54/F with dragging type of pain B/L lower limbs

 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. 

A 54 yr old female with dragging type of pain from lower back to soles since 20yrs

PATIENT HISTORY 

At the age of 8yr she fell on the floor and she couldn't get up for 10 to 15min.

It occurs monthly twice or thrice.

Each episode last for 10 to 20min.

At the age of 18 she got married.

At the age of 20 she gave birth to child.

At the age of 22 she started getting joint ,adbominal pain and muscle pains and she consulted doctor and took treatement.

At the age of 35 she took injection at antero lateral thigh for dizziness .

After 2 to 3 days she started getting flank and legs pains.

At the age of 36 (2004year) she consulted doctor for  amennorhea.

At the age of 39 tumor was detected by USG 

In 2007  Hysterosalpingography was done.

After Hysterosalpingography

UTI infections occured due to catheter.

From Past 5yrs she is suffering with wrist pain.

Dengue 1year back.

Severe pains of both flank and legs

COVID 3 years back.

In 2011 

Migrane.

Resolved on medication.

PAST HISTORY.

hypotension

PERSONAL HISTORY 

Diet mixed.

Appetite normal.

Bowel and bladder movement regular.

Addictions no.

FAMILY HISTORY.

MOTHER AND FATHER HAD SIMILAR COMPLAINTS LIKE FLANK AND LEG PAINS.

TREATMENT HISTORY.

Indocaine sr 75

GENERAL EXAMINATION.

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

We'll built and nourished.

Pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema - absent


VITALS on admission

Temperature- afebrile

Blood pressure- 120/90

Resp rate-19cpm

Heart rate- 81bpm



































PROVISIONAL DIAGNOSIS.

Spondylo arthropathy with left more than right with plantar fascitis


Discharge summary:

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