64F With Recurrent Laryngeal Nerve Palsy With Hoarseness 3 yrs, Hypertension Telangana PaJR

06-01-2025

This is an Online E Log Book to discuss our patient's de-identified health data shared after taking her signed informed consent. Here we discuss our patient's problems through series of inputs from available global online community experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

PPM 1 - We saw this patient this Saturday in the OPD and she was showing in ENT for hoarseness of voice and they had diagnosed left vocal cord palsy but apparently discharged her without a chest X-ray not thinking of recurrent laryngeal nerve palsy (perhaps because she didn't have a bovine cough)! @PPM2 was seeing this and recalling how you would not leave an opportunity as a PG to needle biopsy these lesions. @PPM3 @PPM4 would you like to give it a try tomorrow with @PPM5?

PPM 2 - Those were the days!

Now I'm a computer junkie seeing a patient for normal TSH and low T4 (in one random lab report) and contemplating the meaning of life and why Krishna willfully did not stop Duryodhana from going to war!

Oh well!

PPM 1 - 😂

PPM 2 - Can that be labelled as a pancoast tumor sir?

PPM 1 - Yes if it turns out to be bronchogenic carcinoma but I'm hoping it turns out to be tuberculosis.

PPM 1 - 

Afternoon session: 

Chasing the same patient's chest X-ray and HRCT suspicious shadows with ultrasound in the hope of a diagnosis for her 3 year old left vocal cord palsy and 

hoarseness 👇

https://youtu.be/wUSVgawTu3k?feature=shared

EMR SUMMARY

 she came back again yesterday with complaints of bone pains radiating down from both the hypochondria to the thighs:

Age/Gender : 65 Years/Female

Address :

Discharge Type: Relieved

Admission Date: 06/01/2025 09:35 AM

Diagnosis

Fever and body-aches 3 days

ISOLATED) RECURRENT LARYNGEAL NERVE PALSY with hoarseness 3 years 

HYPERTENSION

Case History and Clinical Findings

CHIEF COMPLAINTS:

COMPLAINTS OF FEVER SINCE 3 DAYS, COUGH SINCE 3 DAYS, BODY PAINS SINCE YESTERDAY

HISTORY OF PRESENTING ILLNESS:

PATIENT WAS APPARENTLY ASYMPTOMATIC 3 DAYS BACK THE HE DEVELOPED FEVER, LOW GRADE, INTERMITTENT WITH NO CHILLS AND RIGORS, COUGH WITH SPUTUM, SCANTY, WHITISH, MUCOID, NON BLOOD TINGED, NON FOUL SMELLING, ASSOCIATED WITH BODY PAINS.

H/O LOSS OF WEIGHT AND LOSS OF ASPPETITE SINCE 6 MONTHS H/O GRADE 2 BREATHLESSNESS ON AND OFF

NO H/O BLEEDING TENDENCIES, BURNING MICTURITION, PAIN ABDOMEN NO H/O CHEST PAIN, PALPITATIONS, PND, APNEA

PAST HISTORY: K/C/O HTN SINCE 4 YEARS ON MET-XL 50MG, AMLODIPINE 5 MG NOT TAKEN MEDICATION SINCE 2 DAYS

H/O TB 40 YEARS AGO PERSONAL HISTORY: APPETITE- LOST

 

REGULAR BOWEL MOVEMENT MICTURATION- NORMAL

NO ADDICTIONS

FAMILY HISTORY: NOT SIGNIFICANT GENERAL EXAMINATION:

PATIENT IS C/C/C

NO PALLOR, CYANOSIS, CLUBBING, LYMPHEDENOPATHY, ICTERUS, EDEMA BP: 150/70 MMHG

PR: 121 BPM

RR: 18 CPM SPO2: 87% AT RA GRBS: 97 MG/DL

CVS: S1 S2 +, NO MURMURS RESPIRATORY SYSTEM: BAE+ ABDOMEN: BOWEL SOUNDS- NORMAL CNS: NORMAL

PULMONOLOGY REFERAL WAS TAKEN ON 6/1/25 I/V/O CHEST X RAY FININGS I.E, SHOWING LEFT UPPER LOBE FIBROSIS.CONSERVATIVE MANAGEMENT WAS GIVEN.

Investigation

RFT 06-01-2025 10:02:AM UREA 24 mg/dl 50-17 mg/dl CREATININE 0.8 mg/dl 1.2-0.6 mg/dl URIC

ACID 2.0 mmol/L 6-2.6 mmol/LCALCIUM 9.9 mg/dl 10.2-8.6 mg/dl PHOSPHOROUS 2.7 mg/dl 4.5-2.5

mg/dl SODIUM 137 mmol/L 145-136 mmol/LPOTASSIUM 3.9 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 99

mmol/L 98-107 mmol/L

LIVER FUNCTION TEST (LFT) 06-01-2025 10:02:AM Total Bilurubin 0.58 mg/dl 1-0 mg/dl Direct Bilurubin 0.19 mg/dl 0.2-0.0 mg/dl SGOT(AST) 58 IU/L 31-0 IU/LSGPT(ALT) 25 IU/L 34-0

IU/LALKALINE PHOSPHATASE 119 IU/L 141-53 IU/LTOTAL PROTEINS 6.7 gm/dl 8.3-6.4 gm/dl ALBUMIN 3.3 gm/dl 4.6-3.2 gm/dlA/G RATIO 0.98COMPLETE URINE EXAMINATION (CUE) 06-01-2025 10:02:AM COLOUR Pale yellow APPEARANCE Clear REACTION Acidic SP.GRAVITY

1.010ALBUMIN +SUGAR Nil BILE SALTS Nil BILE PIGMENTS Nil PUS CELLS 3-4EPITHELIAL CELLS 2-4RED BLOOD CELLS Nil CRYSTALS Nil CASTS Nil AMORPHOUS DEPOSITS

Absent OTHERS Nil

HBsAg-RAPID 06-01-2025 10:02:AM Negative Anti HCV Antibodies - RAPID 06-01-2025 10:02:AM

Non Reactive

 

WIDAL TEST 07-01-2025 12:54:AM S.typhi 'O' Antibodies No Agglutination seen S.typhi 'H' Antibodies No Agglutination seen S.PARATYPHI 'AH' ANTIBODY No Agglutination seen S.PARATYPHI 'BH' ANTIBODY No Agglutination seen

ON 6/01/25 USG DONE SHOWING NO SONOLOGICAL ABNORMALITIES. ON 6/01/25 2D ECHO SHOWING -

MODERATE PAH, MILD AR, MILD MODE SO MR TRIVAL PR NO RWNA, NO AS/MS CALCIFIED AV

GOOD LV SYSTOLIC FUNCTIONS

GRADE 1 DIASTOLIC DYSFUNCTIONS, NO LV

HRCT OF CHEST DONE ON 6/1/25 SHOWING

CHRONIC LEFT UPPER LOBE COLLAPSE WITH NO OBSTRUCTING MASS LESION. COMPENSATORY OVERINFLATION OF RIGHT LUNG UPPER LOBE AND LEFT LUNG LOWER LOBE.

MILD FIBROSIS IN POSTERIOR SEGMENT OF RIGHT LUNG UPPER LOBE AND RIGHT MIDDLE LOBE WITH BRONCHIECTASIS IN RIGHT MIDDLE LOBE.

ENLARGED B/L PARATRACHEAL LYMPH NODES MEASURING 9-10MM.

Treatment Given (Enter only Generic Name)

INJ.PIPTAZ 4.5GM IV/TIDX 5DAYS TAB.METXL 25MG PO/BD X 5DAYS TAB.ULTRACET PO1/2/QID X5DAYS TAB.PCM 650MG PO/TID X5DAYS TAB.PAN 40MG PO/OD X5DAYS SYP.ASCORYL 10ML PO/TID X5DAYS SYP.ARISTOZYME 10ML PO/TID X5DAYS NEB.IPRAVENT 6TH HOURLY X 5DAYS NEB.BUDECORT 8TH HOURLY X5DAYS

PROTEIN POWDER IN 1GLASS OF MILK-BD X5DAYS

Advice at Discharge

TAB.METXL 25MG PO/BD X 7DAYS TAB.ULTRACET PO1/2/QID X 7DAYS TAB.PCM 650MG PO/TID X7DAYS TAB.PAN 40MG PO/OD X7DAYS SYP.ASCORYL 10ML PO/TID X7DAYS

 

SYP.ARISTOZYME 10ML PO/TID X7DAYS NEB.IPRAVENT 6TH HOURLY X7DAYS NEB.BUDECORT 8TH HOURLY X 7DAYS PROTEIN POWDER IN 1GLASS OF MILK-BD

Follow Up

REVIEW AFTER 1WEEK TO GM OPD OR IF SOS

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE, DONOT MISS MEDICATIONS. In case

of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care, when and how to obtain urgent care have been explained to me in my own language

SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF PG/INTERNEE

SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY

Discharge Date Date:13/01/2025 Ward: FMW Unit:GM-1

 10-02-2025

PPM 1 - @Caretaker how is your patient now?

Please share her daily hourly activities and also mention when the pain increases every day.

PA - Doctor, the patient is having severe knee pains from the time she left the hospital. No relief with medication.

PPM 1 - Previously she was having pains in the upper sides of her back radiating to her thighs? What happened to that pain? Can they share a deidentified image front and back and lateral with arms and then mark the painful areas with a red marker?

PA - They are planning to the hospital tomorrow alongwith the patient.

PPM 1 - 👍

Yes what we are suspecting is that it could be an indolent malignancy that is slowly spread to the bones but at this juncture it's difficult to investigate unless we get a PET scan which is going to be prohibitively expensive and also detecting a metastatic spread may not really change our line of treatment other than continuing the analgesics that we are giving her.

19-02-2025

PPM 1 - OPD Reviewed this patient just now.

While we had earlier put all our money on malignancy and mets currently we are forced to rethink this could be enthesitis due to her recent post viral chikungunya.