65 year old female with Generalised weakness

 

This is 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 patients’ clinical problems with collective current best evidence-based inputs. 

J. Akash

R.no. 43

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 diagnosis and treatment plan.

 A 65 year old female came to the hospital with the chief complaint of :

       Generalised  weakness since 3 months

    pain and burning sensation in the fingertips                       since 2months

   Difficulty in swallowing since 2 months &Hoarseness of voice since 5days

   Ear pain  since 2 months

HISTORY OF PRESENTING ILLNESS :

 patient was apparently normal 3 years back then she was diagnosed with Diabetes & she is on oral hypoglycemic drugs 

 History of Generalised weakness since 1 year 

History of difficulty in swallowing to solids , normal to fluids.for dysphagia she was given some antibiotics and analgesics by local doctor 

History of ear pain which was aggrevating on exposure to air, reliving on taking medication not associated with any discharge

She developed Pain & burning Sensation in the distal finger tips which was aggrevating while eating & relieving on taking medication

she came to hospital with the same complaints on 28th march 2022 ,she was prescribed medication & advised to admit hospital.

She history of fall on 28th march in the evng when she went to take bath. 

Due to trauma hematoma is formed around eye

PERSONAL HISTORY:

Appetite: Normal

Diet: mixed

Bowel& bladder: regular

Sleep: adequate

Addictions: No addictions

PAST HISTORY:

She has deviation of mouth since age of 5months on right side , she was on herbal medication

-She is a known case of diabetes mellitus since 3 years and she is on regular medication. 

MENSTRUAL HISTORY: attained menopause

FAMILY HISTORY : Insignificant

GENERAL EXAMINATION:

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

Well built and well nourished.

No pallor ,icterus, clubbing, cyanosis, edema, generalised lymphadenopathy.

Vitals :

Temperature: Afebrile

Pulse : 82bpm

BP : 100/70 mm of Hg

RR: 17 cpm

SYSTEMIC EXAMINATION:

 CNS :

highmotor function: intact

Tone:                           Right        Left

              upperlimb     Normal    normal

              lowelimb :     normal     normal

Power:                           Right         left

               upperlimb        5/5.         5/5  

               lowerlimb          5/5          5/5

INVESTIGATIONS:

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 g/dL

A/G ratio: 0.89

    

Chest X-ray: 

 

ECG: 

Xrays:

Provisional Diagnosis:

Reynauds phenomenon with? scleroderma(sclerodactyly)

With laryngopharyngeal reflux disease with 

Right mild NPDR & Left moderate NPDR

Treatment :

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

Treatment plan on 01/04/2022 :