Hi, I am p.samhitha, 5th Sem Medical Student.This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent

I am p.samhitha, 5th Sem Medical Student.This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment 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, investigations and come up with a diagnosis and treatment plan.54F came to the OPD with chief complaint of generalised body ache

C/c : 
Pt came to OPD with chief complaints of generalised body pain

Hopi: 
Pain was insidious in onset and gradually progressive ,aggreviates on work and relieves on rest.
She even complains of joint pains 
H/O headache, fever,dizziness, blurring of vision and a significant amount of weight loss
No H/O palpations,chest pain,vomitings

Past history: 
K/C/O DM for past 1 and 1/2 years and is on metformin 500 medication
Not a K/C/O HTN, Thyroid, CAD, asthma

Personal history
Diet is mixed
Appetite is lost
Sleep is adequate
Bowel n bladder movements are normal
No known allergies
No addictions
No surgeries

Family history: 
No significant family history

General examination:
Patient was moderately built, weak , conscious
No signs of pallor,icterus, clubbing, cyanosis, lymphedenopathy,pedal edema
No significant marka
Bp:120/80mm of Hg
RR: 12cycles per minute
Pulse rate: 72bpm
Temperature:afebrile

Clinical images :Pt didn't provide any consent

Reports:
Patient's fasting GRBS = 106mg/dl

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