Clinical Decision Support System (CDSS)

PATIENT PROFILE
Gender: Male
Age: 42 years
Complaints: Rapid fatigue, heaviness after eating, poor sleep, excess weight in the abdominal area.

COMPLETE BLOOD COUNT
Hemoglobin (HGB): 148 g/L (Norm: 130 – 160)
Erythrocytes (RBC): 5.1 x10^12/L (Norm: 4.0 – 5.5)
Hematocrit (HCT): 44 % (Norm: 39 – 49)
Platelets (PLT): 240 x10^9/L (Norm: 180 – 320)
Leukocytes (WBC): 7.2 x10^9/L (Norm: 4.0 – 9.0)
ESR: 8 mm/h (Norm: 2 – 15)
Eosinophils: 6.5 % (Norm: 1 – 5)

BIOCHEMICAL ANALYSIS
Glucose (fasting): 6.1 mmol/L (Norm: 3.3 – 5.9)
Insulin: 14.5 mcIU/mL (Norm: 2.6 – 10.0)
Glycated Hemoglobin: 5.8 % (Norm: < 6.0)
Total Protein: 72 g/L (Norm: 66 – 87)
Total Bilirubin: 15.0 µmol/L (Norm: 3.4 – 17.1)
ALT: 35 U/L (Norm: < 41)
AST: 28 U/L (Norm: < 40)
Total Cholesterol: 6.8 mmol/L (Norm: < 5.2)
LDL (Bad Cholesterol): 4.2 mmol/L (Norm: < 3.0)
HDL (Good Cholesterol): 0.9 mmol/L (Norm: > 1.0)
Triglycerides: 2.1 mmol/L (Norm: < 1.7)
Uric Acid: 410 µmol/L (Norm: 202 – 416)
Ferritin: 35 µg/L (Norm: 30 – 400)
Homocysteine: 14 µmol/L (Norm: 5 – 12)

HORMONES AND VITAMINS
TSH (Thyroid Stimulating Hormone): 2.1 mIU/L (Norm: 0.4 – 4.0)
Vitamin D (25-OH): 19 ng/mL (Norm: 30 – 100)

CLINICAL SUMMARY
Patient: Male, 42 years old.
Leading syndromes: Metabolic syndrome, asthenic syndrome, dyslipidemia, Vitamin D deficiency.

1. Summary of Current Status
The clinical picture and laboratory data correspond to the criteria of metabolic syndrome.
Identified:
— Impaired fasting glycemia (Glucose 6.1 mmol/L) against the background of hyperinsulinemia (14.5 mcIU/mL). Calculated HOMA-IR index ≈ 3.9 (norm < 2.7), confirming pronounced insulin resistance.
— Atherogenic dyslipidemia: Increased TC (6.8), LDL (4.2), TG (2.1) with decreased HDL (0.9).
— Hyperhomocysteinemia (14 µmol/L) as an additional CV risk factor.
— Vitamin D deficiency (19 ng/mL).
— Slight eosinophilia (6.5%).

2. Anamnesis (Clarify with Patient)
To verify risks and etiology, it is necessary to clarify:
— Heredity: Type 2 diabetes, early CVD (heart attacks/strokes before 55 years) in first-line relatives.
— Blood pressure: Presence of episodes of increased BP (to verify metabolic syndrome criteria).
— Dietary habits: Consumption of simple carbohydrates, alcohol, frequency of meals (snacking).
— Sleep: Presence of snoring or apnea episodes (OSAS), given complaints of poor sleep, fatigue, and abdominal obesity.
— Allergy history: Presence of allergic reactions (in the context of eosinophilia).

3. Red Flags (Exclude)
— CVD: Exclude IHD (angina pectoris), given high lipid profile and homocysteine.
— OSAS (Obstructive Sleep Apnea Syndrome): High probability with a combination of obesity, poor sleep, and daytime sleepiness.
— NAFLD: Exclude steatohepatitis (despite normal transaminases, the risk of steatosis is high).

4. Examination Plan (Proposal)
Laboratory Diagnostics:
— Vitamins B9 (folic acid) and B12 (to clarify the genesis of hyperhomocysteinemia).
— Total IgE + stool for worm eggs/protozoa (diff. diagnosis of eosinophilia: parasitosis vs allergy).
Instrumental Diagnostics:
— Ultrasound of abdominal organs (assessment of signs of fatty hepatosis).
— BP monitoring (diary or ABPM).
— ECG (screening).

5. Potential Therapeutic Goals
— Correction of insulin resistance: Lifestyle modification (low GI diet, physical activity), consideration of Metformin prescription (if indicated and no contraindications).
— Lipid-lowering therapy: Assessment by SCORE2 scale. Consideration of statin therapy or fibrates (with TG dominance), or correction with diet + Omega-3 in the first line.
— Correction of deficiencies:
  • Vitamin D (loading dose with transition to maintenance).
  • B Vitamins (to lower homocysteine).