50M with dysphagia and altered sensorium.

-

50 year old,male patient with history of dysphagia and altered sensorium.

M.Rambai,8 th semester
Roll number:78


I've 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. 


Following is the view of my case(admitted on 28/5/2021.


CASE:
           
 50 year old,male patient,farmer by occupation,came with chief complaints of Dysphagia ( both solids and liquids) since 2 days
.Altered sensorium since 2 days
. irrelevant speech and not oriented to commands since 2 days
. decreased urine output since 2 days


HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 10 days back, following which he had throat pain, which slowly progressed to difficulty in swallowing to both solids and liquids since 2 days
No hoarseness of voice
Patient starts coughing after drinking small quantity of water
History of fever is present for 3 days,subsided on medication.
.In V/o throat pain_patient visited local hospital, where they told he had oropharyngeal candidiasis and prescribed medication for it.
Following Indirect laryngoscopic procedure, patient went home_ then he had 1 episode of blood tinged vomiting (around100 ml).
Patient has loss of appetite and was not able to eat since 2 days.
No history of weakness , deviation of mouth
No sensory symptoms
No bowel and bladder intolerance
No pedal edema
No history of loose stools,pain abdomen, constipation, burning micturation
No history of cough
No history of hematuria
No shortness of breath


PAST HISTORY:

Patient is a known of Diabetis melitus since 4 years, for which he is taking medication regularly.
No history of hypertension, asthma, epilepsy,CAD
No surgical history


PERSONAL HISTORY:
 
Diet - mixed
Appetite - decreased
Sleep - adequate
Bowel movements - Regular
Bladder - decreased urine output
Addictions - occasional alcoholic
Allergies - None 

FAMILY HISTORY:

There is no significant family history


GENERAL EXAMINATION

The patient was conscious , coherent and co.operative .
He is well oriented to time ,place and person.
Patient is moderately built

Pallor - present
Icterus - present
No cyanosis
No clubbing
No lymphadenopathy
No bilateral pedal edema

VITALS

Temperature -afebrile
Pulse rate -132 BPM
Blood pressure -70/80 mm of Hg
Spo2 -100% at room air
GRBS -381 mg 


SYSTEMIC EXAMINATION

CVS - S1 , S2 heart sounds heard,no murmurs

RESPIRATORY SYSTEM -bilateral air entry present

ABDOMEN - soft and non tender
                       Bowel sounds are heard
                      No organomegaly

CNS :
   Level of consciousness- altered sensorium present
.No signs of menigeal irritation
.motor system - patient not following commands in altered sensorium
. Glasgow scale -E4V3M4


ENT EXAMINATION

 ORAL CAVITY

.Grade 1 trismus is present
                             
.Congestion is present over anterior 2/3 rd of tongue

.white patches are present over buccal mucosa

OROPHARYNX
.white patches are present over soft palate and posterior pharyngeal wall
. congestion is present

NOSE
.External nasal framework - normal
.Vestibule - normal 
.Columella - normal

Anterior Rhinoscopy -mild DNS ( deviated nasal septum)to right side is seen
                Turbinates - normal
                  Nasal mucosa - normal

NECK - No obvious swelling

            constricted pupil (meiosis)


.     
Blood stained lesions in oral cavity

INVESTIGATIONS

CBP - Haemoglobin - 8.5 gm%
          TLC - 32,700 
          DLC - neutrophils -80%
                     Lymphocytes -10%
                    Eosinophils -09%
                     Monocytes -01%
                    Basophils -00%
                  Platelets - adequate

RANDOM BLOOD SUGAR -199 mg/dl

VIRAL SCREENING
 
HIV test 1 and 2 - non reactive
HbsAg - negative


Hemogram

CUE


Urine ketones 


Usg Abdomen

CXR 



ECG

Ent referal was taken in view of dysphagia and oropharyngeal candidiasis




DIAGNOSIS

. Dysphagia secondary to oropharyngeal candidiasis
.?septic encephalopathy
.? Uremic encephalopathy


TREATMENT
.IVF -normal saline -75 ml/hr

.inj -PAN 40 mg /IV/ OD

.inj -PIPTAZ 4.5 g /IV/ STAT

.inj.PIPTAZ 2.25 g /IV/TID

.inj.ZOFER 4 mg /IV/BD

.tab .fluconazole 200 mg/BD _ 5 days

.candid mouth paint for L/A

.inj .HAI s/c

 .inj .optineurin 1 amp in 100 ml NS/ IV/OD

.Tab.Limcee 500 mg / OD

. monitor vitals 4 th hourly

. GRBS charting 6 th hourly.

.2litres of fluid bolus IV was given.

.50 mcg NAHCO3 direct IV given.

.100 mcg NAHCO3 in 200 ml NS/IV was given




Comments

Post a Comment

Popular posts from this blog

20F severe headache, neckpains and vomitings.

-
Image
First admission discharge summary Age/Gender : 21 Years/Female Address : Discharge Type: Relieved Admission Date: 27/09/2022 04:57 PM Date of Operation MLC No DR.ADITYA [SR] DR.CHARAN[PGY3] DR.DEEPIKA[PGY1] Diagnosis SYSTEMIC LUPUS ERYTHEMATOSUS WITH GLOMERULONEPHRITIC FLARE UP OF LUPUS NEPHRITIS ?CATASTROPHIC APLA SECONDARY TO SLE [LIBMAN SACKS ENDOCARDITIS ,CNS THROMBO EMBOLISM, AND RENAL FAILURE] Case History and Clinical Findings 20 YR OLD FEMALE CAME ITH C/O B/L PEDAL EDEMA SINCE 15 DAYS HYPERPIGMENTED MACULES SINCE 15 DAYS FEVER SINCE 15 DAYS ABDOMINAL DISTENSION SINCE 8 DAYS DRY COUGH SINCE 7 DAYS SORE THROAT SINCE 7 DAYS DECREASED APPETITE SINCE 7 DAYS SOB SINCE 5 DAYS DECREASED URINE OUTPUT SINCE 3 DAYS CONSTIPATION SINCE 3 DAYS HOPI -20 YEAR OLD FEMALE CAME WITH C/O OF B/L PEDAL EDEMA EXTENDING TILL THE KNEES PITTING TYPE SINCE 15DAYS   FOR WHICH SHE GOT MEDICAL HEALTH CHECKUP AND PRESCRIBED SOME MEDICATION [UNKNOWN] THEN HER PEDAL EDEMA GOT RESOLVED ALNG WITH FEVER SHE D...
Read more

BLACK FUNGUS in patient with DKA after COVID19 vaccination

-
Image
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. Dr. Saicharan kulkarni - ICU pg Dr. Rakesh Biswas - prof & HOD General Medicine. A 65 year old daily waged labouror was brought to casuality with :  altered sensorium since 1 day,  weakness of Right upperlimb and lower limb since 3 days, Ocular swelling since 3-4 days Facial puffiness since 3-4 days Fever since 12 days. Patient was apparently asymptomatic 3 years back and went to local hospital in/v/o Regular checkup and came to diagnosed with Hypertension since ...
Read more

ONLINE RESUME ( CV )

-
  Dr.Saicharan Kulkarni   MBBS, MD General Medicine General Medicine Specialist | Precision Medicine Advocate |  AI Healthcare Enthusiast | Health Influencer & Coach         Contact Hyderabad 9154575937 Twitter Threads Instagram Email   Hi..👋 i am Dr. Sai charan kulkarni  a dedicated  General Medicine Doctor  committed to enhance patient well-being through a holistic approach. With expertise in  preventive and therapeutic medicine ,  precision healthcare , and the integration of  artificial intelligence  into clinical practice, To empower individuals to take charge of their health, one personalized step at a time. 🌿💙 Objective As a dedicated  General Medicine Doctor , I am committed to enhancing patient well-being through a holistic approach. My expertise spans   preventive and therapeutic medicine ,   precision healthcare , and the integration of   artificial intelligence   into ...
Read more