50/F with dyphagia and sob

 

A 50/F WITH SOB SINCE 20 DAYS, ODYNOPHAGIA SINCE 3 DAYS . 


This is an 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 patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box

A 50yr old female came with c/o shortness of Breath (grade 2) since 20 days

C/o difficulty in swallowing solids and liquids since 3 days

Not able to open mouth since 1 day


HOPI: Pt was apparently alright 10 yrs ago and went to Hospital in view of headache, easy fatigability and was diagnosed with hypertension and started on medications

6 years ago hospital in view of weight gain and easy fatigability and was diagnosed with Hypothyroidism and is using Thyronorm 50mcg

Later was diagnosed with Rheumatoid arthritis but is not on any medication 

3 months ago diagnosed with DM and is not in medication 

2 months back pt had c/o cough with expectoration, pain in chest region. Was diagnosed as PULMONARY MILIARY TB and started ATT. After 1 month of use she started developing redness and itching all over the body, ATT induced Erythroderma, stopped ATT (1-2-22) for 20 days and again started using 20 days back











20days back after being discharged from a hospital admitted for ATT induced Erythroderma. She is having SOB (grade 2), not associated with any orthopnea/PND, pedal Edema, chest pain, or palpitations.

From 3 days she is having difficulty in swallowing solids and liquids and from 1 day not able to open her mouth because of pain and c/o reddish discolouration of the tongue.


PAST HISTORY: k/c/o DM since 3 months, (not on medication) 

HTN since 10 yrs 

(On medication)

K/c/o Pulmonary miliary TB on ATT using 3 tablets /day ( HRZE)

K/c/o Rheumatoid Arthritis and not on medication

K/c/o Hypothyroidism since 6 years On Thyronorm 50mcg


O/E : Pt is conscious, coherent and irritable

Pallor +

Icterus +

No cyanosis/ clubbing/ lymphadenopathy 




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