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







Vitals


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





















Endoscopy:- Presence of esophageal webs 

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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