A 60yr old female came with the complaints of generalised body pains since 2 years

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 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.


This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.


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. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input 

A 60yr old female came with the complaints of generalised body pains since 2 years

HOPI 

Patient was apparently asymptomatic 2 years back and then developed generalised body pains 

With mutliple joint pains and lower backache 

C/o joint stiffness , difficulty in getting up from sitting position 

No h/o trauma, fever, tenderness 

Past history: 

N/k/c/o HTN,DM,TB, EPILEPSY,CVA,CAD, THYROID DISORDERS

H/o blood transfusion 10 years back

Surgical history

Hsterectomy 15 years back

PCNL for renal calculi 10 years back


Personal history: 

Diet mixed 

Appetite normal

Sleep Adequate

Bowel and bladder regular 

Occasional smoker - smokes chutta

 


General examination

Pat is c/c/c well oriented to time place person 

Moderately built and nourished 


No signs of  pallor,icterus, cyanosis ,clubbing, lymphadenopathy generalized edema 









Vitals : 

Temperature 97.6 

PR 82 

BP 130/80 

Spo2 98 at ra 


Systemic examination

CVS - S1 S2 Heard no murmurs 


RS - BAE + NVBS 


CNS : NFND 


P/A : soft,non tender

Provisional diagnosis: ? myalgia

Investigations

RBS-105 mg/dl





Treatment:

1. TAB ULTRACET PO BD

2. TAB NUROKIND PO BD

3.TAB SHELCAL PO BD

4.TAB MVT PO BD

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