17 year old female with vomiting and diarrhoea since one week

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A 17 year old female, resident of Motkur studying in intermediate and staying in hostel came with the chief complaints of 

Vomitings since 1 week

Loose stools since 1 week

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 1 week back, then she developed loose stools and vomitings.

Loose stools were 5episodes per day, water in consistency, non foul smelling, no blood tinged.

Vomitings were 4-5 episodes per day, non projectile, non bilious, contents include food particles.

The vomitings were associated with nausea and stomach pain.

No history of outside food, fever.

10years back,patient's mother observed swelling over the neck 4*4cm approximately and was diagnosed with HYPOTHYROIDISM and was on TAB.THYROXINE 25mcg

3 years ago :- patient complains of generalised weakness, dizziness, history of eating slate pencils(4-5 per day)

No history of trauma, worm infestation, peptic ulcer.

Menstrual History : 

Age at Menarche 11 yrs

She has a 30 days regular cycle every month with menstruation for 3 days, using around 3 pads/day not associated with abdominal pain and clots . But she complains that she has been having small blood clots during menses for about 2 years now .

HISTORY OF PAST ILLNESS:

Known case of HYPOTHYROIDISM since 10years on TAB.THYROXINE 25mcg

Not a known case of HYPERTENSION,DIABETES MELLITUS,ASTHMA, EPILEPSY.

PERSONAL HISTORY:

DIET:Mixed(non veg twice weekly)

APPETITE: decreased since last 15 days

SLEEP: Adequate ( 10 pm- 5am)

BOWEL AND BLADDER MOVEMENTS: Regular

ADDICTIONS: No Addictions

FAMILY HISTORY:

Mother was a known case of THYROID and was on TAB.THYROXINE 100mcg

GENERAL EXAMINATION:

Patient was conscious,coherent and cooperative,well oriented to time,place and person.

Pallor is present

Angular stomatitis with smooth pale tongue 

Icterus, cyanosis, clubbing, generalised lymphadenopathy and pedal edema are absent.

Bilateral submandibular and cervical lymphadenopathy present.

Hyperpigmentation of knuckles, palmar creases , palate and oral mucosa is present .

Vitals

02/11/22 :

Temperature - 99 F

BP - 140/80 mm Hg

HR - 90 bpm

RR - 24 cpm

LOCAL EXAMINATION:

Inspection:swelling at the anterior part of the neck,does not move with protrusion of tongue and moves with deglutition

https://youtube.com/shorts/GVdN2Vtv0jo?feature=share

Palpation :- disseminated margins,nodular,

                        size:6*7cms

Percussion :- 

Auscultation :- no bruits

SYSTEMIC EXAMINATION:

CVS : 

On palpation ‐

 Apex beat was felt in the 5th intercostal space medial to the mid clavicular line.  JVP was normal 

No precordial bulge 

 No parasternal heave

On auscultation ‐ S1, S2 heard , no murmurs

RESPIRATORY SYSTEM

Inspection: trachea central in position, chest moving bilaterally equally with respiration.

Palpation:

Percussion :- resonant in all the fields

Auscultation :- Normal vesicular breath sounds heard.

BAE ++

ABDOMINAL EXAMINATION:

Inspection :- no scars

Palpation :- soft,non tender

Auscultation :- BOWEL SOUNDS HEARD 

CNS EXAMINATION:

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

Temperature N N

     Fine touch N N

       Vibration Right Left

     Upper limb. 15 sec 15 sec

     Lower limb. 11 sec. 10sec

                Tibia. 14 sec. 14sec

                   Toe. 15sec. 15sec

Finger nose co-ordination : +

Investigations:

Fever chart

Hemogram

Serum calcium 

Serum iron and ferritin

Serum phosphorus 

USG - THYROID 

CHEST X RAY

PERIPHERAL SMEAR

USG ABDOMEN 

ECG

Provisional Diagnosis : Acute gastroenteritis (resolved ) with pernicious anemia

Treatment :

1) Tab. Pantop 40 mg PO BD

2) Tab. Zofer 4 mg PO SOS

3) Tab. Sporolac PO BD

4) Tab. Dolo 650 mg PO SOS

5) Tab. Thyronorm 25 micrograms PO OD

Follow up 

4/11/22

S:

No fresh complaints today

O:

Pt is C/C/C

Bp:120/80mm hg

PR:96bpm

Temp:98F

Spo2:98%on RA

GRBS:108

RR:20cpm

CVS:S1 and S2 +

P/A: Soft Non tender

RS:BAE+ NVBS heard

CNS:NFND

A:

Acute gastroenteritis(resolved)

Pernicious anemia?

Addisons?

Autoimmune thyroiditis subclinical Hypothyroidism

P:

1)Tab zofer 4mg po/sos

2)Tab Thyronorm 25mcg po/of

3)Tab Livogen 150mg po/od

4)Inj Hydroxy lobalamine1mg IM/od

5/11/22

S

No fresh complaints today

O:

Pt is C/C/C

Bp:130/800mm hg

PR:80bpm

Temp:98.7F

Spo2:98%

RR:20cpm

CVS:S1 and S2 +

P/A: Soft Non tender

RS:BAE+ NVBS heard

CNS:NFND

A:

Pernicious anemia?

Addisons?

Autoimmune thyroiditis subclinical Hypothyroidism

P:

1)Tab zofer 4mg po/sos

2)Tab Thyronorm 25mcg po/of

3)Tab Livogen 150mg po/od

4)Inj Hydroxy lobalamine1mg IM/od