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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