Name : Ayisha
Age : 65years
Sex : female
I P No: 678
D O A: 27/9/2005
Address: Balussery,
calicut
Presenting
Complaints
-
Obstructive
feeling at throat (5 months) < After eating
-
Difficulty in
swallowing especially for solids (5 months)
-
Cough (1
week) <lying down & night
-
Weakness (5
months)
-
Headache
especially on right forehead (5 months)
History of
presenting complaint
Obstructive
feeling at the throat and difficulty in swallowing solids and
liquids started 5 months back and diagnosed as carcinoma
oesophagus. There is vomiting of food after eating.
History of past
illness
1. History of
asthma : 3 years back Took Ayurvedic
treatment
2. H/O Rheumatic
complaint : 3 years back Took Ayurvedic treatment
Personal History
Place of
birth : Balussery
Educational
status: Illiterate
Religion : Muslim
Appetite :
good; Prefers warm food.
Thirst :
decreased; Prefers warm drinks.
Sleep :
decreased
Stool :
constipated
Urine :
no complaints
Sweat :
generalised
Psychic features
She is mild and
gentle. She prefers company.
Investigations
Endoscopy (26/05/05)
Oesophagus:
There is a
large nodular growth arising from the oesophagus at 32cms
and extending for about 6cms proximally.
Impression
Carcinoma
oesophagus.
Provisional
diagnosis
Carcinoma
oesophagus
Physical
examination
Pulse: 70/mt
B P: 120/ 80 mm of Hg Temp: 98◦ F
General Survey
Moderately built
and nourished
Pallor present
No cyanosis, not
icteric.
No clubbing
No lymphadenopathy
and No pedal oedema
Systemic
Examination
Examination of
Respiratory system
Examination of
Upper Respiratory tract
No congestion of
nasal mucosa & no deviation of nasal septum & no nasal polyp.
Uvula centrally
placed & no tonsillar enlargement.
Examination of
lower Respiratory tract
Inspection
Trachea appears to
be centrally placed; chest wall bilaterally symmetrical
No kyphosis,
scoliosis or lordosis; no prominent vessels and visible
pulsations
Palpation
No palpable
swelling. Trachea centrally placed. Apex beat palpable.
Percussion
Normal lung
resonance over all lung fields
Auscultation
No wheeze heard
Examination of
Central Nervous system
Examination of
higher mental functions
Patient is
conscious, intelligent, normal behaviour, past and present
memory present, orientation of time, place and person present,
no hallucination, delusion, illusion and speech normal.
Examination of
Cranial nerves
Olfactory Nerve
No anosmia,
parosmia and hallucination of smell.
Optic Nerve
There is no
obstruction on the field of vision
Oculomoto Nerve, Trochlear
Nerve, Abducens
Ocular movements
are within normal limits. No nystagmus. Pupil reacts to light.
Trigeminal Nerve
Sensation over
face is intact. Corneal and conjunctival reflexes intact. Jaw
jerk present.
Facial Nerve
Eye closure,
frowning, raising the eye brow present
Can blow, whistle
and show the teeth
Vestibulocochlear Nerve
No impairment of
hearing
Glossopharyngeal Nerves and
Vagus
Gag reflex present
Uvula centrally
placed
Hypoglossal Nerve:
Can move tongue in all directions
Sensory System:
With in
normal limit
Examination of
motor System:
Within normal limits
Signs of meningeal
irritation:
No
signs of meningeal irritation
Analysis of
symptoms
Symptoms of
the patient
|
Symptoms of
the disease
|
Prefers
company
|
Obstructive
feeling at throat
|
Desires warm
drinks
|
Difficulty
in swallowing solids
|
Desires warm
food
|
Vomiting of
food; frothy vomitus
|
Desires
pungent things
|
Weakness
|
Evaluation of
symptoms
Mental
generals
|
Physical
generals
|
Particulars
|
Common
|
Prefers
company
|
Prefers warm
drinks
|
Cough< night
|
Obstructive
feeling at throat
|
Prefers warm
food
|
Cough< lying
down
|
Difficulty
in swallowing solids
|
Prefers
pungent things
|
Right sided
headache
|
Vomiting of
food
|
Weakness
|
Weakness
|
Totality of
symptoms
