A 50 YEAR OLD WOMAN WITH SOB,ODYNOPHAGIA

 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT.    

This E blog 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 diagnosis and treatment plan 

A 50 year old woman came to OPD with chief complaints of shortness of breath ( grade 2) since 20 days ,difficulty in swallowing both solids and liquids since 4 days .

HISTORY OF PRESENT ILLNESS:

Patient was apparently alright 10 yrs ago and went to Hospital in view of headache, easy fatigability and was diagnosed with hypertension and started on medications

6 years ago hospital in view of weight gain and easy fatigability and was diagnosed with Hypothyroidism and is using Thyronorm 50mcg

Later was diagnosed with Rheumatoid arthritis but is not on any medication 

3 months ago diagnosed with DM and is not in medication 

2 months back pt had c/o cough with expectoration, pain in chest region. Was diagnosed as PULMONARY MILIARY TB and started ATT. After 1 month of use she started developing redness and itching all over the body, ATT induced Erythroderma, stopped ATT (1-2-22) for 20 days and again started using 20 days back

20days back after being discharged from a hospital admitted for ATT induced Erythroderma. She is having SOB (grade 2), not associated with any orthopnea/PND, pedal Edema, chest pain, or palpitations.

From 4 days she is having difficulty in swallowing solids and liquids and from 2 daya she is not able to open her mouth because of pain and c/o reddish discolouration of the tongue.

PAST HISTORY: she is a k/c/o HTN since 10 years (on medication)

 Hypothyroidism since 6 years ( on thyronorm 50 mcg

DM since 3 months( not on medication)

k/c/o of miliary TB and she is on ATT ( HRZE), she is also suffering from rheumatoid arthritis

PERSONAL HISTORY:

DIET:mixed

APPETITE: good

BOWEL AND BLADDER MOVEMENTS:regulat

SLEEP: not adequate

ADDICTIONS :no addictions  

FAMILY HISTORY:  no significant family history

allergic reactions due to ATT

GENERAL PHYSICAL EXAMINATION: 

Patient is conscious,coherent ,irritable

pallor and icterus +

cyanosis,clubbing,lymphadenopathy absent

Vitals at the time of admission: 

Temperature:100F

PR: 98bpm

BP:130/80mm Hg

RR:27cpm

Spo2: 95%

GRBS:105gm%

SYSTEMIC EXAMINATION:

CVS: JVP NORMAL, Apex beat 5th IV space mid clavicular lines1s2 +

RS: BAE + , B/L crepts + (ISA, IAA)

P/A: soft, non tender , BS +

CNS : No focal neurological deficits

RBS: 70mg/dl

HbA1c : 6.8%

RFT

Blood Urea: 136mg/dl 

S. Creatinine: 4.8mg/dl

Na 139

K 3.0

Cl 102

Hemogram

HB 7.2

TC 15,000

MCV 80.4

PCV 21.5

MCH 27.0

MCHC 33.6

PLT 3.67

RDW 62

P.S NORMOCYTIC, NORMOCHROMIC

Serum iron : 45ug/dl

ABG

pH 7.34

PCo2 18.8

PaO2 92.4

HCO3 12.2

SpO2 96

LFT

TB 2.8

DB 0.74

AST 14

ALT 10

ALP 673

TP 7.4

ALB 2.23

CUE

ALB ++

Sugars nil

Pus cells plenty

Epithelial cells 1-2

ESR - 70

CRP - POSITIVE

Chest X-ray:

LATERAL VIEW OF NECK:

ECG:

HRCT chest:

Few small volume medianal lumph nodes noted

Both lungs are studded with tiny nodular densities - Likely Milliary tuberculosis.

Small air filled cyst noted left lower lobe.

No evidence of effusion.

USG ABDOMEN:

Patient Referals

DERMATOLOGY:

PULMONOLOGY:

ENT:

PROVISIONAL DIAGNOSIS:

Dysphagia under evaluation

Anemia under evaluation

?Plummer Vinson Syndrome

AKI secondary to ?pre renal ?UTI

Steven-johnson syndrome secondary to ATT with

Urosepsis with

Milliary pulmonary tuberculosis with

?nephrotic syndrome

DM,HTN, HYPOTHYROIDISM, RHEUMATOID ARTHRITIS

Treatment:

IVF NS/RL/DNS @ 75 ml/hr

Inj. NaHCO3 50meq over 10 mins + 50meq over 40 mins

NEB. Ipravent 1resp inH TID

NEB. BUDICORT 1RESP INH TID

INJ. HUMAN ATRAPID according to sliding scale

Inj. PIPTAZ 2.25 gm IV TID

T. Thyronorm 50 mg PO OD

INJ. PAN 40 MG IV OD

T. AMLONG 5 MG PO OD

MUCOPAIN JEL L/A 40 MINS BEFORE MEAL

Betadine mouth wash TID

Liquid paraffin all over body TID

Reference

https://swathi162.blogspot.com/2022/03/50-year-old-female-with-dysphagia-under.html?m=1