62 year old female with burning sensation in right hand fingertips

CBBLE UDHC SIMILAR CASES 

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 62 year old female, herder by occupation, came with chief complaints of
  • H/o fall on 28/3/22 at 8 PM and 29/3/22 at 3 AM
  • Pedal edema till above ankle since 1 week 
  • Burning sensation of right fingertips since 2 months 
  • Dryness of mouth and inability to swallow since 2 months 
  • Drowsiness since 2 months 
  • Generalized weakness since 1 year 
  • Ear pain and ringing sensation in ears on and off since 2 years 

History of presenting illness: 

Patient was apparently asymptomatic 2 years back and then developed burning sensation of right fingertips since 2 months, which is constant, increases on activity such as mixing food or combing hair. There is no bluish discolouration or paleness of fingers . 

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 squat position, before she could support herself with her hands she fell on her face and that resulted in a swollen right eye.
 
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. 

Dryness of mouth since 2 months associated with intolerance to solid foods. She apparently can only swallow if she drinks water along with her food. She feels like her voice has also changed as she feels pain on trying to talk. 
She feels excessively drowsy since two months, her attenders tell that she prefers sleeping most of the time and is not doing her chores. 

She experiences generalized weakness ever since her husband passed away away due to uncontrolled sugars(both his legs were amputated). 

She experienced pain in both her ears associated with ringing sensation, 2 years back. Not associated with any discharge or loss of hearing. She used ? Medication for it and it reduced. But the ringing sensation does come up occasionally. 

She has pitting type of pedal edema till above her ankle. 

Past history: 

On observing, her mouth is deviated to right side, when asked she reveals she experienced an episode of stroke 5 months of age. She says they used a lot of herbal medicine to correct her deviation. 

3-4 years on regular check up she was diagnosed with Diabetes Mellitus and is on medication for it. 

General examination 

Patient is conscious, coherent and cooperative. 

Pallor is present. 
No icterus, cyanosis, clubbing, koilonychia, lymphadenopathy. 

Temp: 98.5
PR: 90 bpm
BP: 110/70 mm hg
SpO2: 98%
 




Thickening of skin present on her right middle finger. 










CVS: S1 S2 present 
No murmurs, thrills heard. 

RS: BAE present, NVBS heard. 

CNS: E4V5M6

HMF: intact. Conscious. 

Tone:   R.     L
UL.     N.      N 
LL.     N.      N 

Power:  R.     L
UL.       5/5.  5/5
LL.       5/5.  5/5

Reflexes:    R.     L
B.               ++.     ++
T.               ++    + +
S.               ++     ++
K.               ++    ++
A.               ++     ++  

Investigations: 

RBS: 164 mg/dl

Se. Creatinine: 1.2
Se. Uric acid: 11.1
Blood urea: 41

Na: 138
K: 4.8
Cl: 101

LFT: 
Db: 0.16
Tb: 0.57
AST: 64
ALT: 57
ALP: 204
TP: 8.0
Albumin: 3.6
A/G ratio: 0.89

Chest x ray: 



ECG: 


2D ECHO 


Diagnosis:

Raynaud’s phenomenon with AKI
? Scleroderma 

Treatment: 

1. Tab. NIFEDIPINE 10mg TID 
2. IV FLUIDS 2 NS 
3. Inj. ACTRAPID 10 units 
(Morning- afternoon-night)
4. Tab. FOLITRAX 7.5mg once a week 
Every Wednesday 
5. Tab.FOLIC ACID 5mg once a week on Tuesday. 

https://caseopinionsbyrollno156.blogspot.com/2022/03/62-year-old-female-with-burning.html


New admission
ICU 6th bed
30/3/22

S: 
Burning sensation in right fingertips 
Pedal edema till above ankle 
Dryness of mouth 

O: 
Patient is conscious, coherent and cooperative. 

Pallor is present. 
No icterus, cyanosis, clubbing, koilonychia, lymphadenopathy. 
Temp: 97.8
PR: 99 bpm
BP: 120/70 mm hg
SpO2: 98%

CVS: S1 S2 present 
No murmurs, thrills heard. 

RS: BAE present, NVBS heard. 

CNS: E4V5M6

RBS: 164 mg/dl

Se. Creatinine: 1.2
Se. Uric acid: 11.1
Blood urea: 41
Na: 138
K: 4.8
Cl: 101
LFT: 
Db: 0.16
Tb: 0.57
AST: 64
ALT: 57
ALP: 204
TP: 8.0
Albumin: 3.6
A/G ratio: 0.89

A:
Raynaud’s phenomenon with AKI
? Scleroderma 


P: 
1. Tab. NIFEDIPINE 10mg TID 
2. IV FLUIDS 2 NS 
3. Inj. ACTRAPID 10 units 
(Morning- afternoon-night)
4. Tab. FOLITRAX 7.5mg once a week 
Every Wednesday 
5. Tab.FOLIC ACID 5mg once a week on Tuesday.


ENT referral done I/V/O dryness of mouth, difficulty in swallowing solids. 




30/3/22:
Hb:8.3 
TLC: 8000
N/L/E/M: 50/35/5/10
Plt: 1.87 lakh

Se uric acid: 11.5


HbA1c(30/3/22): 6.5 %

LFT: 
Db: 0.17
Tb: 0.6
AST: 55
ALT: 52
ALP: 197
TP: 7.7
Albumin: 3.53

A/G ratio: 0.85

X Ray to look for calcifications






 

Opthalmology referral to look for Roth’s spots to rule out Infective Endocarditis






Comments

Post a Comment

Popular posts from this blog

Medicine Blended Assignment (October)

Image
  I have been given the following cases to solve in an attmept 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 diagnosis and coem up with a treatment plan. This is the link of the questions asked regarding the cases: https://medicinedepartment.blo gspot.com/2020/09/medicine-pap er-for-october-2020-first.html ?m=1 Below are my answers to the Medicine Assignment based on my comprehension of the cases.  First case "57 year old man with jaundice, pedal edema and abdominal distension since three years and bleeding gums since three days" https://swathibogari158. blogspot.com/2020/09/chronic- decompensated-liver-disease. html 1) What is the reason for this patient's ascites?  Ans. This patient has the following features: History  Presenting complaints of Jaundice (icterus seen on sclera) Bilateral Pedal edema (pitting type) extending to...
Read more

Medicine blended assessment

Image
  I have 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 diagnosis with a treatment plan. You can find the complete case here   https://alekyatummala.blogspot.com/2020/09/45-yr-female-with-anasarca.html?m=1 . CASE:   The presenting complaints in order of priority according to me are: 1. Pedal edema Onset: insidious; on and off from 5 months back and progressive edema since 5 days. Bilateral pedal edema. Pitting type (Renal?Cardiac?Hepatic?Severe Malnutrition?)  Progressive over a course of 1 week. Started in lower limbs and progressed to cause facial puffiness and abdominal distention. (facial puffiness hinting at renal cause? could aso be myxoedema?) Aggravating factors: Walking Relieving factors: on rest. Patient went to a doctor regarding this complaint where she was  asked to redu...
Read more

Active learning of the topic Paraparesis

Hello. We had been given a few cases every week to enhance our competence in the field of medicine and taught to enhance our learning by having active conversations with our peers and teachers. You can find the case details here   https://vaish7.blogspot.com/2020/05/medicine.html?m=1  and my interpretation of the case here  https://caseopinionsbyrollno156.blogspot.com/2020/05/trio-of-paraparesis-cases.html I have borrowed this excerpt from my peer  https://medcases.blogspot.com/2020/05/case-discussion-on-paraparesis-case.html   We were given 3 cases of paraparesis with very different etiologies. But in the journey of reaching the diagnosis we came up with a lot of questions. Here's  a peak [29/05/20, 8:38:56 PM] Student16: 1.WHAT IS THE REASON FOR  Elevated Liver enzymes and reduced Creatinine and Lymphocytes ; Frequent Change of Position recommended to the patient ; Rt sided reflexes being more pronounced than left sided ? Does is have anything t...
Read more