25 year old female CC swelling in lower limbs and headache

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings investigations and come up with diagnosis and treatment plan.

A 25  year old female student , resident of West Bengal came to GM OPD with 

Chief complaint 

Swelling in right and left lower limbs since 2017

Headache since 2017

History of presenting Illness:- 

Patient was  apparently asymptomatic 6 years ago.On one fine day after she woke up , she observed swellings in the both limbs  below knee level.It was insidious in onset, progressive,has no aggravating factors, relieved on massage. It is not associated with pain.

H/o headache since 6 years  in the occipital region and associated with photophobia and phonophobia. No history of lacrimation .

Headache is more when she gets up in the morning and relieved immediately after few hours on its own  for which she went to hospital and after examination she was diagnosed with migraine.

History  of pain while writing since 7 years  which used to start after writing a paragraph (20-30 lines) relieved on rest.

Daily routine:- 

Previously patient wakes up around 7-8 am in the morning, goes for walking occasionally for one hour , returns home drinks and eats breakfast after an hour . 

Presently - She couldn't go for walk , because she became weak ( because of anemia??) .At the same time she also feels dizzy while walking.

After brisk walking for a while, she will have difficult in breathing,sweating and palpitation which relieved on taking rest.

Previously,at 11 Am goes to college and returns home by 3 for lunch ,takes rest for sometime .Around 6 pm , she will snacks and do her work . Around 8 pm she will have her dinner with family, goes to sleep while using her phone by 12 pm .

Present - Since  3 months she gets tired easily unable to do her work  ,sleeps a lot than her usual time .

Past history :-

In the year of 2022, around june- July She had severe tooth pain ,consulted a dentist , after routine investigations she got to know about high blood sugar levels . So , dentist treated her conservatively until blood sugars are normal and  treated her conservatively.

In the month of Aug , She had pain in left upper quadrant, consulted a  physician , after a thorough investigations, she was diagnosed with gall bladder stones on USG . She got treated conservatively.

Personal History:- 

Diet - Mixed 

Sleep - Adequate 

Appetite - normal 

B&B - regular 

No addictions .

Menstrual history:- 

Menarche - 13 years 

5/30 - 3 pads / day 

Family history:- 

Her paternal grand father have diabetes mellitus 

Treatment History:- 

Tab.DIAPRIDE M1 Forte 

Tab.FOLIC ACID 5 mg 

Underwent surgery for gall stones 

General Examination:-

Patient was conscious coherent co-operative

Pallor - present

No icterus, cyanosis, clubbing, lymphadenopathy, edema.

FBS - 191 mg/dl

PLBS -  241 mg/dl

Clinical images

 

Systemic examination:-

CVS: S1 S2 heard , no murmurs 

RS: BAE present ,NVBS heard 

CNS: No focal neurological deficits found 

P/A: Non tender,no organomegaly 

PROVISIONAL DIAGNOSIS :- 

Diabetes Mellitus and  Anemia under evaluation 

Investigations:-

Previous ultrasound report 

Complete Blood picture