59 year old female with HYPOTHYROIDISM

NAME : M. NAGA VARSHA

BATCH : 2017

ADMISSION NO. 176015

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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.

FOLLOWING IS THE VIEW OF MY CASE

A 59 year old female presented to hospital with

CHIEF COMPLAINTS:

C/O pain in epigastric region with burning sensation

Constipation present

HISTORY OF PRESENT ILLNESS

A 59 year old patient from North Bengal teacher by occupation was apparently asymptomatic then she developed pain in epigastric region with burning sensation with nausea radiating to right shoulder and right lower back.
No SOB, palpitations
Relieved after medication. Aggravated on taking spicy food, milk.
No c/o vomiting,
patient also have c/o difficulty in passing feces (constipation) and incomplete passing of stools.
patient regularly takes purgatives.
patient have c/o weakness since 10-12 years with seasonal variations, more in summers.
patient complaints of pain in ankle joints, wrist joints, and interphalangeal joints causing difficulty in walking and doing household works.
patient c/o fever which is sudden in onset and relieved on medication.

PAST HISTORY

H/o of cholecystectomy in 2019
H/o of surgery for hemnorriods and fissure in ano in 2002
H/o of hypothyroidism on medication since 12 years
N/K/C/O DM, HTN, TB epilepsy, asthma

H/O MILD DREPRESSION WITH ANXIETY (USED SSSRI+BZD)
At the age of 9-10 yrs, diagnosed with typhoid fever. For 2 days was not able to see through eyes. After recovery became right.
At the age of 12, she suffered from jaundice, which resolved within a month. But since then c/o abd bloating, indigestion, vomiting (especially after eating food or drinking milk), alternate symptoms of diarrhea and constipation, and epigastric burning sensation which would resolve on its own.
At age of 16-17 yrs (48kgs), she noticed whenever she drinks milk at night, at midnight she would vomit. Becomes alright in the morning.
At the age of 18-19 yrs (52kgs), whenever she eats spicy, oily foods she would experience acidity and in the evening, would vomit. Most of the time vomiting would happen in the evening or night.
After going to the hostel, she would often rely on puffed rice, biscuits, and tea instead of proper meals because she did not like the hostel's canteen food. She started c/o constipation (very hard scanty stool, incomplete defecation).
At the age of 21, one day started c/o pain involving all joints which intensified quickly (getting down from bed became difficult) and restricted her movements. After a wk, she got treated with homeopathy medicine which reduced her pain. But still, to date c/o lower back pain (cannot sit down on the floor), cannot write for long, count money using fingers, or carry luggage. Resting her jts reduces pain.
At the age of 23, started c/o constipation (2-3 days no passing of stool; had to put a lot of pressure and insert a finger inside the anus to stimulate the passage of stool). At first little blood used to come once in 3-4 months with stool. Later in 1986, at the age of 25 yrs started c/o frequent heavy bleeding pr and a burning sensation while passing stool. Dr diagnosed it as hemorrhoids and anal fissures. She used allopathy and homeopathy medicines which used to give temporary relief.
When 24-25 yrs old, she was studying and doing a job (very stressful period as per pt, had to travel long distances daily).
When 27-28 yrs old(45kgs), due to heavy bleeding pr rectum and painful defecation, went to a local Dr. who after performing ?proctoscopy (felt extreme pain) told her to sit outside. While sitting outside she lost consciousness (5 mins). After she became conscious, for 2-3 sec she could not recognize anyone. When trying to move she felt extremely weak and lay down. After 1-1.5 hrs was able to go home.
One day while returning from a market, while walking she again lost consciousness (2-3 mins).
At the age of 30 yrs, while pregnant felt alright (no pain, or bleeding pr). A few months after delivery again symptoms reappeared.
At the age of 36-37 yrs, again typhoid. First misdiagnosed and treated for malaria for 12-13 days. Since the fever not reducing, retested and typhoid was detected. She can't attend school for a month because of weakness.
At the age of 38 yrs, a consulting Dr prescribed medications for hemorrhoids, taking which would reduce bleeding and pain for 7 days, then again reappear. But as side-effects just after taking those medications, she would c/o severe acidity, abd bloating, nausea, decreased appetite, malaise and a whole day lay down on a bed. She would only be able to eat sweet turnip.
In 2002 aged 38 yrs, due to heavy bleeding and pain, she went to Chennai where Dr. did a colonoscopy and said everything is fine. Hearing this her family scolded her saying she made up all this. She sought no further treatment and decided to endure it.
At the age of 38 yrs, while tooth extraction, she lost consciousness (5mins). A few months later, again during tooth extraction lost consciousness.
Whe age 38-39yrs, one day heavy bleeding pr and pain. She had a seizure attack lasting 30 mins. Her family did hot oil massage. Was taken to a hospital where a colonoscopy was done and immediate Sx was recommended for hemorrhoids and fissures. But because the Dr was ill-tempered, pt did not give consent and returned home. For 7 days no bleeding. After which again bleeding started. She got admitted and was operated on. At that time her Hb was gm/dl. Because of her gastric problems antacid was recommended. She started using it daily.
At age of 40 yrs, went to puri, and she c/o lightheadedness and her BP was found to be low. For her constipation, Dr prescribed Duphalc (taking for the past 16-17 yrs to date almost every day, feels better, good appetite, easy to pass bowel). She reported since then only after doing head massage, hammering her head and shoulder would make her pass stool.
At age of 43 yrs, lost her husband. At that time her appetite decreased, became stone-faced, couldn't sleep after 2 am without hugging a devotional book.
When aged 44 yrs, c/o frozen shoulder which got relieved with physiotherapy. She went to Chennai for a checkup. Drank sweet lemon juice with family in the evening. Within mins c/o acidity, epigastric burning sensation. The next day went for a checkup. While sitting, felt severe body weakness and warned family members that she is going to lose consciousness. Lost consciousness for a few mins. Got admitted. The next day high fever and cold therapy were used. A lot of tests were performed, after which she c/o nausea, and body weakness and needed a wheelchair to reach the station after discharge.
On returning home, Dr prescribed saline with medications. She was not able to eat anything and vomited water. A nurse advised her to eat turmeric mixed with rice one spoon at first and slowly increase the quantity. That helped. Her wt 38 kg. One month almost bedridden.
In 2012 aged 48 yrs, because of feeling extreme weakness and dizziness, she visited Dr. who detected hypothyroidism. On medication since then. Dosage was changed many times as lab reports were wrong.
Till 2015 i.e for 14-15 yrs after Sx, no more complaints of rectal bleeding or pain. But, a little out of normal routine (e.g eating rice and vegetable curry at the school canteen) would lead to vomiting (all half-digested fool clearly visible, acidic smell) within hours.
In 2016 aged 52 yrs, bleeding pr started slowly, which increased a lot by 2017. A colonoscopy was done and a repeat Sx was recommended, which she did not do. Using laxatives and ointments provides a bit of relief. She reported during acidity and gas formation doing head and shoulder massage, or compressing the chest would make her feel better.
In 2019, her mom passed away. A few months later, took her son (diagnosed early with schizophrenia) to Siliguri for thyroid testing. While standing in a queue, she fainted. Hospitalized and her Hb was 8.6 gm/dl. 3 days later discharged.
In 2019 Oct., one day after eating started c/o slight epigastric pain which decreased on taking medications. But, since Nov started c/o sudden severe pain in rt upper quadrant which radiated towards the shoulder blades and also in the center of the abdomen just below the sternum. Started eating only water, rice, chilies, and banana because eating anything else triggered vomiting within 30 mins. Went to Hyderabad in Dec and was diagnosed with gallstones. Sx done. At that time proctoscopy was also done for her bleeding pr and Sx was recommended which she did not do.
Since 2020 Feb, c/o her feet swelling up to lateral and medial malleolus (left leg more) and painful which intensifies on walking. With medicine, the pain reduces a bit. In 2021, lost her balance and fell twice.
8 months ago, because of her swelling and painful feet, she went to Dr. who detected osteoporosis.
In Sep 2022, she suffered from severe diarrhea (8-9 times watery stool for 1 day), generalized body weakness, and nausea. She was given saline. Her bleeding pr increased with extreme pain and swelling. Dr prescribed medicines (which reduced the bleeding amount) for 13 days and recommended Sx. She got treated instead by a homeopathy Dr whose medication caused much relief. No bleeding if stool is soft.
In Jan 2023, shortly after eating pittha dipped in milk c/o sharp pain in the epigastric region which lasted for almost an hour. She realized she can't tolerate milk products even curd (acidity) or cottage cheese

PSYCHOSOCIAL COMPONENT:

The patient hid the fact that she was having an affair with her professor from her family because she was aware that her family won't allow her to marry him because of their age diff (18-19 yrs). When the family found out about their relationship, they opposed her decision to marry him, citing reasons such as the age gap and his belonging to a joint family. Since childhood, she always considered her mother's words and decisions as final, opposing her for the first time was emotionally very stressful for the pt. Seeing her adamant to change her decision, her family finally gave in.
After getting married she moved in to stay with her husband's joint family. Her sister-in-laws resented the fact that they were housewives while she is a teacher and earns money. So, never let her do any kind of household work and would pass bad remarks on her back. They would intentionally cook items that she did not like to eat nor let her cook, because of which many days she had to leave for school on an empty stomach. During holidays, she would go to eat at her parent's home which was nearby.
They would forcefully not let her take care of her son or her husband citing she should focus on her profession and would try to bend her son's mind saying she has no contribution to his growing up. This created distance between her and her son, where the latter would often accuse the pt of not looking after him or his father who was very dear to him. Her in-laws would leave no stone unturned to point out her mistakes and say bad things about her to her husband, whereas the latter trying to keep good relations with other family members would often find fault in her, trying to show others as if he is not listening to any of her words. Only among her inlaws, did her husband's elder brother and elder sister treat her with respect.
When her husband fell ill, she was never included while deciding about his treatment, neither he told her anything, and would only get irritated when she tried to enquire about his health. After falling ill and on his death bed he realized the reality of the situation and his mistreatment of her.
The loss of her husband greatly impacted her son (aged 10.5 years) who slowly started resenting her, holding her responsible as he was told so by her sister in laws.
A few months after, her husband died due to CKD as a result of fluctuating BP, and his younger brother also fell ill and became bedridden. At that time younger brother was on dialysis and the home environment was sad and depressing, which was affecting her son's studies. Hence she took her son and started staying in her parent's home. But, since her son liked his father's family more (she guess because they won't make her study, he would play all day and also get to hear things spoken about his mother by her in-laws), so he would often force her to take him there. After class 10th exam, he won't get up from bed and forced her to take him to his father's home. Once there, he did not want to return. This happened often. She forcefully brought him back before his higher secondary exam.
After getting into college, he won't study at all and dropped out in the first year, then again in 3rd year. He experienced episodes of mood swings and would often get violent and very abusive using foul language (pt guess he learned from youtube videos). Pt cited the reason behind this is him losing all his loved ones (in a span of 2 yrs his father, father's 3 brothers, and 2 sisters all died all of whom were pt of high uncontrolled DM). Because he didn't like the food prepared at his father's home, he slowly reduced frequenting his father's home.
He would go to his father's home, enter a room, make her sit outside (to later recite what he had learned with her), and close the doors. In between, he would peek outside to check if she is there or not. If she leaves for the washroom or goes to eat at her parent's home, he would scream, throw away things, does not eat food, and shout using foul language. While reciting, if he gets one word wrong he would start banging his head, throw a pen at her, and blame and scold her.
Since 2016, he (currently 29 yrs old) had stopped going out, won't bathe, change clothes, nor allow changing bedsheets. He won't study or do anything at all. Always staying in one closed room. All day sleep or watch youtube videos or listen to songs. Is very sensitive and would often get violent (throw away everything e.g table fan, food plate), and use extremely vulgar words at her.
In the years 2019 and 2020 pt lost her mother and father respectively, which also affected her emotionally. She was especially close to her mother.
In her parent's home, after her parent's death, only she and her son along with her brother and his family stay together. When small she used to take care of both her son and her brother's son, which also caused jealousy in her son. Brother often takes money from her for his business which he does not like at all. Whenever he sees any expensive phone/object in his cousin's hand he gets angry saying to her mother that they are enjoying her money (pt is okay with giving money to brother since she feels he cares for her it is her responsibility) and threatening her that soon he will order something very expensive online and by any means, she has to arrange for the money and that would be her punishment. He likes online shopping and would often order food from outside. Brother's wife does not like him and treats him badly. So, he also does not like his mom to mix with them or sit and watch TV with them together. He is very sensitive and suspicious of what is happening around him.
If he sees someone enjoying he would get angry. If sees her mom smiling he would blame her for everything and ask how can she smile when her husband is dead and her son is not like this.
Pt had taken him to a lot of Psychiatrists who diagnosed him with severe depression and schizophrenia. Previously, he won't take any medication, but for the past few months, he takes money from his mom to go and buy medications. His mom denied any history of addiction. Drs had recommended sending him to an asylum but she is afraid that if he dies there.
Pt is deeply stressed out because of this situation and will retire from her job within a few months. She is concerned about what will happen to her son after her death and prioritizes his treatment over her.

Family history:

No significant family history

GENERAL PHYSICAL EXAMINATION:

Patient is conscious, coherent and cooperative.

Examined after taking valid informed consent in a well enlightened room.

Pallor - absent
Icterus - absent
Clubbing -absent
Lymphadenopathy - absent
Cyanosis - absent
Pedal edema -absent

VITALS:

Temperature: afebrile
Pulse rate: 72bpm, normal volume and rhyme

Respiratory Rate: 16 cpm
Blood Pressure: 100/60 mm Hg measured in right arm in sitting position

CVS : s1s2 heard, no murmurs
CNS : NFND
RESPIRATORTY : BAE +, NVBS
JOINTS EXAMINATION:

WRIST, MCP, PIP, DIP- NO SWELLING, TENDERNESS, RESTRICTION OF MOMENTS ANKLE- PAIN DURING PLANTAR FLEXION ? TALOCALCANEAL LEFT> RIGHT PAIN AT HEEL ON PROLONGED WALKING, DECREASED WITH CHANGE IN FOOTWEAR ENDOCRINOLOGY REFERRAL DOONE ON 10/02/2023: DIAGNOSED HYPOTHYROIDISM AND OSTEOPOROSIS ADVICED THYRONORM 50MCG PO OD