45F HTN DM HYPOTHYROIDISM

 Thankyou Govardhini

Cheif complaints 

A 45 year old female came to GM opd with chief complaints of Neckpain since 10 days and low grade fever since 10 days 

Patient was resident of guntur where she lives with her parents and her 3 siblings,she is a 3rd child,Did not go to school and entered handloom work at 10years of age.

She was married at age of 15years and and by the age of 17 she had first child and after 3 years of 1st child birth she got concieved had spontaneous abortion at 6months of gestational age due to work pressure and increased stress.3 years after the second pregnancy she had 3rd child and at 3 months of age the baby died due to fever.she felt depressed at worried about that event.After 3 years from that event she gave birth to 4th child with no health issues.

Since then she is doing fine with her life.

4 years ago she had h/o generalised weakness for which she went to local hospital and diagnosed of having hypertension and started on Tab.Losartan(50mg)+Tab.Hydrochlorthiazide(12.5 mg) and after starting that medication she felt better till 2 months

She is c/o neck pain since 10 days 

2 months back then she developed neck pain insidious in onset gradually progressive and aggravated since past 10 days. 

Restriction of movements+.

Neck Pain aggravates on flexion and extension of neck.

No h/o trauma. 

Low grade fever not associated with chills and rigors since 10 days,Intermittent in nature.

No h/o sob,cough,sore throat,Abdominal pain,vomitings,loose stools, Tingling of b/l upper limbs+.

Past History :

K/c/o htn since 4 years and on medication T. losertan 50 mg+Hydrochlorothiazide 12.5 mg po/od 

N/k/c/o DM, thyroid,CVA,epilepsy, Asthma,CAD

Personal History :

Appetite -Normal

Diet -Mixed

Sleep -Adequate 

Bowel and Bladder -Normal and Regular

Addictions -None

Daily Routine:

Patient is a Weaver by occupation. She works at her own house.

She wakes up by 6 am in the morning. She has her breakfast around 8 am. Then she starts her work by 9am. She works till 1pm. Then she has her Lunch by 2pm and sleeps for an hour. She continues her work till 6pm. She then has her dinner by around 8pm and goes to sleep by 10 pm.

The Daily Routine of the patient is disturbed due to severe neck pain since 10 days.

On General examination 

Patient is concious coherent cooperative 

Well oriented to time place person 

Moderately build and nourished

No Pallor ,Icterus ,cyanosis ,clubbing , koilonychia ,lymphadenopathy

Bilateral Pedal Edema +

Vitals 

Temperature – Afebrile ( 98.6 F )

Pulse rate – 80 bpm , regular 

Respiratory rate – 16 cpm

BP – 140/90 mm Hg 

SPO2 – 98% on room air  

GRBS – 256 mg/dl

Systemic Examination:

CVS- S1 S2 heard

RS- BLAE +

P/A- Soft,NT BS+

CNS:

HMF - Intact 

Speech – Normal 

Kernigs sign - Negative 

Brudzunski sign - Negative

Motor and sensory system – Normal 

Reflexes – Normal 

Cranial Nerves – Intact 

Gait – Normal

Cerebellum – Normal  

GCS Score – 15/15

Hyperechoic Lesion On USG Neck

Provisional Diagnosis 

?Cervical Radiculopathy

Denovo Hypothyroidism

Denovo Diabetes Mellitus Type 2

Hypertension 

TREATMENT

1.INJ. Diclofenac Im/sos

2.T.Dolo 650 mg po/sos

3.T. Nicardia 10 mg po/sos

4.T. Losartan+T. Hydrochlorothiazide 50mg/ 12.5 mg 

5.T. vertin 8 mg po/bd 

6.T. Thyronorm 75 mcg po/od 

7.T. Metformin 500 mg po/be

8.T. Cinod 10 mg po/od

9.T. Myoril 2ml IM/BD

10.INJ. Zofer 4mg IV/SOS

11.INJ.PAN 40mg/IV/OD

12.T.PREGABA 75MG/PO/HS

Follow up on  10 oct 2023

Fbs:-106 mg/dl

Plbs:-150

Hba1c-6.7

Outcome:- goodcontrol

Discharge summary 

Diagnosis

NECK PAIN- CERVICA RADICUOPATHY WITH PARASPINAL SPASM K/C/O HTN SINCE 4 YEARS WITH PERIPHERAL VERTIGO SECONDARY TO VERTEBRO BASILAR INSUFFICIENCY WITH DENOVO THYROID DISEASE (HYPOTHYROIDISM) WITH LEFT CERVICAL LYMPHADENOPATHY WITH DENOVO DM 2 WITH MIGRAINE

Case History and Clinical Findings

C/O NECK PAIN SINCE 10 DAYS

PATIENT WAS APPARENTLY ASYMPTOMATIC 2 MONTS AGO THEN SHE DEVELOPED NECK PAIN OF INSIDIOUS ONSET GRADUALLY PROGRESSIVE AND AGGRAVATED SINCE PAST 10 DAYS. RESTRICTIPON OF MOVEMENTS PRESENT, PAIN AGGRAVATES ON FLEXION AND EXTENSION OF NECK.

LOW GRADE FEVER IS PRESENT NOT ASSOCIATED WITH CHILLS AND RIGORS SINCE 10 DAYS.

NO H/O COUGH, SOB, COLD, SORE THROAT, ABDOMINAL PAIN, VOMITINGS, LOOSE STOOLS, TINGLING OF BILATERAL UPPER LIMB.

NO H/O TRAUMA PAST HISTORY:

K/C/O HTN SINCE 4 YEARS AND ON T.LOSARTAN 50MG + HYDROCHLOROTHIAZIDE 12.5 MG N/K/C/O DMII,CVA,CAD,TB,EPILEPSY.

GENERAL EXAMINATION:

 

PATIENT IS CONSCIOUS, COHERENT,COOPERATIVE. MODERATELY BUILT AND NOURISHED

NO SIGNS OF PALLOR,ICTERUS,CLUBBING,CYANOSIS,LYMPHEDENOPATHY,EDEMA VITALS:

TEMP: 98.6F PR: 78BPM

BP: 130/90MMHG RR: 18CPM

CVS: S1S2 HEARD RS: BAE+

P/A: SOFT, NONTENDER CNS EXAMINATION -NFND

PUPILS: NORAML IN SIZE, REACTIVE TO LIGHT TONE RT LT

UL NORMAL NORMAL LL NORMAL NORMAL POWER RT LT

UL 5/5 5/5 LL 5/5 5/5

REFLEXES RT LT BICEPS 2+ 2+

TRICEPS 2+ 2+

SUPINATOR 1+ 1+

KNEE 2+ 2+ ANKLE -- --

PLANTAR FLEXION FLEXION

NECK EXAMINATION:

NECK MOVEMENTS- RESTRICTED NECK STIFFNESS- ABSENT KERNIGS SIGN- NEGATIVE BRUDZINSKI SIGN- NEGATIVE RHOMBERG SIGN- NEGATIVE

FINGER FINGER INCOORDINATION- ANSENT

 

FINGER NOSE COORDINATION- ABSENT SPINE TENDERNESS- ABSENT NYSTAGMUS- ABSENT

EOM MOVEMENTS- NEGATIVE DIPLOPIA- ABSENT

NO RAISED ICT FEATURES

CERVICAL LYMPH NODES - PALPABLE ON LT OCCIPITAL ANGLE NO PALPABLE AXILLARY LYMPH NODES

THYROID SWELLING - PRESENT

GENERAL SURGERY REFFERAL WAS DONE ON 24/8/23 ADVICE :

NO ACTIVE SURGICAL INTERVENTION NEEDED

1. CONTINUE TREATMENT FOR HYPOTHYROIDISM

2. REVIEW AFTER 3 MONTHS IN GS OPD FOR REVIEW ORTHOPAEDICS REFFERAL WAS DONE ON 24/8/23 ADVICE:

DIAGNOSIS:CERVICAL DISC DEGENERATIVE DISEASE WITH MUSCLE SPASM OF NECK MUSCLES

TREATMENT:

TAB.HIFENAC MR BD 1 WEEK TAB. PAN 40MG OD 1 WEEK IFT/TENS APPLICATION

TAB. TRIGABATIN 100MG X 3 WEEKS

ENT REFFERAL DONE ON 24/8/23 I/V/O VERTIGO ADVICE

1.T.VERTIN 8 MG BD TO BE CONTINUED ENDOCRINOLOGY REFFERAL DONE ON 25/8/23 ADVICE:

1. DIABETIC DIET

2. T.THYRONOEM 75MCG

3. T.METFORMIN 500MG PO/BD

Investigation

22/8/23--23/8/23-- 26/8/23

 

TLC

5,300/4.300/ 10,000

HEMOGLOBIN 10.3/11.5/ 12.1 HEMATOCRIT

29.9/34.1/ 36.9

PLATLET 2.05/2.22/ 2.92/ IMPRESSION NCNC ANAEMIA/ NCNC NC NC ANAEMIA / BLOOD PICTURE

RFT

B.UREA 11/10/ 15

S.CREATININE 0.8/0.8/ 0.7 S.NA+ 137/138/ 139 S.K+

4.1/4.2/ 4.2

S.CL- 101/101/ 103 S.CA+2 1.20/1.18/ 1.17

LFT-22/8/23 T.BILURUBIN-0.77 D.BILURUBIN-0.20 AST-94

ALT-92

 

ALP-311 T.PROTEIN-7.2 ALBUMIN-4.1 CUE - 22/8/23 SUGAR- +++ ALBUMIN- NIL PUS CELLS: 3-4 RBC-NIL

CAST-NIL

SEROLOGY(HIV, HBSAG, HCV)-NEGATIVE BLOOD GROUP- B POSITIVE

ESR-40MM/1ST HOUR HB1AC-7.0

T3,T4,TSH-0.98, 8.70,29.51

USG NECK

IMPRESSION- DIFFUSE THYROIDITIS CERVICAL LYMPHADENOPATHY

TIRADS 3 LESION IN RIGHT LOBE OF THYROID

Treatment Given(Enter only Generic Name)

1. INJ.DICLOFENAC IM/SOS

2. INJ. ZOFER 4MG IV/SOS

3. T.PANTOP 40MG PO/OD

4. T.DOLO 650 MG PO/SOS

5. T. NICARDIA 10MG PO/SOS

6. T. LOSARTAN= T. HYDROCHLORTHIAZIDE 50MG/12.5 MG PO/OD

7. T.VERTIN 80MG PO/BD

8. T. THYRONORM 75MCG PO/OD

9. T. METFORMIN 500MG PO/BD

10. INJ.MYORIL (2ML) IM/BD

11. T.PREGABALIN 75MG PO/HS

12. T.CLONAZEPAM 0.25MG PO/HS

 

Advice at Discharge

1. INJ.DICLOFENAC IM/SOS

2. INJ. ZOFER 4MG IV/SOS

3. T.PANTOP 40MG PO/OD

4. T.DOLO 650 MG PO/SOS

5. T. NICARDIA 10MG PO/SOS

6. T. LOSARTAN= T. HYDROCHLORTHIAZIDE 50MG/12.5 MG PO/OD

7. T.VERTIN 80MG PO/BD

8. T. THYRONORM 75MCG PO/OD

9. T. METFORMIN 500MG PO/BD

10. INJ.MYORIL (2ML) IM/BD

11. T.PREGABALIN 75MG PO/HS

12. T.CLONAZEPAM 0.25MG PO/HS

Case 3

https://himajav.blogspot.com/2024/05/45f-htn-dm-hypothyroidism.html

### Thematic Analysis of the Case

#### 1. **Coding:**

   - **Chronic Conditions:** Hypertension for four years, treated with Losartan and Hydrochlorothiazide.

   - **Acute Symptoms:** Neck pain for 10 days, intermittent low-grade fever, and tingling in bilateral upper limbs.

   - **Psychosocial Stressors:** Multiple pregnancy losses, including a miscarriage and infant death, contributing to past depressive episodes.

#### 2. **Categorization:**

   - **Chronic Disease Impact:** The patient's hypertension is managed, but recent neck pain and fever could be indicative of another underlying issue, such as infection or musculoskeletal strain.

   - **Occupational Influence:** The patient's work as a weaver may have contributed to the onset and progression of neck pain.

#### 3. **Theme Identification:**

   - **Musculoskeletal Strain and Chronic Disease:** Repetitive occupational movements may have aggravated the neck pain, while underlying hypertension could predispose her to other complications.

   - **Socioeconomic and Psychological Factors:** The patient’s personal history of losses and stress may influence her pain perception and overall health.

#### 4. **Theme Representation (Learning Points):**

   - **Interplay of Occupation and Health:** The repetitive nature of the patient's work likely contributed to her neck pain, suggesting the need for ergonomic adjustments or physical therapy.

   - **Mental Health and Chronic Illness:** The psychological impact of past traumatic events (infant deaths) should not be overlooked, as they can influence the patient's current health behaviors and pain management strategies.