Case of a 65 year old female with pain in the fingertips and difficulty in swallowing solids

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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 come up with a diagnosis and treatment plan.

CASE PRESENTATION:

This is a case of a 65 year old female, herder by occupation, who came on 28/3/22 with :

CHIEF COMPLAINTS :

Pain in the right fingertips since 2 months
Dryness of mouth and difficulty in swallowing solids since 2 months

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 2 months back and then she developed pricking type of pain and bluish discolouration of the right upper limb distal phalanges.

Patient also complains of dryness of mouth since 2 months associated with intolerance to solid foods. She can only swallow solid foods with water. She has noticed hoarseness in her voice since 3 days.

She had pain and ringing sensation in the right ear associated with aural fullness 2 months back. She was taken to the hospital and was prescribed medication. The pain reduced but tinnitus is intermittent in nature.

Patient also complains of generalized weakness since 1 month. She also has a history of loss of consciousness few times.

The patient attenders mentioned that she has been sleeping for longer hours for the past few months.

On 28/3/22 at 3 am, she woke up to urinate, 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.

4 years back she had pain in the left lower limb which was associated with redness and swelling. This was attributed to a insect bite for which she was taken to the hospital and on evaluation she was diagnosed with diabetes. From then on she has been on medication for diabetes.

PAST HISTORY:

She had a history of stroke at the age of 5 months and her mouth is deviated to the right side since then. She has used some herbal medication to correct her mouth deviation.

K/C/O Diabetes mellitus since 4 years and has been on regular medication since then.

Not a K/C/O HTN, TB, epilepsy, asthma.

FAMILY HISTORY:

The patient's husband had H/O diabetes.

PERSONAL HISTORY:

Diet: Mixed

Sleep: Increased

Appetite: Decreased

Bowel and bladder: Regular

No addictions

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative.