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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