17 year old girl complaining of vomitings and diarrhea with history of anemia and hypothyroidism
17 YEAR OLD GIRL COMPLAINING OF VOMITINGS AND DIARRHEA WITH HISTORY OF ANEMIA AND HYPOTHYROIDISM
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A 17 year old girl, studying intermediate 2nd year, residing in a hostel, presented to the OPD with chief complaints of vomitings and diarrhea for a week .
History of presenting illness : The patient was apparently asymptomatic 10 yrs back, then her mother noticed a swelling on her neck, which when showed at a hospital was diagnosed to be hypothyroid for which she is using THYRONORM 25 micrograms .
Since 3 years her hemoglobin levels have been between 7-8 mg/dl, but in the past week it has dropped down to 6 mg/dl for which she has received IV iron supplementation.
No history of trauma, peptic ulcers, worm infestations.
The patient complains of fatigue since 3 years as she is unable to walk or do minimal activity for 10 min continuously.
The patient also has history of pica as she has been consuming slate pencils since 3 years.
The patient complains of weight gain since 3 years from 45 kg to 65 kg.
The patient is now complaining of 5 episodes/day of nausea, vomitings and diarrhea since 1 week . She had non projectile, non bilious vomitings with food particles as contents . The stools were watery in consistency, non foul smelling, non blood stained associated with abdominal pain. She has been receiving saline and other fluids from a local hospital but there has been no improvement of symptoms and hence has presented to our OPD .
Menstrual history : Menarche at 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 .
Past history : She is a known case of anemia and hypothyroidism ( using THYRONORM 25 micrograms ).
No history of DM, HTN, asthma, epilepsy .
Personal history :
Diet - mixed
Appetite - decreased since 15 days
Sleep - adequate ( from 10 pm to 5 am )
Bowel and bladder movements - regular
Family history : The patient's mother also has hypothyroidism since 14 years ( on medication - THYRONORM 100 micrograms ).
General Examination : The patient is conscious, coherent and cooperative, well built and nourished.
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 .
Acanthosis nigricans also present .
VITALS :
02/11/22 :
Temperature - 99 F
BP - 140/80 mm Hg
HR - 90 bpm
RR - 24 cpm
03/11/22 :
Temperature - 98 F
BP - 120/70 mm Hg
HR - 88 bpm
RR - 20 cpm
04/11/22 :
Temperature - 98 F
BP - 120/80 mm Hg
HR - 96 bpm
RR - 20 cpm
05/11/22 :
Temperature - 98.7 F
BP - 130/80 mm Hg
HR - 80 bpm
RR - 20 cpm
Systemic Examination :
CVS :
On palpation ‐
• Apex beat was felt in the left 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
RS :
On inspection ‐
• Chest is bilaterally symmetrical
• Expansion of chest: Equal on both sides
• Position of trachea: Central
• No visible scars, sinuses, pulsations
On palpation :
• Expansion of chest was equal on both sides.
• Position of trachea: Central
• Tactile Vocal Fremitus: resonant note was felt.
On percussion: all lung areas were resonant
On auscultation :
• Bilateral air entry was present, normal vesicular breath sounds were heard.
• Vocal resonance: resonant in all areas
P/A : soft, non tender, no organomegaly, no distension, bowel sounds heard.
CNS : The patient is well oriented to time, place, person.
Higher mental functions are intact.
Cranial nerve examination :‐
All cranial nerves are intact and functioning.
Motor System Examination :‐
• Normal bulk in upper and lower limbs
• Normal tone in upper and lower limbs
• Normal power in upper and lower limbs
• Gait is normal .
. Reflexes :
Right. Left
Biceps. +2. +2
Triceps. +2. +2
Supinator. +2. +2
Knee +2. +2
Ankle. Flexor. Flexor
Sensory System Examination :‐
Normal sensations are felt in all the dermatomes.
No cerebellar signs .
No meningeal signs.
Local Examination of thyroid :
Inspection : Swelling in the anterior part of neck moving with deglutition but not moving with protrusion of tongue .
Palpation : Circumscribed margins with approximate size of 6×4 cm .
Auscultation : no bruit heard .
Investigations :
Fever chart
Peripheral smear
Chest X ray
USG of abdomen
USG of neck
ECG
Provisional Diagnosis : Acute gastroenteritis (resolved ) with pernicious anemia
Treatment :
02/11/22 :
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
03/11/22 :
1) Tab. Pantop 40 mg PO BD
2) Tab. Zofer 4 mg PO SOS
3) Tab. Thyronorm 25 micrograms PO OD
4) Tab. Livogen 150 mg PO OD
5) Inj. Hydroxycobalamin 1mg IM OD
04/11/22 :
1) Tab. Zofer 4 mg PO SOS
2) Tab. Thyronorm 25 micrograms PO OD
3) Tab. Livogen 150 mg PO OD
4) Inj. Hydroxycobalamin 1mg IM OD
05/11/22 :
1) Tab. Zofer 4 mg PO SOS
2) Tab. Thyronorm 25 micrograms PO OD
3) Tab. Livogen 150 mg PO OD
4) Inj. Hydroxycobalamin 1mg IM OD
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