65 year old female with difficulty in swallowing

N.Deepa, 9th semester

Roll no. 93

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.

Date of admission : 29/03/2022

CASE :

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

~Generalised weakness since 1year

~Pain of right 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

HOPI :

• 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 and she is on regular oral medication since then.

• 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 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, after getting down the bus, she landed on a sloped 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