Case history -03





This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here, we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs

A 35 yr old female patient presented to the opd with chief complaint of passage of loose stools since 1 month.

HISTORY OF PRESENT ILLNESS  

Patient was apparently alright 1 month back and gives history of passage of large volumes stool, hard in consistency occasionally. History of intermittent fever and no history of constipation,cough and loss of appetite.patient also complaints of tiredness and weakness.

HISTORY OF PAST ILLNESS 

There is no history of hypertension,diabetes mellitus,tuberculosis,asthma,epilepsy

PERSONAL HISTORY 

Diet is mixed                                                                              Sleep is adequate                                                                     Bowel movements are irregular and micturition is normal                    Normal appetite                                                                             No allergy to known drugs                                                            No habits of alcohol and tobacco  consumption                                                                                She is married  

FAMILY HISTORY   

There is no history of similar complaints in the family members 

GENERAL EXAMINATION 

The patient is conscious, coherent and cooperative.she is well oriented to time,place and person. Moderately built and nourished.                                                                                      No anemia                                                                                     No pallor                                                                                         No clubbing                                                                                  No icterus                                                                                        No cyanosis                                                                                  No lymphadenopathy                                                                   No malnutrition                                                                            No dehydration            

Vitals:                                                                                            PR 102bpm.                                                                                 RR 16cpm                                                                                     BP  120/90mmHg                                                                                        SpO2 98% in room air                                                              Temp is febrile 

SYSTEMIC EXAMINATION 

CARDIOVASCULAR SYSTEM 

Inspection: 

Chest wall is bilaterally symmetrical                                            No precordial bulge                                                                      No thrills, cardiac murmurs,visible pulsation,engorged veins,scars and sinuses                                                         

Palpation: 

Jvp - normal                                                                           

Auscultation: 

S1&S2 are heard 

RESPIRATORY SYSTEM

Bilateral airway +

Dyspnoea - no

Wheeze -no

Position of trachea- central

Breath sounds -vesicular 

ABDOMEN 

Shape- scaphoid 

Soft and No tenderness 

No palpable mass or free fluid 

CENTRAL NERVOUS SYSTEM 

Patient is  conscious 

Reflexes are normal 

Speech is normal 

PROVISIONAL DIAGNOSIS 

Hyperthyroidism 

INVESTIGATION 













TREATMENT 

•On 13th September 

IVF 2NS,2RL,1DNS -150ml per hour

IVF 10amp Optineuron in 100ml NS -IV OD

Inj Pan 40mg /IV OD

Inj zofer 4mg /IV SOS

ORS SACHETS in a glass of water (after each episode)

BP charting 8th hourly 

Tab DOLO 650mg PO.SOS 

•On 15th September 

IVF 2NS,1RL,1DNS -150ml per hour

Plenty of oral fluids 

Inj optineuron 1amp in 100ml NS -IV OD 

Inj Zofer 4mg /IV/SOS

Inj Pan 40mg/IV/OD

Tab DOLO 650mg/pO/SOS

ORS sachets in 1L of water 

Monitor vitals 4th hourly 

•On 16th September 

IVF 2NS,1RL,1DNS -150ml/hour

Inj optineuron 1amp in 100ml NS IV/OD 

Inj Zofer 4mg/IV/SOS

Inj PAN 40mg/IV/OD

Tab DoLo 650mg/PO/SOS.                                                 

ORS sachets in 1L of water 

Monitor vitals 4th hourly 

•On 17th September 

IVF 2NS,1RL,1DNS -150ml/hour

Inj optineuron 1amp in 100ml NS IV/OD 

Inj Zofer 4mg/IV/SOS

Inj carbimazole 5mg/BD

Inj PAN 40mg/IV/OD

Tab DoLo 650mg/PO/SOS.                                                 

ORS sachets in 1L of water 

Monitor vitals 4th hourly 

•On 18th September 

Tab CARBIMAZOLE 10mg/PO/BD (before food)

Tab PROPRANOLOL 40mg/PO/BD

Tab SHELCAL 500mg/PO/OD 

Monitor vitals 4th hourly.



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