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A 53 year-old female, presented with heaviness in chest since one-week of duration. Chest pain was gripping in nature, localized to retrosternal region, was not associated with sweating, palpitation, anxiety. There was no increase in pain following physical activity. The pain was non radiating, no h/o of any injury or trauma. She was having on and off history of generalized weakness, fatigability, increased frequency of urination. She was never diagnosed as hypertensive or diabetic in the past. She attained menopause at the age of 52 years. Family history: mother is a known diabetes mellitus and hypertension, she is on OHA since 5 years, and for hypertension is taking Telmisartan 40 mg once a day. She used to smoke but quitted since 10 years. Her lifestyle is very sedentary. Examination: No signs of pallor, icterus, cyanosis, lymphadenopathy, koilonychia Physical examination: obese woman Height 165 cm, weight 82 kg, BMI of 32 kg/m2, waist circumference: 36, hip Circumference: 38 inches, waist hip ratio: 0.94 Pulse rate: 98/min; regular, normal volume, no radio radial, no radio femoral delay. Blood pressure: 160/110 mmHg in right and left upper limb. She was having black velvety hyperpigmentation of the skin especially on the neck possibly acanthosis nigricans, apart from this patch, rest of the systemic examination is normal. Her random blood sugar was 210 mg/dL as measured by Glucometer. She was advised to under all the investigation and review. INVESTIGATIONS · Fasting blood sugar: 150 mg/dL, Plbs: 280 · Lipid profile: Triglyceride:241, TC: 320, LDLC: 235, HDL-C:38 · Liver function test showed mildly raised AST and ALT, · Renal function test normal, HbA1C was 8.46%. · Thyroid function tests normal. · Serum cortisol: normal · Serum oestradiol: normal · DHEAS, testosterone, progesterone: normal. · FSH 57.1 mU/L, LH 27.9 mU/L(menopausal range) · Urine picture: protein present, glucose positive, no leukocyte, macroalbuminuria, · Electrocardiogram: mild LVH with stain pattern, echocardiography : normal · Chest radiograph normal · Pap smear results normal. DIAGNOSIS · Type 2 Diabetes Mellitus · Hypertensive · Hyperlipedemia · Metabolic syndrome Treatment: Non-pharmacological Measures: 1. Diet 2. Reduction of weight 3. Exercise 4. Salt intake should be reduced 5. Behavioral modification Medication: She was initiated on · Metformin 500 mg morning and evening one tablet a day, · Atorvastatin 10 mg at night, · Telmisartan 40 mg once a day. · She was referred to a dietician for dietary advice. Over next two weeks the patient was reviewed her fasting blood sugar 135 mg/dl, Plbs: 240 mg/dL blood pressure was normal. Her medication dose of metformin was increased to 850 mg morning and evening. Patient was reviewed after a month she had reduced 6 kg of weight with the diet modification with pharmacotherapy. She was on low carbohydrate diet, low fat and high fiber. The random blood sugar was 108 mg/dL, pulse 90/ min, BP: 120/70 mmHg. On review the investigation results are as follows; FBS 117 mg/dL, HbA1C 6.69%, TC 230, LDL-C 124, HDL-C 36, Tg 274 and the liver enzymes remained the same. Atorvastatin dose was stepped upto 20 mg and patient was also started on omega 3 fatty acids in view of persistent increase in triglyceride levels despite diet modification. Ophthalmologist opinion was taken for evaluation of early diabetic retinopathy. Patient was explained how to take the foot care and regarding the proper footwear. On the given situations above; Discuss what is happening to the patient. Why was atorvastatin stepped up? Why is foot care given emphasis? Give the significance on the following laboratory results: fasting blood sugar 135 mg/dl, random blood sugar was 108 mg/dL, FBS 117 mg/dL, HbA1C 6.69%, TC 230, LDL-C 124, HDL-C 36, Tg 274, and omega 3 fatty acids. Aside from Pharmocological management a Non-pharmacological Measures was advised give reasons why these are being ordered: 1. Diet 2. Reduction of weight 3. Exercise 4. Salt intake should be reduced 5. Behavioral modification 6. The patient was discharged a month ago, create a discharge plan to this patient.

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