65F Burning pain all over body since 15days, known hypertensive

 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 65 year old patient came to the OPD with 

HOPI: Patient was apparently asymptomatic 15 days till she developed burning type of pain all over the body, predominantly on the legs and back which was insidious in onset, gradually progressive relived on.      

The burning pain is associated with itching which produces lesions on repeated scratching.    

Patient also complains of sudden contraction of hands and leg cramps since 10 days 

Patient has history of giddiness/vertigo since 

Negative history: no fever, nausea, vomiting, headache s

Past history: Patient is a known hypertensive since 11 months and is on    Which she takes once daily 

Surgical history: patient met with a RTA 11months back due to which she has rods inserted in both her left leg and left arm

No DM, thyroid, asthma, TB, CAD or CVA 

Personal history: 

Sleep: 

Diet:

Appetite: 

Bowel and bladder movements: 

Addictions: 

Allergies:

Family history: 

General examination: 

Patient is conscious, coherent and cooperative 

She is moderately built and nourished 

Pallor: no

Icterus:no

Cyanosis: no 

Clubbing:no

Lymphadenopathy:

Edema: no 

Vitals: 

BP: 150/100

X-ray of neck