Anecdotal self reflections on their internship learning with some video evidence of procedures performed

This case has been given to solve in an attempt to understand and analyse the patient's clinical data, and develop my competency in reading and comprehensive study on the clinical data including history, clinical findings, investigations, and coming up with diagnosis and treatment plans. This is an 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 patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.

While I was working in the Unit, I encountered a 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. 

Later I found out that she knew that she had Hypertension but she never took medication for it. Upon examination, it was found out that she has BP of 200/100 mmHg which was alarming for me and hence I informed my mentors about it. She was immediately transferred to AMC for crucial treatment of her Hypertension. 

12/9/23

ward: AMC

DOA: 11/9/23

S - C/o loss of near vision in both eyes since 2-3 years and watery 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.

k/c/o hypertension since 6 months. Not on any antihypertensive medication. 

K/C/O Hypothyroidism and on tab. Thyronorm 25 mcg regularly.

H/ O hemithyroidectomy done 3 years back. 

O :  Hypertension since 6 months. Not on any antihypertensive medication. 

A: On examination 

Patient is conscious coherent and cooperative. 

No Pallor, Icterus, cyanosis, clubbing, lymphadenopathy, edema.

She has a horizontal scar on the anterior aspect of neck with regards to the history of hemithyroidectomy surgery done 3 years back. 

Vitals:

Temp: 97.8 F

PR: 96 BPM

BP: 200/100 MM/HG

RR: 18 CPM

GRBS: 130 MG/DL

SPO2: 99%

CVS: S1 ,S2 heard

RS: B/L AE present , NVBS +. No added sounds

P/A: Soft, non tender, no organomegaly.

No rigidity,Guarding.

CNS: NFND

P:

1. Tab. THYRONORM 25 MCG PO/OD before breakfast  

2. tab amlodipine 5 mg PO/OD

3. Tab. Met-xl 50 mg PO/ BD

4.  Tab atarvastatin

5. strictly Monitor BP.

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.

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 )

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

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 DYSFUNCION +.

- 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. After proper treatment with anti hypertensive medications was given, the patient’s blood pressure returned back to normal limits. Thorough BP monitoring was done as well.

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. 

LEARNING POINTS: 

1. I have learnt how the high blood pressure can affect the end organ system very drastically. 

Here are some links to learn further about it.

https://pubmed.ncbi.nlm.nih.gov/21509040/

https://www.healthline.com/health/hypertensive-retinopathy

2. Correlation of obesity with hypertension

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5038894/