cervical canal stenosis with hypothyroidism
Post on 04-Dec-2014
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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…
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