17 year old female with mucosal hyperpigmentation,loose stools,vomiting,

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CASE:

17 year old female complaints of vomitings and loose stools since 1week ,hyperpigmentation on buccal mucosa,hypothyroidism 


CHIEF COMPLAINTS:

Vomitings since 1week

Loose stools since 1week

Fever since 3 days


HISTORY OF PRESENT ILLNESS:


Patient was apparently asymptomatic One week back,then she too outside junk food followed by which she developed loose stools and vomitings

Loose stools:- 4-5episodes, water in consistency, non foul smelling, no blood tinged


Vomitings:- 4-5 episodes, non projectile, non bilious,non foul smelling contents include food particles,Which subsided on taking medication,


Fever was incidious in onset, associated with chills and rigor,which revealed by taking medication


Patient's mother observed swelling over the neck 10 years ago and was diagnosed with HYPOTHYROIDISM and is taking TAB.THYROXINE 25mcg....


Patient has history of eating slate pencils since 4 years.(5-6 slate pencils per day)


History of itching 3 years ago and was taken to hospital which relieved by taking medication.


 Patient is observing irregular menses from last 3months ,associated with dysmenorrhea and clots 


Patient also complained of generalised weakness since 1week.


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


APPETITE:Normal


SLEEP: Adequate


BOWEL AND BLADDER MOVEMENTS: Regular

ADDICTIONS: No Addictions

ALLERGY:Present 3years ago, subsided on taking medication.

FAMILY HISTORY:

Mother is suffering from HYPOTHYROIDISM  and is  on TAB.THYROXINE 100mcg..

GENERAL EXAMINATION:

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

Hyperpigmentation notes over the palate and the buccal mucosa 


Pallor:


Pigmentation seen on knuckes:


Icterus:- absent
Cyanosis:- absent
Clubbing:- absent
Lymph nodes:- Bilateral cervical and submandibular lymph nodes palpable.

Vital signs:
BP:- Supine :- 130/80 mm Hg 
        Standing :- 120/60 mm Hg
PULSE RATE :- Supine :- 88 BPM 
                           standing :- 83 BPM 
SpO2 :- 98 
Respiratory Rate :- 18cpm
GRBS :- 98 mg/dl

SYSTEMIC EXAMINATION:
CVS: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 ++

LOCAL EXAMINATION:
Inspection:swelling at the anterior part of the neck,does not move with protrusion of tongue and moves with deglutition
Palpation :- disseminated 
Auscultation: No bruits

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 : +

FEVER CHART:

INVESTIGATIONS:
A)HAEMOGRAM:


B)serum iron



C)Ferritin levels



D)Phosphorus levels


E)ultrasound neck:

F)chest xray:

G)peripheral smear:

H)ECG:

PROVISIONAL DIAGNOSIS:

pernicious anemia with autoimmune thyroiditis ?
Addison's disease ?

TREATMENT:

1.NALMOL 
2.TAB.PANTOP 40mg BD
3.TAB.ZOFER 4mg SOS
4.TAB.SPOROLAC (ROUTE:PERORAL) BD
5.TAB.DOLO 650mg SOS
6.TAB.THYRONORM 25mcg OD
7.ORS SACHET IN 1LT WATER TO DRINK AFTER EACH LOOSE STOOLS.
8.VITALS STORING EVERY 4TH HRLY



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