65 year old female with difficulty in swallowing

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Jatin Sharma

Roll no. 46

65 year old female with difficulty in swallowing

-A 65 year old female, herder by occupation, bought to the opd with chief complaints of

-Ear pain and ringing sensation in ears on and off since 2 years 

-Generalized weakness since 1year

-Pain of right hand fingertips since 2 months 

-Dryness of mouth and inability to swallow since 2 months

-H/o fall on 28/3/22 at 8 PM and 29/3/22 at 3 AM  

History of presenting illness 

- Patient was apparently asymptomatic 4 years back. Later after the death of her husband , her family members took her to the hospital because she was experiencing weakness. Then she was tested and diagnosed with diabetes mellitus. 

- She developed ringing sensation and pain in ears on and off since 2 years. She also complains of fullness in the ear. Not associated with any discharge or loss of hearing. She says that it decreases on taking medication( No information regarding the medication) But the ringing sensation does come up occasionally. 

- Dryness of mouth since 2 months associated with difficulty in swallowing. It was insidious in onset and gradually progressive. The difficulty in swallowing is more for solids than liquids. She apparently can only swallow if she drinks water along with her food. It is associated with loss of appetite and early satiety. She feels like her voice has also changed as she feels pain on trying to talk. 

- Pricking type of Pain of right hand fingertips since 2 months, which is constant, increases on activity such as mixing food or combing hair so she stopped doing house chores and sleeps most of the time.There is discoloration at the tips of fingers. 

- 2 months back, while getting down the bus, she landed on an uneven surface, lost her balance and tumbled down. She lost her consciousness for 5 minutes and was later woken up by her daughter and was given water. She walked back home after this episode. She had trauma to head and laceration on her left arm. 

- She has history of fall on 28/3/22 at 8pm when she went to take a bath, she sat on a stool and fell back. 

- At 3 AM, she woke up to urinate, went to the washroom and sat in squatting position, before she could support herself with her hands, she fell on her face and that resulted in a swollen right eye.

Past history 

- She has deviation of mouth since age of 5months on right side for which she used a lot of ?herbal medication

- She is a known case of diabetes mellitus since 4 years and she is on regular medication. 

Personal history 

- Diet : Mixed

- Appetite : Decreased

- Bowel and bladder movements : Regular

- Sleep : Disturbed 

- No allergies

- No addictions

Menstrual history 

- Attained menopause

Family history 

-No history of diabetes, hypertension, heart disease, TB, Cancer

General examination 

- Patient is conscious, coherent , co-operative and oriented to time, place and person. 

 consent is taken. 

Well built and well nourished. 

- Pallor is present. 

- No icterus, cyanosis, clubbing, generalized lymphadenopathy and bilateral pedal edema. 

Vitals 

PR: 90bpm

BP: 110/70mmHg

RR: 16cpm

Temperature: Afebrile

Systemic examination 

CVS: S1 S2 present 

No murmurs, thrills heard. 

RS: BAE present, NVBS heard. 

CNS: E4V5M6

HMF: intact. Conscious. 

Tone:   R.     L

UL.     N.      N 

LL.     N.      N 

Power:  R.     L

UL.       5/5.  5/5

LL.       5/5.  5/5

Rhomberg  sign - negative 

Gait

Investigations 

30/3/22

HB 8.3

PCV 24.1

MCV 89.6

PLT 1.87 L

RBS: 164 mg/dl

Se. Creatinine: 1.2 mg/dL( on 29/3/2022) 

                            2.4mg /dL ( on 28/3/2022) 

Se. Uric acid: 11.1 mg/dL

Blood urea: 41 mg/dL

Na: 138 mEq/L

K: 4.8 mEq/L

Cl: 101 mEq/L

LFT: 

Db: 0.16 mg/dL

Tb: 0.57 mg/dL

AST: 64 IU/L

ALT: 57 IU/L

ALP: 204 IU/L

TP: 8.0 gm/dL

Albumin: 3.6 gm/dL

A/G ratio: 0.89

Chest X-ray

ECG

ENT REFERAL : 

Doppler 2d echo:

X- rays :

Provisional Diagnosis:

- Crest syndrome? 

- Heart failure? 

- RAYNAUDS phenomenon  with scleroderma ?

Treatment plan:

1. Tab. NIFEDIPINE 10mg TID 

2. IV FLUIDS 2 NS 

3. Inj. ACTRAPID 10 units 

(Morning- afternoon-night)

4. Tab. FOLITRAX  ( methotrexate)7.5mg once a week 

Every Wednesday 

5. Tab.FOLIC ACID 5mg once a week on Tuesday.

1/4/22

1. Tab. NIFEDIPINE 10mg TID 

2. IV FLUIDS 2 NS 

3. Inj. ACTRAPID 10 units 

(Morning- afternoon-night)

4. Tab. FOLITRAX ( methotrexate)7.5mg once a week 

Every Wednesday 

5. Tab.FOLIC ACID 5mg once a week on Tuesday.

6.GRBS 6th hourly (8.am,2.pm,8pm, 2am)

7.T.LYSER-D (2 BD)

8.T.PAN 40 mg OD 

9.T. LIMCE 500mg afternoon