33 years old female with Ulcer & Previous H/O throat pain and hypothyroidism

E-LOGS MEDICINE

Hi, I am Arefin Sadat, a final-year MBBS student. This is an E-Log that depicts the patient-centred approach to learning medicine. This E-Log has been created after taking consent from the patient and their relatives. The links that were used by me for understanding the available data on the particular disease have been mentioned below in each post. I hope you learn valuable information after giving it a good read.

CASE OF A 33-YEAR-OLD FEMALE 

CHIEF COMPLAINTS

1) Complain of throat pain for 2 months.

2) Ulcer on left leg.

History of Present illness

Patient was apparently asymptomatic 3 years back ,then she developed increased cold intolerance (although she’s having cold intolerance since childhood ),decreased weight(?),decreased appetite for which she was investigated and 

Then she was diagnosed with hypothyroidism in march ,2019 

~she was started on 25mcg [thyronorm]initially,used for 3 months

~she stopped taking medication for next 3 months[assuming her thyroid has become normal]

~in the month of sep 2019,went for a check up ,her TSH was high and was started on 50 mcg again 

~subsequently it was increased to 75 mcg

 and then to  100 mcg[in dec 2020][as her tsh was  not decreasing]

~she used 100 mcg for 6 months.

~around the month of june ,2021 she developed palpitations,fearfulness,anxiety

~consulted doctor again -she was told  that her TSH has fallen down to ~0.1  [as she was using the wrong dosage ]..she was started on antidepressants too ..she used them for about one month and then stopped (coz she feels more sleepy when she takes them and was unable to look after her child )

•Right now she’s on thyronorm 50 mcg 

•2 years back she had throat pain for which she consulted doctor and was diagnosed with pharyngitis,got treated for about 5-7 days and got relieved.

•In the month of May ,2022  her husband met with an accident ,following which she experienced neck pain,breast pain and back pain ,she took homeopathic medication for that ...and she says that she feels a lot better now after taking homeopathic medication (the pain has decreased comparatively)...initially she was not able to move her neck sideways d/t pain ,later after taking medication she felt a lot better and was able to move her head and neck sideways .

•From the month of June ,2022 she’s having anxiety issues (even before that she started having stressful days since 5 years ),she feels stressful regarding health issues of her family members ,whenever her child gets sick ,whenever her husband doesn’t pick up the call/comes home late from work

The stress increased when her husband met with a bike accident in May 2022,

She was prescribed sleeping pills ..she didn’t take them

Initially later on  in September She took them for about 10 days (as she had disturbed sleep ) 

•Pt is having throat pain since September,2022

Throat pain (prickling ,itchy)since 2 months ,

Aggravates on taking cool things  relieves on eating /drinking hot foods 

There’s no difficulty in swallowing solids/liquids ,

But she complaints of pain when she swallows her saliva (?)

Ear pain (initially she had left ear pain later she has pain in right ear also )

Pain is insidious in onset ,intermittent and pricking type of pain 

Not a/w ear discharge or decreased hearing 

The pain increases on exposure to cold climates  

A/w:

Hair fall +

Loss of appetite +

Palpitations +

Easy fatigue 

No dry skin,bowel and bladder movements regular 

History of Past Illness:

H/o surgery to the right breast (removal of lump )(in the year of 2005 )

•H/o LSCS In the year of 2017 

•Hypothyroidism since 2019 

Family History:

Her grandmother and her father underwent surgery for 

Tumor removal 

Grandmother:underwent surgery for removal of tumor from stomach (?)

Father :Underwent surgery for removal of tumor over thigh 

Menstrual history :

Attained menarche at the age of 11 years 

Cycles regular (6/28 day cycle)

Marital history :

Got married in the year of 2014 

Age of first child birth :27 years (in 2017)(LSCS)

She had bleeding PV in her 5th month of pregnancy,she was given some medication for that and bleeding has stopped and then she again had bleeding PV just 7 days prior to her EDD ,following which she was admitted and LSCS was done and baby was delivered (wt of baby at birth :3.9 kg,cried immediately after birth ,no h/o nicu admissions)

No h/o abortions,miscarriages 

H/o using contraceptive pills

Personal history:

Appetite -reduced 

Diet-mixed

Bowel and bladder movements-regular 

Sleep-disturbed 

Addictions-consumes pan 

Allergies-none

(Initially before marriage she used to consume 1 pan /day 

Or 1 pan in 2-3 days 

Later after her child birth ,and increased stress ,she started eating 3 -4 pan / day ,)

General examination :

Pt is conscious coherent and cooperative well oriented to time place and person 

Well built and nourished 

Vitals:

PR-104bpm

BP-110/60 mmHg

RR-20 cpm

Temp-97.4 F

GRBS-133 mg/dL

No pallor ,icterus,cyanosis,clubbing ,generalised lymphadenopathy,edema 

Scar over right breast (upper inner quadrant)

Current Updates:

On october 31, blood come out while cleaning the nose.

On nov 1, she noticed small lump on vaginal area where she had also itching. also burning sensation during micturation.

On nov 14, she had whitish vaginal discharge with little blood and she experienced this 3 times before in June,July and October month in 2022.

On Nov 28, she reported to have a strong sensation like 'Electric shock' in her left breast which radiate from left armpit.

Dec 15, she had abscess in left leg and lower abdomen.

The abscess are recurrent in nature. She had it in 2016, 2022 and now on in 2023 also.

Clinical images of Ulcer(left leg): 

March 2:

March 3:(Morning)

March 3:(Afternoon)

March 3: (Night)

March 4:

March 6:

March 8:

March 10:

March 12:

March 14:

March 15: