general medicine

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 global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've 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 a diagnosis and treatment plan.

A 48 year old female patient came to the hospital with the chief complaints of swelling in the neck since 1 year and difficulty in swallowing since 6 months. The patient even complaints of burning micturition since 10 days 

HISTORY OF PRESENT ILLNESS:
patient was apparently asymptotic 1year back, then she observed pea sized swelling in the neck which gradually increased. patient has weight loss since 2 months.

HISTORY OF PAST ILLNESS:
no h/o DM
no h/o HTN
h/o thyroid since 1 year
patient was on tab. carbimazole 25mg
vitals:
temp- 98.5 F
PR - 112/min
RR- 18/min
BP- 110/80 mmHg
Spo2 - 99%
CVS- S1 S2 + no murmurs

IMAGES:
ultrasound:
2D ECHO:
ECG:
DIAGNOSIS:
TOXIC ADENOMA ( THYROTOXICOSIS)

TREATMENT:
1. Tab. carbimazole 10mg/  pd/ TID
2. monitor vitals hourly
3. Tab. pro

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