A 27 YEAR OLD FEMALE WITH MYALGIA AND ARTHRALGIA

23/11/2022
Student Name- D.Vineesha Chowdary 
2017 batch

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 evidence based input
This E blog also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome
I've 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. 

CHIEF COMPLAINTS-

A 22 year old female presented to the OPD with chief complaints of myalgia and arthralgia since three days.

HISTORY OF PRESENTING ILLNESS-

Patient was apparently asymptomatic three days ago when she developed myalgia that is squeezing in type and present throughout the day and associated with generalised weakness. It was not associated with fever.

PAST HISTORY- 

Patient has a history of similar episodes since 8 years.

Patient is not a known case of hypertension, diabetes, TB, asthma or epilepsy.

FAMILY HISTORY-

No significant family history

PERSONAL HISTORY-

Appetite- Normal 

Diet- Mixed

Bowel movements- normal 

Bladder movements- normal 

Sleep- adequate 

Any addictions- No 

Any allergies- No 

GENERAL EXAMINATION-

Done after obtaining consent, in the presence of attendant with adequate exposure

Patient is conscious, coherent, cooperative and well oriented to time, place and person

Patient is well nourished and moderately built

Vitals-

On 23/11/22

Temperature- 98.4F

Blood pressure- 110/70 mmHg

Pulse rate- 84 bp

Respiratory rate- 17 cpm

SpO2- 98%

Pallor- Absent

Icterus- Absent

Cyanosis- Absent

Clubbing- Absent

Lymphadenopathy- Absent

Edema- Absent

ABDOMINAL EXAMINATION-

INSPECTION- Umbilicus inverted , No abdominal distention, no visible pulsations, scars and swelling.

PALPATION-  Soft, non tender, no organomegaly.

AUSCULTATION- Bowel sounds heard

CVS EXAMINATION-

INSPECTION- No visible pulsations, scars, engorged veins. No rise in JVP. 

PALPATION- Apex beat is felt at 5th Intercoastal space medial to mid clavicular line.

AUSCULTATION- S1, S2 heard, no murmurs.

RESPIRATORY SYSTEM-

INSPECTION-  Shape of chest is elliptical, b/l symmetrical.

PALPATION- Trachea is central. Expansion of chest is symmetrical.

  Bilateral Airway Entry - positive

AUSCULTATION- Normal vesicular breath sounds.

CNS EXAMINATION-

No signs of meningeal signs

Cranial nerves: normal

Sensory system: normal

Motor system: normal

Reflexes: Right.     Left. 

Biceps.      ++          ++

Triceps.     +             +

Supinator   +            +

Knee.         ++         ++

Ankle          +           +

Gait: normal.

INVESTIGATIONS- 

HAEMOGRAM- 

S.ELECTROLYTES- 

S.UREA-

S.CREATININE-

S.CALCIUM-

U.CALCIUM-

U.CHLORIDE-

SPOT URINARY SODIUM-

SPOT URINARY POTASSIUM-

S.OSMOLALITY-

LFT-

USG-

ECG-

2D ECHO-

CHEST X RAY- 

PROVISIONAL DIAGNOSIS- 

HYPOKALAEMIA UNDER EVALUATION

TREATMENT- 

1) IVF NS/RL @75ML/HR

2) INJ.KCL 20mEQL in 500ml NS/IV/ OVER 5 HRS.