A 60-year-old man with A 60-year-old man with weight loss and bilateral leg weight loss and bilateral leg swellingswelling

Dr. Md. Abdul Mumit SarkarResident Phase – A(Gastroenterology)

Endocrinology Department

Patient InformationPatient InformationName Mr. M S M

Sex Male

Age 60 years

Address Nogorkanda, Faridpur

Occupation Retired police man

Date of admission 20-08-2013

Presenting complaintsPresenting complaints Increased frequency of defecation

3 yrs

Progressive weight loss 3 yrs

Bilateral leg swelling 20 days

History of present illnessHistory of present illness Defaecation8-10 times/daySemisolid stoolNot mixed with bloodNo relation with foods or drugsNot abdominal pain

History of present illnessHistory of present illness

Weight lossProgressiveLost 10kg during his course of illnessNormal appetiteAssociated heat intoleranceNo associated increased thirst or

increased frequency of micturitionNo H/O fever,cough,haemoptysis or

night sweat

History of present illnessHistory of present illnessBilateral leg swellingSwelling of scrotum and prepuceAssociated with exertional

dyspnoea,orthpnoea & palpitation

No H/O chest painNo H/O scanty high coloured uineNo past H/O of jaundice

History of present illnessHistory of present illness

No H/O contact with known TB patient

Past HistoryPast HistoryH/O hospital admission in 1999

with the complaints of fever and black tarry stool.

Blood transfusion-1 unit

Family historyHe is father of 5 childrenNo H/O thyroid or cardiac disease

in the family

Socioeconomic historyLow socioeconomic status

Personal historyNon smoker No H/O alcohol abuseDrinks tube well water Uses sanitary latrine

Treatment HistoryTreatment HistoryTab-Propranolol(40mg) 1/2 01/2

(29/7/13)

General Examination(on General Examination(on admission)admission)Anxious lookingCooperative Well oriented to time, place and

personBelow average body builtMildly anaemicAanicteric

General Examination(on General Examination(on admission)admission)ExophthalmosSwelling of eye lidsFine tremorThyroid gland-Normal PR - 60beats/min irregularly

irregular Pulsus deficit-present

General ExaminationGeneral ExaminationBP 110 / 70 mmHg in sitting position over right armJVP Raised RR 18/min Weight 57 kgTemp 980FOedema ++

Systemic ExaminationSystemic ExaminationCardiovascular SystemApex beat-Lt. 6th ICS 11cm from midline ThrustingNo Lt.parasternal heaveNo thrill1st heart sound soft in mitral areaNormal 2nd heart soundPansystolic murmer-over mitral area No radiation

Respiratory System Respiratory System ExaminationExaminationTrachea-centralBreath sound-vesicular & reduced

from rt.8th intercostal space and downward

Vocal resonance-reducedPercussion note-DullFine inspiratory cerpitation over

both lung bases

Systemic ExaminationSystemic ExaminationPer abdomen Liver 3cm from rt. Sub costal margin in the

mid clavicular line Firm Non tender Smooth surface Rounded border Upper border of liver dullness on rt.5th

intercostal space No hepatic bruit

Per abdomenPer abdomen

No splenomegalyNo para aortic lymphadenopathyNo ascitesNo bruit

Other system examinationOther system examination No abnormality

Provisional diagnosisProvisional diagnosis

Graves’ thyrotoxicosis with ophthalmopathy with CCF with AF

Hospital CourseHospital Course

Treated withTab-Asprin(75mg) 0 1 0Tab-Carvedilol(6.25mg) 1/2 0

1/2Tab-Spironolactone(25mg) 1 0 0Cap-Loperamide(2mg) 1 0 1Tab-Paracetamol(500mg) 1 1 1

Investigations Investigations Test Name 21/08/2013

Hb 9.6g/dl

ESR 70 mm in1st hr

RBC 3.77X1012/L

Platelets 120X109/L

WBC 5X109/L

Neutrophil 48%

Lymphocytes 39%

Monocytes 05%

Eosinophils 08%

basophils 00%

Investigations Investigations Test Name 21/08/2013

HCT 0.31L/L

MCV 82.2fl

MCH 25.5pg

MCHC 31.0g/dl

Blood Film(29/04/2013) RBC: Dimorphic blood picture with microcytes,few elliptical cell and rouleaux formationWBC: Mature with above count and distributionPlatelet-ReducedComment: Bicytopenia

Investigations Result

FPG 3.9mmol/L

HbA1c 5.7%

Serum Creatinine 0.9 mg/dl

Serum Albumin 20g/dl

SGPT 30U/L

Total Cholesterol 84mg/dl

LDL-Cholesterol 43mg/dl

HDL-Cholesterol 32mg/dl

Triglyceride 45mg/dl

InvestigationsInvestigationsUrine R/M/E (21/08/2013)

Pus cells :0-2/hpfRBC : NilEpithelial Cells: 0-2/hpf

Protein : nilChest Xray(21/08/13)

Right sided mild pleural effusion with

consolidation

Investigations Investigations Test Name 30/07/2013 21/08/2013

FT3 2.13ng/ml

FT4 1.34ng/ml 2.67ng/ml

TSH 0.09mIU/L 0.045mIU/L

ECG-Atrial fibrillation with lateral ischemia

Thyroid Scan FindingThyroid Scan Finding

Both lobes of thyroid gland are enlarged. There is uniform and increased radio tracer accumulation shown throughout the gland.There is no background activity is seen.

USG Of Thyroid GlandUSG Of Thyroid GlandBoth lobes of thyroid gland are

enlarged (AP of right lobe-20.5 mm, AP of left lobe-22mm).Thyroid parenchyma is heterogenous in echotexture.

Problem listsProblem listsWhen to start definitive

treatment of thyrotoxicosis?Is management of CCF optimum?Is there any role of

anticoagulant?What is the cause of bicytopenia?What is the cause of cardiac

murmur?

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