65/F with Altered sensorium secondary to hyperthyroidism

[13/3/2023]

A 65 year old female pt presented to Gen surg opd with complaints/of

 swelling in front of neck since 2years

 C/o pain in swelling since 20 days

Pt was apparently asymptomatic 2 years back then she developed a swelling in neck which is insidious in onset, gradually progressive to present size of 9x6cm. Associated with pain (pricking type), 

non radiating, 

no aggrevating or relieving factors

H/0 difficulty in swallowing since 6 months.

H/o difficulty in breathing since 6 months

No h/o hoarseness of voice

No other swelling in the neck

No other h/o s/o hypothyroidism 

No h/o fever, nausea, vomiting 

No h/o loss of appetite or weight loss

No h/o sleep disturbances 

Bowel and bladder habits regular.

DIAGNOSIS: SOLITARY THYROID NODULE

ON [19/3/2023]

PT REFERRED TO GEN MED I/V/0 SHORTNESS OF BREATH AND IRRITABILITY SINCE TWO DAYS.

 

Hopi:

No h/o bone pain, cough, hemoptysis, jaundice, abdomen fullness, headache and seizures. 

 

Past history:

H/o hyperthyroidism since 11years

Surgical history of Right hemithyroidectomy 6 years back

H/o hysterectomy done 40 yrs ago

Not a k c o Hypertension, CAD, TB, asthma, epilepsy. 

PSYCHIATRY REFERRAL: 

C/O 

INCREASED IRRITABILITY 

Unability to recognise family members 

Abnormal behaviour in the form of moaning and incoherent sounds , trying to get up and leave 

Pts sleep decreased, appetite decreased 

Self care and hygiene maintained by od.

Not able to do regular daily activities due to physical illness.

Hopi:

No h/o head injury, seizure activity 

No h/o blood in vomiting/ stool

No h/o pervasive low moods, easy fatiguability or suicidal ideations

No h/o palpitations, fearfulness or feeling of impending doom

No h/o grandiose or flight if thoughts

No h/o repetitive thoughts or actions

Past history 

H/o alcohol consumption since 30 years [initially toddy currently whiskey][consumption amounts accurately not known]

Family History: no significant psychiatric illness in family

MSE: pt sitting on the bed awake and alert but not responding to her name. pt is restrained to the bed (soft restrain) . 

Thin built , cannula in place

Enterotoxigenic E. coli (ETEC) + not maintained

Psychomotor agitation increased

Speech - incoherent and decreased 

Mood/Affect - agitated and IRRITABILITE 

Thought and perception- cnbe

Not oriented to time place and person 

* delirium due to general medical condition * 

psychiatric Treatment plan 

1.Tab pregabalin 75mg

2.tab oxazepam 15mg po/sos

 Personal History:

DIET: MIXED 

APPETITE: NORMAL 

BOWEL AND BLADDER MOVEMENTS: REGULAR 

SLEEP: ADEQUATE 

ADDICTIONS: NO

Family History: 

H/o thyroid swelling malignancy in father.

Treatment history:

 CARBIMAZOLE 10mg po/bd

 Salbutamol for dyspnea 

Menstrual History

Menarche 11 years

Age at marriage 15 years

Age at 1st child born 18years

Menopause at 45 years

General Examination 

O/e Pt is c/c/c

Oriented to time place and person

Temp : 97.4

Pr : 84/min

BP: 130 /80 mmhg

Spo2 : 98% on RA

Cvs : s1s2+ no murmurs 

RS : bae+ ,nvbs

Moderately built and nourished 

Texture of skin - normal

Hair - Normap

Exophthalmos -present

Tremors - present

No signs of pallor,icterus, cyanosis,lymphadenopathy & pedal edema 

Local examination 

 

On inspection 

A 8x6cm Solitary vertically oval swelling seen on left side of neck.

Extending superiorily above thyroid bone.

Inferiorly beyond the suprastwrnal notch 5cm away from right sternocleidomastoid 

Engorged veins present 

 A transverse scar of 3x1cm present at right side of neck

Skin over swelling NORMAL

smooth surface

Borders are well defined 

Swelling moves up&down with deglutation

No visible pulsations

Lower border of swelling visible

Trachea appears to be deviated to right side

No other swellings in neck 

No discolouration or erythema

Palpation: 

No local rise of temperature 

No tenderness

All inspectory findings confirmed

Surface is smooth,

Hard in consistency 

Restricted mobility 

KOSHERS NEGATIVE - 

Carotid pulsations fast on both sides

NO PALPABLE THRILL,

NO PALPABLE CERVICAL LYMPH NODES

Auscultation 

No resonant note over manubrium sternum

Percussion 

Bruit heard

DIAGNOSIS 

Altered sensorium secondary to 

?Hyponatremia ?uremia

?Aki on ckd

Solitary thyroid nodule 2° to hyperthyroidism 

Hypercalecimia and hyperkalemia secondary to CKD

Heart failure with mid range ejection fraction

Treatment

1.Iv fluids 0.9% NS @ 50ML/hr

2.INJ lasix 20mg iv/od

3. Tab ECOSPRIN 75/10 p0/od

4. Tab nodosis 500mg po/bd

5. TAB CARBIMAZOLE 20mg po/bd

6. Tab propanolol 20mg po/bd

7. Strict I/O monitoring 

8. GRBS MONITORING 6TH HOURLY 

9. Vitals 4th hrly 

10. TAB AMLONG 5mg po/only after informing respective Dr's.

25/4/2023

Amc bed 3

S

No Fever spikes

Stools passed

O

Pt is c/c/c

Oriented to time place and person

Temp : 98.3

Pr : 86/min

BP: 130 /70 mmhg

Spo2 : 98% on RA

RR : 18/min

Cvs : s1s2+ no murmurs 

RS : bae+ ,nvbs

Cns : NAD 

GCS: E4V5M6

P/A : soft, non tender 

A

Altered sensorium secondary to 

?Hyponatremia (resolved)

?uremia

?Aki prerenal (resolved)

Solitary thyroid nodule 2° to hyperthyroidism 

Hypercalecimia and hyperkalemia secondary to RF

Heart failure with REDUCED ejection fraction (35%)

S/P RT. HEMITHYROIDECTOMY 15YRS BACK WITH HTN

P

1.. Tab ECOSPRIN AV 75/10 p0/od

2. TAB CARBIMAZOLE 20mg po/bd

3. Tab propanolol 20mg po/bd

4. Tab DYTOR 20mg po/bd

5. NODOSIS. 500MG PO/BD

6. OINT. THROMBOPHOBE LA/TID

7. GRBS MONITORING 6TH HOURLY 

8. Vitals 4th hrly