35 yr old female , labourer by occupation

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Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.”


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 




 



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