A 75 year old female with Dysphagia under evaluation
Date of admission: 09/09/21:
A 75 year old female came to casuality with c/o : Difficulty in swallowing to both solids and liquids since 1 week .
HOPI:
Pt was apparently asymptomatic 20 days back. Then she had h/o decrease appetite and got worsened since 7 days which was a/w pain abdomen , constricting type/colicky type of pain . H/o weight loss since 2 to 3 years - decreased progressively. No H/o nausea, vomiting, fever, cold, cough , abdominal bloating .
Past history:
Not k/c/o type 2 DM, HTN, Asthma, TB, Epilepsy
No similar complaints in the past
Personal history:
Diet: mixed
Appetite : decreased
Sleep: adequate
Bowel n bladder : regular
Addictions: No
O/E:
Pt is conscious, oriented to time, place, person
No pallor, Icterus, cyanosis, clubbing , lymphadenopathy , edema
vitals:
Temp-afebrile
Bp- 110/70 mm hg
PR- 72bpm
Spo2-99% at RA
RR-18 cpm
GRBS -149 mg/dl
Systemic examination:
Cvs: s1 s2 present , no murmurs
RS:BAE present , NVBS
P/A: soft, non tender
Cns- intact
Provisional diagnosis:
Dysphagia under evaluation
Abdomen:
Investigations :
Hemogram-
Hb:11.8
TLC: 9700
PLT : 2.8 lakhs/cumm
ESR: 25mm /1st hr
RFT:
Blood urea -31
Serum Creatinine- 1.1 mg/dl
Na+ 144
K+ 3.7
Cl- 102
LFT:
TB- 2.37 mg/dl
DB- 0.72 mg/dl
ALP- 289 meq/lit
SGOT- 18 IU/lit
SGPT- 16IU/lit
TP- 5.2 gm/dl
Albumin: 2.89
A/G ratio: 1.25
Serology: negative
Chest xray:
Treatment given:
Day 0:
1. IV fluids - ns with optineuron@ 100 ml/hr, RL, DNS
2. Inj. Pan 40 mg IV OD
3. Inj. Zofer 4 mg IV sos
4. Inj. Buscopan 1 amp IV sos
5. Inform sos
Day 1:
IV fluids - ns with optineuron@ 100 ml/hr, RL, DNS
2. Inj. Pan 40 mg IV OD
3. Inj. Zofer 4 mg IV sos
4. Inj. Buscopan 1 amp IV sos
5. Inform sos
Day 2:
IV fluids - ns with optineuron@ 100 ml/hr, RL, DNS
2. Inj. Pan 40 mg IV OD
3. Inj. Zofer 4 mg IV sos
4. Inj. Buscopan 1 amp IV sos
5. Inform sos
Advice at discharge:
plan for endoscopy
Discharge summary:
