FIBROMYALGIA OF RIGHT SHOULDER TRAPEZIUS TENDERNESS

ACID PEPTIC DISEASE

IRON DEFICIENCY ANEMIA SECONDARY TO NUTRITIONAL DEFICIENCY

MELESMA +PITYRIASIS VERSICOLOR

DENEVO DIABETES MELLITUS

DENEVO HYPERTENSION


Case History and Clinical Findings

C/O

RIGHT SHOULDER PAIN SINCE 6MONTHS

LOWER BACKACHE SINCE 6 MONTHS

CHEST PAIN SINCE 1 WEEK


HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC AND ALRIGHT 6 MONTHS BACK AND THEN

SHE DEVELOPED SHOULDER PAIN @ RIGHT SIDED OF SUPRASCAPULAR

AREA,PAIN+,INSIDIOUS ONSET GRADUALLY PROGRESSIVE,TENDERNESS - ,NO

RESTRICTION OF MOVEMENTS,AGGREVATING ON DOING HEAVY WORK AND NO RELIEVING

FACTORS A/W LOWER BACK ACHE SINCE 6 MONTHS,PAIN+ ,TENDERNESS- ,AGGREVATING ON BENDING AND WORKING AND RELIEVED BY TAKING REST


CHEST PAIN SINCE 1 WEEK AT RETROSTERNAL REGION, EPIGASTRIC REGIONAL PAIN


+,BURNING SENSATION +,REGURGITATION -,BELCHINGS -,AGGREVATING ON EATING SPICY


FOOD AND NO RELIEVING FACTORS


N/H/O FEVER,COLD,COUGH,ALLERGIES


N/H/O ABDOMINAL PAIN,NAUSEA,VOMITING,LOOSE STOOLS


N/H/O CHEST PAIN,PALPITATIONS,SATING,SOBWE


N/H/O BURNING MICTURITION ,CONSTIPATION,PEDAL EDEMA, AND REDUCED URINE


OUTPUT


N/H/O TRAUMA AND ANY INJURY TO SHOULDER AND LOWER BACKACHE


N/K/C/O HTN,DMII,EPILEPSY,ASTHMA,CVA,CAD


ON EXAMINATION :


PT IS CONSCIOUS,COHERENT,COOPERATIVE


NO PALLOR ,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY , PEDAL EDEMA


TEMP:96.8 F


BP: 130/90MMHG


PR80 BPM


RR: 18 CPM


CVS: S1,S2+


CNS : NFND


RS:BLAE+,NVBS+,


GRBS:12/04/24 :104MG/DL


 13/04/24 :151MG/DL


 14/04/24:


 AT 10 AM: 157MG/DL


 AT 1PM:174MG/DL


 AT 4PM :164 MG/DL


 AT 7PM:173 MG/DL


 AT 10PM :213MG/DL


 AT 2AM: 257MG/DL


 AT 7AM 169 MG/DL


ON 15/04/24


 AT 10AM :161MG/DL


 AT 1PM: 174MG/DL


 AT 4PM: 205MG/D


AT 7PM:216 MG/DL


 AT 10PM :220MG/DL


 AT 2AM: 190MG/DL


 AT 7AM 158MG/DL


PA:SOFT, NT


DERMATOLOGY REFERAL ON 13/04/24 :


DIAGNOSIS : MELESMA +PITYRIASIS VERSICOLOR


ADVICE : TAB. FLUCONOZOLE 400MG STAT


 CANDID TV LOTION L/A (20 MIN BEFORE BATH) FOR 21 DAYS


 DEMELAN CREAM L/A (FACE) OD FOR 4WEEKS


 PHOTOBAN SPF 50 L/A TID FOR 4 WEEKS


ORTHOPAEDICS REFERALON 13/04/24 :


DIAGNOSIS : DEGENERATIVE CHANGES , FIBROMYALGIA OF RIGHT SHOULDER ,TRAPEZIUS


TENDERNESS

ADVICE : TAB. HIFENAC-SP


 TAB. MYORIL 4MG


 TAB .QUADRIS -7


 PHYSIO NECK STRENTHENING EXERCISE


 PROPER DIET DAILY 1EGG/DAY


COURSE AT HOSPITAL : PATIENT WAS ADMITTED IN HOSPITAL IN VIEW OF RIGHT


SHOULDER PAIN AND LOWER BACK ACHE SINCE 6 MONTHS AND CHEST PAIN SINCE


1WEEK .ON FURTHER EVALUATION PATIENT IS DIAGNOSED WITH 1)FIBROMYALGIA OF


RIGHT SHOULDER TRAPEZIUS TENDON 2) ACID PEPTIC DISEASE 3) IRON DEFICIENCY


ANEMIA SECONDARY TO NUTRITIONAL DEFICIENCY 4)MELASMA +PITYRIASIS VERSICOLOR


5) DENEVO DIABETES MELLITUS 6) DENEVO HYPERTENSION .AND ON FURTHER


EVALUATION DERMATOLOGY OPINION WAS TAKEN ON 13/04/24 AND WAS ADVISED WITH ,:


TAB. FLUCONOZOLE 400MG STAT


 CANDID TV LOTION L/A (20 MIN BEFORE BATH) FOR 21 DAYS


 DEMELAN CREAM L/A (FACE) OD FOR 4WEEKS


 PHOTOBAN SPF 50 L/A TID FOR 4 WEEKS


ORTHOPEDICS OPINION WAS ALSO TAKEN ON 13/04/24 AND WAS ADVISED WITH


TAB. HIFENAC-SP


 TAB. MYORIL 4MG


TAB .QUADRIS -7


 PHYSIO NECK STRENTHENING EXERCISE


 PROPER DIET DAILY 1EGG/DAY


AND PATIENT WAS TREATED WITH NSAIDS, MUSCLE RELAXANTS, ORALGLYCEMIC AGENTS


,ARBS, OROFER-XT,ANTACIDS .PATIENT AND PATIENTS ATTENDERS WAS COUNSCELLED


TO CONTINUE THE TABLETS AND WAS DISCHARGED IN HEMODYNAMICALLY STABLE


CONDITION .


Investigation


HEMOGRAM 12/04/24

HEMOGLOBIN 7.8GM/DL

TLC 6300CELLS/CUMM

NEUTROPHILS 61 %

LYMPHOCYTES 30%

EOSINOPHILS 03%

MONOCYTES 06%

BASOPHILS 00 %

PCV 25.6 VOL%

MCV 59.8 FL

MCH 18.2 PG

MCHC 30.5%

RDW-CV 16.9 %

RDW-SD 36.2 FL

RBC COUNT 4.28 MILLIONS/CUMM

PLATELET COUNT 3.96 LAKHS/CU MM


SMEAR

RBC MICROCYTIC HYPOOCHROMIC

WBC WITH IN NORMAL LIMITS

PLATELETS ADEQUATE

HEMOPARASITES NOT SEEN

IMPRESSION MICROCYTIC HYPOOCHROMIC ANEMIA



RFT 12-04-2024 04:41:PM

UREA 15 mg/dl 42-12 mg/dl

CREATININE 0.8 mg/dl 1.1-0.6 mg/dl

URIC ACID 4.5 mmol/L 6-2.6 mmol/L

CALCIUM 10.0 mg/dl 10.2-8.6 mg/dl

PHOSPHOROUS 2.7 mg/dl 4.5-2.5 mg/dl

SODIUM 137 mmol/L 145-136 mmol/L

POTASSIUM 4.2 mmol/L. 5.1-3.5 mmol/L.

CHLORIDE 105 mmol/L 98-107 mmol/L


LIVER FUNCTION TEST (LFT) 12-04-2024 04:41:PM

Total Bilurubin 0.68 mg/dl 1-0 mg/dl

Direct Bilurubin 0.18 mg/dl 0.2-0.0 mg/dl

SGOT(AST) 14 IU/L 31-0 IU/L

SGPT(ALT) 11 IU/L 34-0 IU/L

ALKALINE PHOSPHATASE 140 IU/L 98-42 IU/L

TOTAL PROTEINS 7.0 gm/dl 8.3-6.4 gm/dl

ALBUMIN 4.1 gm/dl 5.2-3.5 gm/dl

A/G RATIO 1.46


HBsAg-RAPID 12-04-2024 04:41:PM Negative

Anti HCV Antibodies - RAPID 12-04-2024 04:41:PM Non Reactive

HIV 1/2RAPID TEST NON REACTIVE


RBS 191 MG/DL


COMPLETE URINE EXAMINATION (CUE) 12-04-2024 04:41:PM

COLOUR Pale yellow

APPEARANCE Clear

REACTION Acidic

SP.GRAVITY 1.010

ALBUMIN Trace

SUGAR Nil

BILE SALTS Nil

BILE PIGMENTS Nil

PUS CELLS 2-4

EPITHELIAL CELLS 2-3

RED BLOOD CELLS Nil

CRYSTALS Nil

CASTS Nil

AMORPHOUS DEPOSITS Absent

OTHERS Nil


PLBS 177 MG/DL


RETICULOCYTE COUNT 0.9 %


SERUM IRON 64 UG/DL


HBA1C 6.9 %


2D ECHO : ON 13/04/24

EF:60%

IVC 1.1CMS ,COLLAPSING


IMPRESSION:

TRIVIAL TR+,NO PAH,MILD AR+, NO MR

NO RWMA ,CONCENTRIC LVH +

GOOD LV SYSTOLIC FUNCTION

GRADE I DIASTOLIC DYSFUNCTION

NO PE/CLOTS


USG: ON 13/04/24

IMPRESSION : GRADE I FATTY LIVER



Treatment Given(Enter only Generic Name)


TAB. PAN 40MG PO/OD/BBF

TAB. MYORIL 4MG PO/BD

TAB .QUADRIS -7 PO/OD

TAB.HIFENAC-P PO/BD

TAB.OROFER XT PO/OD

TAB.SHELCAL-CT PO/OD

 CANDID TV LOTION L/A (20 MIN BEFORE BATH) FOR 21 DAYS

 DEMELAN CREAM L/A (FACE) OD FOR 4WEEKS

 PHOTOBAN SPF 50 L/A TID FOR 4 WEEKS

SYP.SUCRALFATE PO/TID

TAB.MVT PO/OD

TAB. METFORMIN 500MG PO/OD


Advice at Discharge


TAB. PAN 40MG PO/OD/BBF X1WEEK

TAB. HIFENAC-P PO/BD X1WEEK

TAB. MYORIL 4MG PO/BD X1WEEK

TAB .QUADRIS -7 PO/OD X1WEEK

TAB.OROFER XT PO/OD X 3 MONTHS

TAB.SHELCAL-CT PO/OD X1WEEK

CANDID TV LOTION L/A (20 MIN BEFORE BATH) FOR 21 DAYS

DEMELAN CREAM L/A (FACE) OD FOR 4WEEKS

PHOTOBAN SPF 50 L/A TID FOR 4 WEEKS

SYP. SUCRALFATE PO/TID

TAB.TELMA 20MG PO/OD

1 EGG WHITE /DAY

GRBS 70 PROFILE

TAB. METFORMIN 500MG PO/OD CONTINUE..

Follow up:No limitation in physical activity

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