50 year old Female with Dysphagia secondary to strictures/oesophagealwebs iron deficiency anemia CLD Ascites and Proximal myopathy
November 21, 2020
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Her is the case as I have seen:
CASE DISCUSSION
50 year old Female came with complaints of
-Loss of appetite since 2 months
-Throat pain since 2 months
-Difficulty swallowing(to certain solids) since 2 months
-Burning sensation in throat since 2 months .
-Pt was having difficulty standing up from a squatting position since last 15 days.
History of Present Illness
Patient was apparently asymptomatic 2 months back when she developed throat pain, dysphagia (to certain solids), and burning sensation in the throat.
Pt was having difficulty sitting/standing since 15 days due to pain in the LL and also weakness due to decrease in the power of proximal muscles of LL.
No complaints of fever, palpitations, headache, burning, micturition, loss of consciousness.
Past History
Not a k/c/o asthma, diabetes, hypertension, or epilepsy
No H/o any surgery in past
No H/o similar complaints in the past.
Personal History
Patient is a non-vegetarian with decreased appetite having adequate sleep and normal bowel and bladder habits and no addictions.
On Examination
Patient is conscious, coherent, cooperative
Poorly build and malnourished
Pallor- absent
Icterus-absent
Cyanosis-absent
Clubbing- absent
Lymphadenopathy-absent
Edema-absent
Paronychia Present on both hands and feet
Glossitis Present
Angular Cheilitis Present in both corners of the mouth
Pt is afebrile
BP: 100/70 mmm Hg
PR: 66 regular
RR: 22 cycles/min
Systemic Examination
CVS: S1 S2 heard, No murmurs
RS: BAE + , NVBS
PA: Distended abdomen and suprapubic swelling present
CNS: Reflexes absent
Investigations and Findings
Hemoglobin:- 8gm/dL
Ferritin:- 15.1 ng/ml
ESR: 60mm/ 1st hour
Provisional Diagnosis
Dysphasia Secondary to stricture/oesophageal webs
Iron Deficiency Anemia
Compensated Liver Disease and Ascites
Proximal myopathy
Treatments
1) Inj optineuron 1 ampule in 500ml NS/iv/OD
2) Inj PAN 40 mg/iv/OD
3) T. Orofer- xT /OD
4) Monitor BP, PR, RR
DAY 1
Patient complained of vomiting sensation immediately after eating
Pt is afebrile
BP: 90/60 mmm Hg
PR: 69 regular
RR: 20 cycles/min
CVS: S1 S2 heard, No murmurs
RS: BAE + , NVBS
CNS: Well Oriented in T/P/P but reflexes still absent
Stools Passed
No fever spikes
GRBS: 80mg/gl
1) Inj Optineuron 1 amp in 100ml NS/IV/OD
2) Inj PAN 40mg mg/IV/OD
3) T. OROFER- xT / OD
4) Monitor BP, PR, RR
5) Protein powder 2 tbsp in 1 glass of milk
6) Syrup. Cremaffin
Day 2
No fresh complaints
Pt is afebrile
BP: 100/60 mmm Hg
PR: 68 regular
RR: 20 cycles/min
CVS: S1 S2 heard, No murmurs
RS: BAE + , NVBS
CNS: Well Oriented in T/P/P but reflexes still absent
No fever spikes
And stools not passed
GRBS: 85mg/dl
Abdominal Girth: 58 cms
1) Inj Optineuron 1 amp in 100ml NS/IV/OD
2) Inj PAN 40mg mg/IV/OD
3) T. OROFER- xT / OD
4) Monitor BP, PR, RR
5) Protein powder 2 tbsp in 1 glass of milk
6) Syrup. Cremaffin
7) T Lasilactone
8) Fluid Restriction <1.5L/day and salt restriction <2.5 gm/day
9) T. Riboflavin 10mg/OD
10) T. MVT /OD
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