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

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May 29,2021

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 one and half   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 has altered sensorium and not responding to commands. 

 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

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

Oral lesions of mucormycosis

Patient coughed out sputum for KOH mount

His sputum for AFB came positive

KOH mount showed septate hyphae suggestive of aspergillosis

 DIAGNOSIS

.  Dysphagia with ? Uremic encephalopathy

.Kochs with pulmonary and esophageal involvement

.with superadded aspergillosis,oral candidiasis,AKI, uncontrolled sugars

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

 DEATH SUMMARY

 

CAUSE OF DEATH

Antecedent cause of death kochs with pulmonary and esophageal involvement

With superadded aspergillosis

Oral candidasis,AKI , uncontrolled sugars

                   

Immediate cause of death sudden cardiac arrest,severe hypotension