Evidence Based Patient Care: 46 years lady suffering from headache and backache seeking medical advice

This is a de-identified open-online-patient-record with initial information from Doctor's notes, diagnostic test results, as well as patients' voice. Posted here after collecting informed "Patient Consent" (DOWNLOADABLE HERE) by Health Worker DEBASISH ACHARJEE from PIN Code area 731204 for discussion.

ID: Buchanania731lanzan.spreng

Sir,

I am 46 years aged lady, suffering from head ache and back pain, seeking medical experts’ advice, due to COVID-19 lock down, I’m facing difficulties to consult with local medical practitioner.

I have been a diabetic patient since mid-2015, but have not been able to get proper treatment and have not paid much attention to myself because I am alone. I am currently undergoing treatment under a doctor from Kolkata for the past few years (due to distance from xyz to Kolkata I consult with every 6 months gap), if needed I consult with local Doctor from xyz. Since I am alone, I cannot make any special consideration for better treatment facilities at tertiary level Medical Institution. I have been suffering for a long time but I have not been able to do anything. I need further treatment now. I am following prescription and I am better, except for headaches and back pains. Today said pain increased. Due to COVID19 lock down I am facing difficulties to consult any local doctor.

Date	Test name	Result	Reference	Remarks
21-06-2019	LIPID PROFILE (PACKAGE)
	S.CHOLESTEROL	150 mg/dl	0-200
	S. TRIGLYCERIDE	157 mg/dl	0-200
	S. HDL CHOLESTEROL	57 mg/dl	>35
	S. LDL CHOLESTEROL	75 mg/dl	0-130
	VLDL	18 mg/dl	0-40
	CHOLESTEROL HDL	2.63	0-5
	HDL/LDL	0.76
21-06-2019	TSH	2.1
21-06-2019	GLUCOSE (F)	133 mg/dl	70-110
	GLUCOSE (P)	219 mg/dl	70-140

ECG report attached ( Impression: Within Normal Limit)

Current medications:

1. SR Tab. Pioplus 2 (Glimepride 2mg + Mertformin 500mg + Pioglitazone 15 mg) - 1 Tab daily

2. Tab. Eltroxin 75 mcg (Thyroxine Sodium 75 mcg)- 1 Tab daily

3. Tab. Giftan-50 (Losartan Potassium 50mg) – 1 Tab daily

4. Tab. Orvas 10 ( Atorvastatin 10mg) 1 –Tab daily

5. ME-PXL (Pregabalin 75mg + Methylcobalamin 1500mcg) (Discontinued as doctors advise)

6. SR Cap. Rablet D. (Rabeprazol 20 mg + Domperidone 30mg) -1 cap

Personal Medical History: I had an accident in 2016 when I fell from a scooter. I got injury in head. I have been healthy since I was little. However, jaundice occurred at the age of 2 years.

Family Medical History: Both parents died of heart attacks. Mother was a heart patient and died after a long illness. Dad was a diabetic patient but died suddenly of a heart attack.

Prescriptions: