42 yr old woman with multiple health events since birth

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 a diagnosis and the following is my analysis of this patients problem:

the problems in order of priority i found are

CHIEF COMPLAINTS.

1) Frequent falls to the left. Left foot started giving out as well as hand. one fall down stairs sprained and broke ankle (last year) X-ray below. Poor stress response.

2) Swelling/ hair loss (head and eyelashes) Fatigue. Left jaw pain up into face.

3) Breathing difficulties.

4)intolerance from most foods, smoke.  

5)Always less urination which increase when fasting.

 6)Sleep was bad with 2-4 hours.

Obstetric history:

H/o of ectopic pregnancy.

Menstrual history:

Menarche -14 years

During mensus severe headache and abdominal pain.

Diagnosed with PCOD.

Family history: 

Mother had fibromyalgia.

Father got heart attacks in early 40's

Drug history: 

Allergic to sulfa drugs and antimalarials .

Surgical history: 

LASIK done at 35 yrs is failed and diagnosed as dyslexic.

Personal history

Apple once a day

Sleep: inadequate

Bowel/ Bladder movements: regular

Appetite: reduced

No addictions

Investigations done

CBP shows she is anaemic

AST and ALT increased

Chest x ray shows left atrial enlargement

 

Further investigations

1.Ldh levels

2.bilirubin levels

3.peripheral blood smear

Treatment

She is on medication of Cimetidine

Control of triggers which cause swelling. 

2.increased pain tolerance

Onset: since 4 years still present

Associated complaints

Multiple fractures

Fracture of knee

Probably diagnosis

Osteoarthritis

Pcod may be reason because of low estrogen 

CIPA congenital intolerance to pain with anhydrosis

3.Sleep deprivation

Onset: 

Since birth

Duration of sleep 2 to 4 hours

Probable causes are G6PD deficiency in this there will be impaired glycolysis so glycine is inhibitory NT

AMPDI deficiency

 Treatment :she is on medication of serine and Cemitidine

4.Decreased frequency of  urination probably due to G6PD deficiency in this there is reduced production of NADPH and lack of ions which cause decrease in urinary output and dark color urine. 

Other causes could be physical trauma, infection 

Investigations : urinary output 

CUE

CT abdomen

Blood test

Treatment :increased fluid intake, diuretics, anti microbials in case of infection.