60 Y/ F with complaint of loss of near vision in both eyes
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MED CASE :
60 Year old Female with complaints of loss of near vision in both eyes since 2-3 years and watery eye discharge with itching in both eyes since 1 year.
CHIEF COMPLAINTS :
Complaints of loss of near vision in both eyes since 2 years and watery eye discharge with itching in both eyes since 1 year.
HISTORY OF PRESENT ILLNESS:
Patient was apparently alright 2 years back and then developed loss of near vision in both eyes. Loss of vision was gradual in onset, and it consistently kept getting worse. She also complained of water eye discharge with itching in both eyes since 1 year.
She also has complaints of alopecia, weight gain, loss of appetite.
No C/O constipation and cold or heat intolerance.
No C/O concentration difficulty, hoarseness of voice, irritability, impaired memory.
HISTORY OF PAST ILLNESS:
K/C/O Hypothyroidism (iatrogenic) since she was operated for hemithyroidectomy due to presence of mass in the neck 3 years ago. She is on medication Tab. Thyronorm 25mcg PO/OD, before breakfast, since 3 years.
K/C/O Hypertension since 6 months and she is not on any anti-hypertensive medication.
Not a K/C/O DM, CVA, CAD, epilepsy, asthma, TB.
PERSONAL HISTORY:
Diet- mixed. She eats all kinds of foods.
Appetite- normal
Sleep- adequate
Bowel- normal.
Bladder- normal.
ALLERGIC HISTORY:
No allergic history to any kind of food or drugs.
GENERAL EXAMINATION:
THE PATIENT IS CONSCIOUS, COHERENT AND CO COOPERATIVE
No PALLOR
No ICTERUS
No CLUBBING
No CYANOSIS
No LYMPHADENOPATHY
No EDEMA
Patient has a horizontal scar on the anterior aspect of neck with regards to the history of hemithyroidectomy surgery done 3 years back.
TEMPERATURE: Afebrile
PR:90 bpm
BP:200/110mmhg
RR:18cpm
GRBS: 130 mg/dl
SYSTEMIC EXAMINATION:
CVS: S1 S2 Heard. No murmurs heard.
RS: BLAE +. Normal vesicular breath sounds heard. No added sounds.
ABDOMEN EXAMINATION:
Inspection:
Abdomen is soft and distended.
No sinuses,scars, pulsations, peristalsis.
Umbilicus is central and inverted.
All quadrants of Abdomen move equally with respiration.
Palpation:
Abdomen is soft on palpation and no tenderness noted in any quadrants.
Percussion:
Resonant note is heard on percussion
shifting dullness negative
Auscultation:
Bowel sounds are heard.
CNS: No Focal Neurological Defects.
INVESTIGATIONS:
12/9:
HEMOGRAM
HAEMOGLOBIN 13.2
TOTAL COUNT 7,800
NEUTROPHILS 63
LYMPHOCYTES 25
EOSINOPHILS 03
MONOCYTES 09
BASOPHILS 00
PCV 40.1
MCV 83.7
MCH 27.6
MCHC 32.9
RDW-CV 14.5
RDW-SD 45.4
RBC COUNT 4.79
PLATELET COUNT 1.91
BLOOD SUGAR – RANDOM:
RBS 81
HBsAg-RAPID, HIV, ANTI-HCV:
Negative
COMPLETE URINE EXAMINATION ( CUE )
Test Result
COLOUR Pale yellow
APPEARANCE Clear
REACTION Acidic
SP.GRAVITY 1.010
ALBUMIN Nil
SUGAR Nil
BILE SALTS Nil
BILE PIGMENTS Nil
PUS CELLS 2-3
EPITHELIAL CELLS 2-3
RED BLOOD CELLS Nil
CRYSTALS Nil
CASTS Nil
AMORPHOUS DEPOSITS Absent
OTHERS Nil
RFT:
Blood Urea 28
Serum Creatinine 0.9
SERUM ELECTROLYTES (Na, K, CI) AND SERUM IONIZED CALCIUM
SODIUM 137
POTASSIUM 4.2
CHLORIDE 101
CALCIUM IONIZED 1.17
T3, T4, TSH
T2 1.08
T4 11.37
TSH 3.50
ECG : NORMAL SINUS RHYTHM.
2D ECHO:
IMPRESSION:
- TRIVIAL AR +, MILD TR+ WITH PAH. NO MR.
- NO RWMA. NO AS/MS, SCLEROTIC AV.
- GOOD LV SYSTOLIC FUNCTION.
- DIASTOLIC DYSFUNC +.
- NO LV CLOT.
ULTRASOUND OF NECK :
FINDINGS:
USG – Neck
Thyroid gland
- Right Lobe :12x15x37mm, normal
- Left Lobe – Not Visualised Post op status
- Isthmus - 4.5mmm, normal
-E/O 2.5X3.1mm, Cystic, anechoic lesion and wider than teller and no vascularity
No calcifications noted in the right lobe of thyroid
- TIRADS 1 lesion
-E/0 Few prominent cervical lymph nodes noted on both sides
Left side – L- II, III largest 5mm
Right Side – L-II
-B/L submandibular glands and parotid glands appear Normal
-B/C IJV and carotid vessels appear normal
Impression
1. TIRADS – 1 lesion in the Right lobe of thyroid
2. Few prominent cervical lymph nodes as described above
DIAGNOSIS:
HYPERTENSION since 6 months.
K/C/O Hypothyroidism since 3 years.
COURSE IN THE HOSPITAL:
The patient came to ophthalmology OPD with complaints of loss of near vision in both eyes since 2-3 years and watery eye discharge with itching in both eyes since 1 year. Ophthalmology examination was performed on the patient. Upon Fundus examination, flame shaped haemorrhage was noted in the right eye. She is a known case of hypertension since 6 months and not on any anti hypertensive medication.
She has a history of hemithyroidectomy done 3 years back and is a known case of hypothyroidism. She is on medication tab thyronorm 25 mcg regularly.
The patient was sent to general medicine department with regards to her history of hypothyroidism. But upon checking her vitals, it was found out that her blood pressure was 200/110 mmhg and hence patient was admitted immediately for hypertensive emergency treatment.
The patient was admitted in general medicine ward and all the necessary investigations were done. Her remaining general and systemic examination is done and turned out normal. Necessary treatment for hypertension was immediately initiated since she has high blood pressure since the time of admission. Her GRBS is within normal range (130 mg/dl).
Her bowel and bladder activity is normal.
Her appetite is sometimes inadequate and no disturbance in sleep during the course of hospital admission.
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