A 33 year old female with background of hypothyroidism c/o throat pain



 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.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-centred online learning portfolio and your valuable comments on 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. 





A 33 year old female came to opd with 
•c/o throat pain since 2 months (ie.,September 2022) 
c/o b/l ear pain since 2 months (ie.,September 2022)




HOPI:
•Patient was apparently asymptomatic 3 years back ,then she developed increased cold intolerance (although she’s having cold intolerance since childhood ),decreased weight(?),decreased appetite for which she was investigated and 
Then she was diagnosed with hypothyroidism in march ,2019 
~she was started on 25mcg [thyronorm]initially,used for 3 months
~she stopped taking medication for next 3 months[assuming her thyroid has become normal]
~in the month of sep 2019,went for a check up ,her TSH was high and was started on 50 mcg again 

~subsequently it was increased to 75 mcg
 and then to  100 mcg[in dec 2020][as her tsh was  not decreasing]
~she used 100 mcg for 6 months.
~around the month of june ,2021 she developed palpitations,fearfulness,anxiety
~consulted doctor again -she was told  that her TSH has fallen down to ~0.1  [as she was using the wrong dosage ]..she was started on antidepressants too ..she used them for about one month and then stopped (coz she feels more sleepy when she takes them and was unable to look after her child )
•Right now she’s on thyronorm 50 mcg 

•2 years back she had throat pain for which she consulted doctor and was diagnosed with pharyngitis ,got treated for about 5-7 days and got relieved.
•In the month of May ,2022  her husband met with an accident ,following which she experienced neck pain,breast pain and back pain ,she took homeopathic medication for that ...and she says that she feels a lot better now after taking homeopathic medication (the pain has decreased comparatively)...initially she was not able to move her neck sideways d/t pain ,later after taking medication she felt a lot better and was able to move her head and neck sideways .
•From the month of June ,2022 she’s having anxiety issues (even before that she started having stressful days since 5 years ),she feels stressful regarding health issues of her family members ,whenever her child gets sick ,whenever her husband doesn’t pick up the call/comes home late from work
The stress increased when her husband met with a bike accident in May 2022,
She was prescribed sleeping pills ..she didn’t take them
Initially later on  in September She took them for about 10 days (as she had disturbed sleep ) 


•Pt is having throat pain since September,2022

Throat pain (prickling ,itchy)since 2 months ,
Aggravates on taking cool things  relieves on eating /drinking hot foods 
There’s no difficulty in swallowing solids/liquids ,
But she complaints of pain when she swallows her saliva (?)

Ear pain (initially she had left ear pain later she has pain in right ear also )
Pain is insidious in onset ,intermittent and pricking type of pain 
Not a/w ear discharge or decreased hearing 
The pain increases on exposure to cold climates  


A/w:

Hair fall +
Loss of appetite +
Palpitations +
Easy fatigue 
No dry skin,bowel and bladder movements regular 


Past history :
•H/o surgery to the right breast (removal of lump )(in the year of 2005 )


•H/o LSCS In the year of 2017 


•Hypothyroidism since 2019 


Family history :

Her grandmother and her father underwent surgery for 

Tumor removal 

Grandmother:underwent surgery for removal of tumor from stomach (?)
Father :Underwent surgery for removal of tumor over thigh 


Menstrual history :
Attained menarche at the age of 11 years 
Cycles regular (6/28 day cycle)




Marital history :
Got married in the year of 2014 
Age of first child birth :27 years (in 2017)(LSCS)
She had bleeding PV in her 5th month of pregnancy,she was given some medication for that and bleeding has stopped and then she again had bleeding PV just 7 days prior to her EDD ,following which she was admitted and LSCS was done and baby was delivered (wt of baby at birth :3.9 kg,cried immediately after birth ,no h/o nicu admissions)
No h/o abortions,miscarriages 
H/o using contraceptive pills


Personal history:

Appetite -reduced 
Diet-mixed
Bowel and bladder movements-regular 
Sleep-disturbed 
Addictions-consumes pan 
Allergies-none

(Initially before marriage she used to consume 1 pan /day 
Or 1 pan in 2-3 days 
Later after her child birth ,and increased stress ,she started eating 3 -4 pan / day ,)

General examination :
Pt is conscious coherent and cooperative well oriented to time place and person 
Well built and nourished 
Vitals:
PR-104bpm
BP-110/60 mmHg
RR-20 cpm
Temp-97.4 F
GRBS-133 mg/dL


No pallor ,icterus,cyanosis,clubbing ,generalised lymphadenopathy,edema 
Scar over right breast (upper inner quadrant)





CVS:
S1S2 +
JVP:n
No added murmurs 

RS:
Trachea central 
Bilateral air entry +
Normal vesicular breath sounds heard 

P/A:
LSCS scar over the lower abdomen 
Abdomen is soft non tender 
No organomegaly

CNS:


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

           Temp                     N                N

    

          fine touch                  N                   N

          vibration                    Rt               Lt

                         UL.            15 sec.         15 sec 

                         LL -MM.     11 sec.         10 sec 

                                Tibia.     14 sec.         14 sec 

                                Toe.        15 sec.          15 sec          

            

•Finger nose coordination+

    


Thyroid examination:

Inspection :

Diffuse swelling in the front of the neck ,moving with deglutition 

No scars /engorged veins /sinuses 

Surface appears smooth 

Margins :demarkable

Palpation :swelling is firm in consistency 

Non tender 

Size :6x6 cm

No retrostrenal extension 

Auscultation:no bruit heard over thyroid 


         



Investigations :
Hemogram :(29/10/22)



Thyroid profile :(29/10/22)


USG neck :(28/10/22)


ECG:(29/10/22)


Diagnosis :

Hypothyroidism under evaluation with thrombocytopenia.



Treatment:

Tab .Thyronorm 50 mcg 





Course in hospital :
29/10/22
•ENT referal I/v/o ear pain and throat pain :
Pt was examined ,
Examination of ear    Rt.             Lt 
                      Pinna.    N.             N
                       EAC.     N.             N
                       TM.    B/L TM intact 
O/E of oral cavity -stained teeth 
Oropharynx-
Base of tongue ,median hyoepiglottic fold,vallecula,epiglottis,AE folds , Arytenoids   Normal 
Vocal cords -normal ,mobile 
Pyriform fossa -normal and no pooling of saliva 
O/E of neck -
No palpable Lymphnodes 
O/E of nose -
External frame work normal 
Vestibule,columella normal 
Diagnosis:globus hystericus secondary to anxiety 


•Dental opinion 


02/11/22:
Dental procedures were done:
-Root planning and scaling were done 

03/11/22:
Ent review in view of dysphagia ,video laryngoscopy was done :
B/L vocal cords mobile ,symmetrical 
No pooling of saliva in the pyriform fossa




SOAP notes :(29/10/22)
S
Throat pain+
Sleep disturbed 
Palpitations+

O
Pt is C/C/C
BP-110/60 mmHg
PR-112 ,regular rate and rhythm 
RR-20 cpm 
Temp-98 F

CVS-
S1S2 +
Jvp n 
No added murmurs 

R/S-
BAE+
NVBS

P/A-
LSCS scar +
No sinuses /engorged veins 
Soft non tender 
No organomegaly 

Thyroid examination -
Diffuse 6x6 cm swelling in the front of the neck 
Moving with deglutition 
Firm in consistency 
No Bruit heard over thyroid 


A
Hypothyroidism under evaluation 

P
Tab thyronorm 50mcg 



SOAP notes :(30/10/22)
S
Throat pain+(Decreased slightly )
No disturbed sleep 
Palpitations decreased 

O
Pt is C/C/C
BP-100/60 mmHg
PR-80,regular rate and rhythm 
RR-20 cpm 
Temp-97 F

CVS-
S1S2 +
Jvp n 
No added murmurs 

R/S-
BAE+
NVBS

P/A-
LSCS scar +
No sinuses /engorged veins 
Soft non tender 
No organomegaly 

Thyroid examination -
Diffuse 6x6 cm swelling in the front of the neck 
Moving with deglutition 
Firm in consistency 
No Bruit heard over thyroid 


A
Hypothyroidism under evaluation  with thrombocytopenia 

P
Tab thyronorm 50mcg 


SOAP notes :(31/10/22)
S
Throat pain+(Decreased slightly )
No disturbed sleep 
Palpitations decreased 

O
Pt is C/C/C
BP-110/60 mmHg
PR-76,regular rate and rhythm 
RR-20 cpm 
Temp-97 F

CVS-
S1S2 +
Jvp n 
No added murmurs 

R/S-
BAE+
NVBS

P/A-
LSCS scar +
No sinuses /engorged veins 
Soft non tender 
No organomegaly 

Thyroid examination -
Diffuse 6x6 cm swelling in the front of the neck 
Moving with deglutition 
Firm in consistency 
No Bruit heard over thyroid 


A
Hypothyroidism under evaluation  with thrombocytopenia 

P
Tab thyronorm 50mcg 


SOAP notes :(31/10/22)
S
Throat pain+(Decreased slightly )
No disturbed sleep 
Palpitations decreased 

O
Pt is C/C/C
BP-110/60 mmHg
PR-76,regular rate and rhythm 
RR-20 cpm 
Temp-97 F

CVS-
S1S2 +
Jvp n 
No added murmurs 

R/S-
BAE+
NVBS

P/A-
LSCS scar +
No sinuses /engorged veins 
Soft non tender 
No organomegaly 

Thyroid examination -
Diffuse 6x6 cm swelling in the front of the neck 
Moving with deglutition 
Firm in consistency 
No Bruit heard over thyroid 


A
Hypothyroidism under evaluation  with thrombocytopenia 

P
Tab thyronorm 50mcg 



SOAP notes :(31/10/22)

S

Throat pain+(Decreased slightly )

No disturbed sleep 

Palpitations decreased 


O

Pt is C/C/C

BP-110/60 mmHg

PR-76,regular rate and rhythm 

RR-20 cpm 

Temp-97 F


CVS-

S1S2 +

Jvp n 

No added murmurs 


R/S-

BAE+

NVBS


P/A-

LSCS scar +

No sinuses /engorged veins 

Soft non tender 

No organomegaly 


Thyroid examination -

Diffuse 6x6 cm swelling in the front of the neck 

Moving with deglutition 

Firm in consistency 

No Bruit heard over thyroid 



A

Hypothyroidism under evaluation  with thrombocytopenia 


P

Tab thyronorm 50mcg 



SOAP notes :(01/11/22)

S

Throat pain+(Decreased slightly )

disturbed sleep +

Palpitations decreased 


O

Pt is C/C/C

BP-100/60mmHg

PR-80bpm,regular rate and rhythm 

RR-20 cpm 

Temp-97F



CVS-

S1S2 +

Jvp n 

No added murmurs 


R/S-

BAE+

NVBS


P/A-

LSCS scar +

No sinuses /engorged veins 

Soft non tender 

No organomegaly 


Thyroid examination -

Diffuse 6x6 cm swelling in the front of the neck 

Moving with deglutition 

Firm in consistency 

No Bruit heard over thyroid 



A

Hypothyroidism under evaluation  with thrombocytopenia 


P

Tab thyronorm 50mcg 



SOAP notes :(02/11/22)

S

Throat pain+(Decreased slightly )

dysphagia +

Easy fatiguability +



O

Pt is C/C/C

BP-110/80mmHg

PR-82bpm,regular rate and rhythm 

RR-18 cpm 

Temp-98.6 F



CVS-

S1S2 +

Jvp n 

No added murmurs 


R/S-

BAE+

NVBS


P/A-

LSCS scar +

No sinuses /engorged veins 

Soft non tender 

No organomegaly 


Thyroid examination -

Diffuse 6x6 cm swelling in the front of the neck 

Moving with deglutition 

Firm in consistency 

No Bruit heard over thyroid 



A

Hypothyroidism   with thrombocytopenia under evaluation 


P

Tab thyronorm 50mcg 



SOAP notes :(03/11/22)

S

Throat pain+(VAS4)

dysphagia +

Easy fatiguability +



O

Pt is C/C/C

BP-110/70mmHg

PR-86 bpm,regular rate and rhythm 

RR-19 cpm 

Temp-98.4 F



CVS-

S1S2 +

Jvp n 

No added murmurs 


R/S-

BAE+

NVBS


P/A-

LSCS scar +

No sinuses /engorged veins 

Soft non tender 

No organomegaly 


Thyroid examination -

Diffuse 6x6 cm swelling in the front of the neck 

Moving with deglutition 

Firm in consistency 

No Bruit heard over thyroid 



A

Hypothyroidism   with thrombocytopenia under evaluation 


P

Tab thyronorm 50mcg 



SOAP notes :(03/11/22)

S

Throat pain+(VAS4)

dysphagia +

Easy fatiguability +



O

Pt is C/C/C

BP-110/80 mmHg

PR-78 bpm,regular rate and rhythm 

RR-21cpm 

Temp-98.2 F





CVS-

S1S2 +

Jvp n 

No added murmurs 


R/S-

BAE+

NVBS


P/A-

LSCS scar +

No sinuses /engorged veins 

Soft non tender 

No organomegaly 


Thyroid examination -

Diffuse 6x6 cm swelling in the front of the neck 

Moving with deglutition 

Firm in consistency 

No Bruit heard over thyroid 



A

Hypothyroidism   with thrombocytopenia under evaluation 


P

Normal diet 

Tab thyronorm 50mcg 

Saline nasal drops 

   3/3/3/3 x 5 days 

Avoid hard blowing of nose 



Discharge summary :





















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