60F with complaints of generalised body pains since 2 years

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Hi!! This is Vijaya ratna,9th semester medical student. 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 and multiple  joint pains along with  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
H/o blood transfusion 10 years back
Surgical history
Hsterectomy 15 years back
PCNL for renal calculi 10 years back

Personal history
Mixed diet
Appetite normal
Sleep Adequate
Bowel and bladder regular 
Occasional smoker - smokes chutta

General examination
Patient 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 RT
RBS 105mg/dl

Systemic examination
CVS - S1 S2 Heard no murmurs 
RS - BAE + NVBS 
CNS : NFND 
P/A : soft,non tender

INVESTIGATIONS 

Provisional diagnosis - myalgia

TREATMENT 
TAB ULTRACET PO BD
TAB NUROKIND PO BD
TAB SHELCAL PO BD
TAB MVT PO BD













 

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