Case of a 28 years old man with dyslipidemia.

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This is the case of a 28 years old man, a doctor by occupation and a resident of West Bengal.

CHIEF COMPLAINT

The patient has the chief complaint of 

      1. Increased visceral fat from 3 years.

      2. Increased cholesterol from 2 months.

 HISTORY OF PRESENTING ILLNESS

The patient was apparently asymptomatic 3 years ago, from when he started noticing increased visceral fat. It was not associated with an increase in weight or any significant change in his daily routine and dietary habits.

2 months ago, in August the patient experienced 2-3 episodes of mild chest pain, that would last for 20-30 secs. The pain was on the left side of the chest beside the sternum . It was dull aching in character and was not radiating to any other site. The pain was not aggravated by any factor . Following the first episode the patient had taken an antacid which gave him relief . In the following episodes the pain subsided on its own . It was fully relieved after 2-3 days. The patient went to the hospital and got a lipid profile done in which his cholesterol was high. The patient is not taking any medication currently.

HISTORY OF PAST ILLNESS

Known case of hypercholesterolemia from 2 months.

Not a known case of DM, HTN, asthma, TB, Epilepsy , Thyroid ,CVD.

FAMILY HISTORY

Father - Known case of Hypercholesterolemia (controlled) and also has visceral fat .

PERSONAL HISTORY

The patient has work related stress.

Appetite- Normal 

Diet- Mixed (Mostly non veg)

Sleep- Adequate except on days of duty (24 hour shifts twice a week)

Bowel and bladder movements- Regular

Alcohol- no

Smoking- no

Allergies- no

Dietary habits - Breakfast - 0930 hrs -Puffed rice and Bengal gram

                          Lunch - 1300-1330 hrs - Plain rice , dal, potato fry , any one non veg curry (chicken , fish or mutton)

                          Snacks- no routine - may or may not eat - Puffed rice and vegetables 

                          Dinner - Plain rice , dal ,two vegetable curries 

Exercise -  No routine exercise - the patient walks to his work place .

CLINICAL IMAGES

31/8/2023

Ac=85cm

Body wt-56kg

Muac=27cm

13/11/2022

 

30/9/2022

1/10/2022

Ac=91cm

Mid upper arm=27cm

(Measured using an inch tape )

INVESTIGATIONS

6/8/2022

24/9/2022