CASE PRESENTATION

Cervical Canal StenosisHypothyroidism

by

Nagaraju B

Patient Name -XXXXIP/OP No -34436/13/14DOA - 15/02/2014DOD - 18/02/2014Department - MedUnit - IVAge - 43yearsSex - FemaleWeight - 60kgs

SUBJECTIVEChief complaint/ History of Presenting illness:

h/o Neck pain since 4 months with radiating to right upper limb.c/o Hoarseness of voice x 1yrc/o Constipation since x 3 monthsc/o Generalized Weakness x 2 monthsc/o Myalgia x 1 monthc/o Coarse skin x 1monthc/o Decreased appetite x 1 monthc/o Facial puffiness x 5 days

Previous history:Attained menopause 2 years back

Past MedicationHistory/Allergy:

Nothing significant

Personal history: Diet- MixedAppetite- DecreasedSleep- DisturbedBowel – Constipation+ Bladder- Normal Habits- None

Physical examination :Conscious, co-operative, alert and oriented.

Vital signs: BP - 116/80mmHg PR – 68bpmRR – 18cpm Temp – afebrile.

Family history: no f/h/o DM, HTN, ASTHAMA, TB

OBJECTIVE

P[+], I[-], C[-], C[+], L[-], E[+]

Systems:-

P/A

RS NAD

CVSCNS

Provisional diagnosis : ? Paresthesia+ ? Hypothyroidism& ? Anemia

TEST TEST VALUE NORMAL VALUE

Hb (g/dl) 11.9 12-16

TLC: (cells/cmm) 4500 4000-11000

DLC : N (%) 64 40-75

L (%) 28 20-45

E (%) 02 1-6

M (%) 05 2-10

B (%) 01 0-1

Platelets (cells/cmm) 1.8 1.5-4.0 lakh/cmm

ESR 21 0-20 mmhr

T3 (ng/ml) 0.14 0.60-1.81ng/ml

T4 (mcg/ml) 0.24 4.5-10.9mcg/ml

TSH (miU/L) 82.0 0.4-4.2miU/L

Radiogrphic Imaging/MRI

Spondylosis changes in cervical spine Grade-I restore

C5 over C6 mild dislocate C4-5, C5-6 & C6-7 levels- No significant canal/neural terminal compromise

LABORATORY INVESTIGATIONS

ASSESMENTBased on the subjective evidence[Hoarseness of

voice, Constipation, Generalized Weakness, Myalgia, Coarse skin, Decreased appetite and Facial puffiness] & objective evidence [ decreased levels of T3, T4, Hb and elevated levels of ESR and TSH], the patient was diagnosed to have Hypothyroidism with Anemia.

Radio Imaging & MRI shows that Spondylosis changes in cervical spine Grade-I restore and C5 over C6 mild dislocate C4-5, C5-6 & C6-7 levels of which can be confirmed to have Cervical Canal Stenosis.

BRAND NAME GENEROIC NAME

DOSE FREQUENCY

DATE DATE END

T. Zentel400 Albendazole 400mg 0-0-1 15/2 ---

T. Eliwel Amitriptylline 10mg 0-0-1 15/2 17/2

T. Eltroxin Thyroxine sod

100mcg 1-0-0 16/2 18/2

T. Gabantin Plus Gabapentin+Methylcobala

100mg+ 500mcg

1-0-1 17/2 18/2

C. Thirty Plus Multivit& Min -- 0-1-0 17/2 18/2

MEDICINE ON DISCHARGE(DAMA)

T. Eliwel 1hsod

x 40days Review on 01/4

T. Eltroxin 1od

T. Gabantin Plus 1hnod

C. Thirty Plus 10d

TREATMENT CHART

Suggestion to Physician-

No drug interaction is found.-Iron & vit-C preparations would have been advised.-Investigation of Stool for ova and cyst would have advised.-Hard cervical collar would have advised.-Laxative might have been added whenever patient feels constipation for time being.

PLAN

Advice to patient- Avoid rapid posture change. Try to relax whenever possible. Try to reduce stress & anxiousness, if any. Make habit of doing exercise at least 30 min

daily. Adhere to medication. Maintain hygiene. Drink plenty of water. Take orange juice and iron rich foods like chicken,

meat, egg and green leafy vegetables like spinach and beetroot.

Take thyroxine tablet on empty stomach Need not be worried, if stool become darker or

yellowish urination after taking 30+. Repeat TFT after 1-2 months as per convenience.

THANK YOU…