin should be initiated and for her
hypothyroidism, Levothyroxine should be considered.
Plan:
1. Discontinue the combination of Lisinopril/HCTZ 20/25 mg PO BID as it interacts with
anti-diabetic drugs causing hyperglycemia (4).
2. Rosiglitazone should not be considered as it cause weight gain
3. Continue Metformin 1000 mg BID with breakfast and dinner.
4. Start Glyburide 5 mg BID
5. Start Sitagliptin 100 mg daily
6. Start Atorvastatin 20 mg bedtime
7. Start Levothyroxine 120 mcg PO for 6 weeks for hypothyroidism with continuous heck
on her T3 and T4 level (2).
8. Start Losartan 25 mg/ day for 4-6 weeks
9. Amlodipine 5 mg OD and then titrate it every 3 weeks as per patient’s condition.
10. Discontinue Ginseng as it has high risk of hypoglycemia.
11. Motivate patient to start doing exercises
12. Encourage her to record her BP and Glucose level daily
13. Orlistat should not be prescribed to her. If her weight is uncontrollable then start patient
with Semaglutide 3 mg PO/ daily for a month (3).
14. Refer her to Nutritionist to control her weight
References:
1. Yang, J., Shin, K. M., Abu Dabrh, A. M., Bierle, D. M., Zhou, X., Bauer, B. A., & Mohabbat, A.
B. (2022). Ginseng for the Treatment of Chronic Fatigue Syndrome: A Systematic Review of
Clinical Studies. Global advances in health and medicine, 11, 2164957X221079790.
https://doi.org/10.1177/2164957X221079790
2. Up to date. Levothyroxine [Internet]. [Updated 2021; cited 2022 October 6, 2022]. Available
from : https://www.uptodate.com/
3. Up to date. Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus
[Internet]. [Updated 2021; cited 2022 October 6, 2022]. Available from
https://www.uptodate.com/contents/glucagon-like-peptide-1-based-therapies-for-the-treatment-
of-type-2-diabetes-mellitus
4. Up to date. Hydrochlorothiazide [Internet]. [Updated 2021; cited 2022 October 6, 2022].
Available from https://www.uptodate.com/contents/search?search=hydrochlorothiazide-drug-
&sp=0&searchType=PLAIN_TEXT&source=USER_INPUT&searchControl=TOP_PULLDOW
N&searchOffset=1&autoComplete=false&language=&max=0&index=&autoCompleteTerm=&r
awSentence=
