35 yr old female , labourer by occupation
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I've 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 :
A 35 year old female ,labourer by occupation came to the the OPD with complaints of passage of stools since one month, 3- 4 episodes per day in large volume.
Patient was apparently asymptomatic 11 months.Later she developed generalized weakness and fever for which she went to the hospital and was diagnosed as typhoid fever for which she underwent treatment.Later 7 months back she developed generalised weakness and fever for which she was again diagnosed as typhoid fever.3 months back she developed fever with cough and cold and was diagnosed as covid positive and treated with medication in home isolation for which she tested negative after 15 days. one month back she has h/o passage of stools of large volume, Normal in consistency with increased frequency (4-5 episodes per day ).Since 15 days pt complains of low grade,intermittent fever especially at night not associated with chills and rigors.1 week back she has history of passage of stools of large volume ,semi solid in constistency with increased frequency (5-6 episodes per day)
No h/o constipation,burning micturition,vomitings,abdominal pain
No history of shortness of breath ,chest pain
No h/o cough,cold,loss of appetite
H/o of frequent falls c/0 frequent back pain
Past history
History of 1 LSCS 8 year back
No history of similar complaints in the past
No history of any complaints related to Hypertension,Diabetes,Asthma,epilepsy,CVA,CAD
Treatment history :
Pt is on syrup potchlor since 10 days and biovol(aluminum hydroxide, magnesium hydroxide,sorbitol) since 10 days
Personal history :
Diet - mixed
Appetite decreased
Sleep - adequate
Normal bladder movements
No history of any alcohol intoxication or smoking habits
O/E:
Pt is conscious,coherent and cooperative.
Moderately built and nourished
Pallor +,
No signs of any icterus,clubbing, cyanosis lymphadenopathy,pedal edema
Vitals:
BP: 120/90
PR: 102 bpm
Spo2: 98%
RR: 16
CVS: s1, S2 heard
RS: b/l airway entry present
P/A: soft
CNS: normal
Movement of thyroid swelling with deglutition
https://youtu.be/UBnDgoV5o8o
Tremors
https://youtube.com/shorts/QcgdjSIeOoQ?
feature=share
Investigations:
Hemogram :
Hb - 11.1
TLC - 10500
Pcv 34
Rbc- 5.09
Plt - 341
Cue : normal
Serology : negative
Urea -15
Creat -0.6
Electrolytes
Na - 142
K -4.2
Cl-102
LFT
TB -0.53
DB-0.20
AST -20
ALT-22
ALP-205
TOTAL PROTEINS -6.1
ALBUMIN-3.4
A/G RATIO - 1.26
ECG
Chest xray
Diagnosis :
Denovo hyperthyroidism
Treatment :
On day 1 of admission :
1)Plenty of oral fluids given
2)IVF - 2NS 1RL 1DNS 150ML/HR
3)INJ.OPTINEURON 1 AMP IN 100 ML NS IV/OD
4)INJ.PAN 40 MG IV/OD
5)INJ.ZOFER 4MG IV /SOS
6)TAB.DOLO 650 MG PO/SOS
7)ORS SACHETS IN 1 LITRE OF WATER
1 DRINK AFTER EACH LOOSE STOOL
8)MONITOR VITALS
On day 2 of admission :
1)Plenty of oral fluids given
2)IVF - 2NS 1RL 1DNS 150ML/HR
3)INJ.OPTINEURON 1 AMP IN 100 ML NS IV/OD
4)INJ.PAN 40 MG IV/OD
5)INJ.ZOFER 4MG IV /SOS
6)TAB.DOLO 650 MG PO/SOS
7)ORS SACHETS IN 1 LITRE OF WATER
1 DRINK AFTER EACH LOOSE STOOL
8)MONITOR VITALS
On day 3 of admission :
1)Plenty of oral fluids given
2)IVF - 2NS 1RL 1DNS 150ML/HR
3)INJ.OPTINEURON 1 AMP IN 100 ML NS IV/OD
4)INJ.PAN 40 MG IV/OD
5)TAB.DOLO 650 MG PO/SOS
6)ORS SACHETS IN 1 LITRE OF WATER
1 DRINK AFTER EACH LOOSE STOOL
7)MONITOR VITALS
8)TAB.CARBIMAZOLE PO/BD
On day 4 :
TOOK FOR ENDOCRINOLOGY OPINION
REGARDING HIGH TSH LEVELS
Advised
1)tab.carbimazole 10 mg PO/BD
2)tab.inderal 1/2 TABLET PO/BD
3)TAB.SHELCAL 500 MG PO/OD
ON DAY 5 :
1)TAB.CARBIMAZOLE PO/BD
2)TAB.SHELCAL 500 MG PO/OD
3)TAB.INDERAL 1/2 TABLET PO/BD
On DAY 6 :
1)TAB.CARBIMAZOLE PO/BD
2)TAB.SHELCAL 500 MG PO/OD
3)TAB.INDERAL 1/2 TABLET PO/BD
