A 17 year old with mucosal hyperpigmentation,loose stools , vomiting

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CASE:

17 year old female complaints of vomitings and loose stools since 1week ,hyperpigmentation on buccal mucosa,hypothyroidism 

CHIEF COMPLAINTS:

Vomitings since 1week

Loose stools since 1week

Fever since 3 days

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic One week back,then she too outside junk food followed by which she developed loose stools and vomitings

Loose stools:- 4-5episodes, water in consistency, non foul smelling, no blood tinged

Vomitings:- 4-5 episodes, non projectile, non bilious,non foul smelling contents include food particles,Which subsided on taking medication,

Fever was incidious in onset, associated with chills and rigor,which revealed by taking medication

Patient's mother observed swelling over the neck 10 years ago and was diagnosed with HYPOTHYROIDISM and is taking TAB.THYROXINE 25mcg....

Patient has history of eating slate pencils since 4 years.(5-6 slate pencils per day)

History of itching 3 years ago and was taken to hospital which relieved by taking medication.

 Patient is observing irregular menses from last 3months ,associated with dysmenorrhea and clots 

Patient also complained of generalised weakness since 1week.

HISTORY OF PAST ILLNESS:

Known case of HYPOTHYROIDISM since 10years on TAB.THYROXINE 25mcg..

Not a known case of HYPERTENSION,DIABETES MELLITUS,ASTHMA, EPILEPSY.

PERSONAL HISTORY:

DIET:Mixed

APPETITE:Normal

SLEEP: Adequate

BOWEL AND BLADDER MOVEMENTS: Regular

ADDICTIONS: No Addictions

ALLERGY:Present 3years ago, subsided on taking medication.

FAMILY HISTORY:

Mother is suffering from HYPOTHYROIDISM  and is  on TAB.THYROXINE 100mcg..

GENERAL EXAMINATION:

Patient was conscious,coherent and cooperative,well oriented to time,place and person

Hyperpigmentation notes over the palate and the buccal mucosa 

Pallor:

Pigmentation seen on knuckes:

Icterus:- absent

Cyanosis:- absent

Clubbing:- absent

Lymph nodes:- Bilateral cervical and submandibular lymph nodes palpable.

Vital signs:

BP:- Supine :- 130/80 mm Hg 

        Standing :- 120/60 mm Hg

PULSE RATE :- Supine :- 88 BPM 

                           standing :- 83 BPM 

SpO2 :- 98 

Respiratory Rate :- 18cpm

GRBS :- 98 mg/dl

SYSTEMIC EXAMINATION:

CVS:S1,S2 heard,no murmurs

RESPIRATORY SYSTEM:

Inspection: trachea central in position, chest moving bilaterally equally with respiration.

Palpation:

Percussion :- resonant in all the fields

Auscultation :- Normal vesicular breath sounds heard.

BAE ++

LOCAL EXAMINATION:

Inspection:swelling at the anterior part of the neck,does not move with protrusion of tongue and moves with deglutition

Palpation :- disseminated 

Auscultation: No bruits

ABDOMINAL EXAMINATION:

Inspection :- no scars

Palpation :- soft,non tender

Auscultation :- BOWEL SOUNDS HEARD 

CNS EXAMINATION:

CRANIAL NERVES: INTACT 

Power

Rt UL-5/5. Lt UL-5/5 

Rt LL-5/5. Lt LL-5/5 

Tone-

Rt UL -N

Lt UL-N

Rt LL-N

Lt LL-N

Reflexes:. RIGHT LEFT

Biceps. ++ ++

Triceps. ++ ++

Supinator. ++ ++

Knee. ++ ++

Ankle. ++ ++

Plantar:. Flexion Flexion       

•SENSORY

crude touch N N

              Pain N N

Temperature N N

     Fine touch N N

       Vibration Right Left

     Upper limb. 15 sec 15 sec

     Lower limb. 11 sec. 10sec

                Tibia. 14 sec. 14sec

                   Toe. 15sec. 15sec

Finger nose co-ordination : +

FEVER CHART:

INVESTIGATIONS:

A)HAEMOGRAM:

B)serum iron

C)Ferritin levels

D)Phosphorus levels

E)ultrasound neck:

F)chest xray:

G)peripheral smear:

H)ECG:

PROVISIONAL DIAGNOSIS:

pernicious anemia with autoimmune thyroiditis ?

Addison's disease ?

TREATMENT:

1.NALMOL 

2.TAB.PANTOP 40mg BD

3.TAB.ZOFER 4mg SOS

4.TAB.SPOROLAC (ROUTE:PERORAL) BD

5.TAB.DOLO 650mg SOS

6.TAB.THYRONORM 25mcg OD

7.ORS SACHET IN 1LT WATER TO DRINK AFTER EACH LOOSE STOOLS.

8.VITALS STORING EVERY 4TH HRLY