42F Burning Micturition since 4months, Body pains since 1 month and Hoarse voice since 1 day

  This is an online e log book to discuss our patients deidentified health data shared after taking his or her guardian’s signed informed consent. Here we discuss our individual patient’s problems with collectors current best evident input. This e blog also reflects my patient centered online learning portfolio and your valuable inputs in the comments 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, investigation and come up with diagnosis and treatment. 

A 42 year old patient came to the OPD with 

HOPI: Patient was apparently asymptomatic 4 months ago till she developed burning micturition which was insidious in onset, gradually progressive and relived on taking medication. She also has a history of frequent urination( 10 times per day) 

There is history of dragging type of pain in the arms, legs, knee and paraspinal region and  since 1 month which is intermittent, temporarily relieved on taking medication and aggravated on working. The pain is associated with pitting type of bilateral pedal edema. 

Patient had a fever 1 day again which was relieved on taking medication but hoarseness of voice persists 

Negative history: nausea, vomiting, headache, cough or rhinitis 

No DM, HTN, asthma, TB, CAD or CVA 

Past history: k/c/o hypothyroidism since 5 years and is on medication which is taken once daily 

Surgical history: patient had a tympanoplasty in both ears 

Right ear : 20 years ago 

Left ear: 5 years ago 

Due to unsafe type of CSOM 

Personal history: 

Sleep: Adequate

Diet:mixed

Appetite: decreased 

Bowel movements: normal 

Bladder movements: burning micturition and increased frequency since many years (10 times per day ) 

Addictions: nil 

Allergies: nil

Family history: husband also has hypothyroidism and burning micturition 

General examination: 

Patient is conscious, coherent and cooperative 

She is moderately built and nourished 

Pallor: no

Icterus:no

Cyanosis: no 

Clubbing:no

Lymphadenopathy:

Edema: pitting type of bilateral pedal edema observed 

Vitals: 

Pulse: 76 bpm

RR:26 rpm

BP: 110/80 mmHg