MEDICINE E-LOG 198 DIVYA POLAGONI

A 29year old male with Thyroiditis with Thyrotoxicos

December 05,2023

This is an a online e log book to discuss our patient's de-identified health data shared after taking his / her / guardians signed informed consent.

Here we discuss our individual patient's problems through series of inputs from available global online community of experts intending to solve those patient's clinical problem with the collective current best evidence-based input.

This E-log also reflects my patient centered online learning portfolio and your valuable inputs.

I have 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 diagnosis and treatment plan.

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

CHIEF COMPLAINTS: 

C/o shivering of hands and legs since 2 months
C/o swelling in front of neck, moving with degulition

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 2 months back and then developed shevering of both hands and legs, insidious in onset and gradually progressive and associated with palpitations, increased appetite, increased frequency of stools, excessive sweating and weight loss, no h/o fever breathlessness,chest tightness,hemoptysis.

PAST HISTORY:

Not a know history of DM, hypertension, epilepsy.
K/c/o bronchial asthama since 7 years using sos

PERSONAL HISTORY:

Mixed diet 
Sleep adequate
Bladder regular
Appetite increased
No allergies 
Consumes alcohol occasionally 

FAMILY HISTORY:

No significant family history

GENERAL EXAMINATION:

Patient is conscious, coherent, 
non cooperative.
Moderately nourished and built
No pallor
No icterus
No cyanosis
No clubbing
No palpable lymphnodes
No Edema

VITALS:
BP : 120/70mmhg
PR: 111bpm
RR: 17
Temperature: afebrile 
Grbs:118mg/dl

SYSTEMIC EXAMINATION:

CVS:
S1 and S2 are heard
No murmurs 

RESPIRATORY SYSTEM:
Trachea central 
Vesicular breath sounds heard
No wheeze or other adventitious sounds

CNS:
No focal neurological deficits
Gait normal
Speech normal
 

PER ABDOMEN:
Soft and non tender
No local rise of temperature 























INVESTIGATIONS:














PROVISIONAL DIAGNOSIS:

*Thyroiditis with thyrotoxicosis 
*k/c/o bronchial asthma

TREATMENT:

Tab:Prednisolone 30 mg OD 
Tab:Pan 40 mg OD 
Tab:Thiamine 100 mg  BD
Tab:Neurobion BD
Tab:MET-XL 25 mg BD
Tab:Neomercazole 10 mg BD

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