This is an online e-log platform to discuss case scenario of a patient with their guardians permission.
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.
17 year female came with the complaints of vomitings and loose stools since 1week
CHIEF COMPLAINTS:
Vomitings since 10 days
Loose stools since 10 days
Fever since 3 days
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic One week back, then she developed loose stools and vomitings.
Loose stools:- 4-5episodes, water in consistency, non foul smelling, no blood tinged.
Vomitings:- 4-5 episodes, non projectile, non bilious,non foul smelling contents include food particles,Which subsided on taking medication.
Fever was incidious in onset, associated with chills and rigor,which subsided on taking medication.
10years back,patient's mother observed swelling over the neck and was diagnosed with HYPOTHYROIDISM and was on TAB.THYROXINE SODIUM 25mcg
3 years ago :- history of itching and was taken to hospital which subsided on taking medication.
Since 2months patient is observing irregular menses,followed by dysmenorrhea,with clots.
Patient also complained of generalised weakness since 1week.
HISTORY OF PAST ILLNESS:
Known case of HYPOTHYROIDISM since 10years on TAB.THYROXINE SODIUM 25mcg.
Not a known case of HYPERTENSION,DIABETES MELLITUS,ASTHMA, EPILEPSY.
PERSONAL HISTORY:
DIET:Mixed(non veg twice weekly)
APPETITE:Normal
SLEEP: Adequate
BOWEL & BLADDER MOVEMENTS: Regular
ADDICTIONS: No Addictions
ALLERGY:Present 3years ago, subsided on taking medication.
FAMILY HISTORY:
Mother was a known case of THYROID and was on TAB.THYROXINE 100mcg..
GENERAL EXAMINATION:
Patient was conscious,coherent and cooperative,well oriented to time,place and person.
Pallor:present
Icterus:- absent
Cyanosis:- absent
Clubbing:- absent
Lymph nodes:- Bilateral cervical and submandibular lymph nodes palpable.
Vital signs:
BP:- Supine :- 130/80mm Hg Standing :- 120/60 mm Hg
PULSE RATE :- Supine: 88BPM standing :- 83 BPM
SPO2 :- 98
Respiratory Rate :- 18cpm
GRBS :- 98 mg/dl
SYSTEMIC EXAMINATION:
CVS:S1,S2 heard,no murmurs
RESPIRATORY SYSTEM:
Inspection: trachea central in position, chest moving bilaterally equally with respiration.
Palpation:
Percussion :- resonant in all the fields
Auscultation :- Normal vesicular breath sounds heard.
BAE ++
LOCAL EXAMINATION:
Inspection:swelling at the anterior part of the neck,does not move with protrusion of tongue and moves with deglutation.
Palpation :- disseminated margins,nodular,
size:6*7cms
Percussion :-
Auscultation :- no bruits
ABDOMINAL EXAMINATION:
Inspection :- no scars
Palpation :- soft,non tender
Auscultation :- BOWEL SOUNDS HEARD
CNS EXAMINATION:
CRANIAL NERVES: INTACT
Power
Rt UL-5/5. Lt UL-5/5
Rt LL-5/5. Lt LL-5/5
Tone-
Rt UL -N
Lt UL-N
Rt LL-N
Lt LL-N
Reflexes:. RIGHT LEFT
Biceps. ++ ++
Triceps. ++ ++
Supinator. ++ ++
Knee. ++ ++
Ankle. ++ ++
Plantar:. Flexion Flexion
•SENSORY
crude touch N N
Pain N N
Temperature N N
Fine touch N N
Vibration Right Left
Upper limb. 15 sec 15 sec
Lower limb. 11 sec. 10sec
Tibia. 14 sec. 14sec
Toe. 15sec. 15sec
Finger nose co-ordination : +
Fever chart
Investigations:
Haemogram
Provisional diagnosis:
AUTOIMMUNE POLYGLANDULAR SYNDROME -2
ENDROCRINE
1)Hashimoto Thyroiditis
2)Addisons disese
NON-ENDOCRINE
1) Pernicious anemia
2)Alopecia
TREATMENT:
1.NALMOL
2.TAB.PANTOP 40mg BD
3.TAB.ZOFER 4mg SOS
4.TAB.SPOROLAC (ROUTE:PERORAL) BD
5.TAB.DOLO 650mg SOS
6.TAB.THYRONORM 50mcg OD
7.ORS SACHET IN 1LT WATER TO DRINK AFTER EACH LOOSE STOOLS.
8.VITALS STORING EVERY 4TH HRLY
9) Inj vitcofol2ml/IM/OD for 3 days at alternative buttocks
10) Tab livogen 150mg per oral once daily before lunch 2 pm sharp
Hyperpigmentation over buccal mucosa and hard palate.
knuckle hyperpigmentation
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