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90 Y/O WITH SWELLING OF TONGUE

 

This is an online E-log entry blog to discuss and understand the clinical data analysis of a patient, to develop competency in comprehending clinical problems, and providing evidence- based inputs in order to come up with a diagnosis and effective treatment plan to the best of my ability.



A 90 year old female, R/O yerramguda came with the chief complaints of:

1. Slurring of speech since 1 day

2. Swelling of tongue since 1day

3. Fever since 1day


The patient was apparently asymtomatic 3 months back when she developed fever, which was high grade, associated with chills and rigors, and decreased on taking medication. The fever subsided after 4 days.

Along with the fever, she also developed redness in the mouth, with no other symptoms as mentioned by her. 

2 months ago, she slipped on the bathroom and fell, which caused a fracture to get right femur. Surgery was done for it at our hospital, and she started walking around with the help of support. She still continues to do so. 

1 day ago, she developed fever which was high grade, associated with chills and rigors. Additionally, she also developed redness of her tongue and pain during swallowing. Additionally, her family noted that she was slurring her words. However, she was still coherent. Following this episode, she was brought to the hospital.

She also has intention tremors since over 30 years, over her limbs and abdomen. However, she does not remember how it started, and did not go to a doctor for the same. 

She had no history of allergies, rash, SOB, cough or lip swelling.


PAST HISTORY

One similar episode 3 months ago

No history of DM, HTN, thyroid, CAD

Surgery done for fracture of femur 2 months ago


PERSONAL HISTORY

Diet: Mixed

Appetite: Normal

Sleep: Adequate

Bowel and bladder: Regular

No allergies or addictions


FAMILY HISTORY

Both her mother and one of her sons also have tremors, however, shr could not remember since when.


DRUG HISTORY

She has been taking PCM SOS and Calcium tablets OD since 2months, following her fracture.


GENERAL EXAMINATION

Patient examined in well lit room with informed consent.

C/C/C and well oriented to time, person, place

Pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema absent

PR: 86bpm

RR: 16cpm

BP: 140/90mmHg

Temp: Febrile, 99

Spo2: 98% at RA





SYSTEMIC EXAMINATION

RS: BAE, NVBS

CVS: S1, S2 heard, no murmurs

P/A: Soft, non tender

CNS: Intention tremors, cranial nerves examination normal 



ORAL EXAMINATION:

1. Swelling of tongue present with blisters on tip of tongue. Tongue tender

2. Upper molar tooth caries present with loss of dentition

3. Generalized gingival edema

4. Erythmatous oral mucosa

5. Angular cheilitis

6. Submental fullness +, with local rise in temperature. Tenderness -

7. Gag reflex +, laryngeal crepitus +

8. Enlarged LN (?), Tender


PROVISIONAL DIAGNOSIS: 

Oral candidiasis with cervical lymphadenopathy and tremors

Ludwig's angina (?)


TREATMENT:

1. IVF NS AND RL (100ML/HR)

2. INJ. AUGMENTIN 1.2GM/IV/BD

3. INJ. METROGYL 500MG IV TID

4. TAB FLUCONAZOLE 100MG/RT/OD

5. TAB PCM 650MG RT TID

6. TAB PAN 40MG/RT/OD

7. TAB ALLEGRA 120MG

8. TAB OPTINEURON IN 100ML NS

9. CHLORHEXIDINE MOUTHWASH

10. VITALS MONITORING



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