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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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