CLINICAL
PATHOLOGICAL
CONFERENCE
DEPARTMENT OF MEDICINE
4TH YEAR MBBS
Maryam Khan
Afsheen Alim
Seetal Singh
BIO DATA
Age : 31 years
Gender : Female
Residence : Malir
Marital status : Married
Occupation: Housewife
Mode of admission : OPD
Date of admission: 8th Jan '24
Presenting complaint
"Fever for 1 -month"
History of Presenting Complaints:
A/c to my patient, she was in usual state of health 1 month
back when she started having fever.
The fever was gradual in onset, intermittent, high grade &
documented around (102°F).
The fever was associated with chills, palpitations and sweating.
History of Presenting Complaints (Continue)
Patient also noticed pain on right lower neck, which was radiating to the right
lower jaw and increased on swallowing, which she presumed to be
toothache.
Pain increased on movement on neck.
Fever and pain subsided temporarily after taking pain killers.
Patient also complaints of losing weight of 6-7kg in just 2weeks.
There is no history of headache, vomiting, ear discharge, chest pain, cough,
sputum or burning micturition.
SYSTEMIC REVIEW
CVS:
Palpitations was present.
There was no history of
shortness of breath, chest
pain or pedal swelling
SYSTEMIC REVIEW
RESPIRATORY SYSTEM
There is no history of cough,
SOB, Sputum, hemoptysis,
wheezing
SYSTEMIC REVIEW
GIT
There is no history of nausea, dysphagia, heartburn,
diarrhea, vomiting, Abdominal pain, constipation and
yellow discolouration
SYSTEMIC REVIEW
Nervous System
There is no history
of weakness, headache,
syncope, fits,
vertigo, numbness
SYSTEMIC REVIEW
Urinary System
There is no history of pain in
flanks, dysuria, hematuria,
burning micturition, polyuria
or oliguria
Past medical History
There is no history of any previous illness or
hospital admissions.
Past surgical History
There is no history of any previou surgery.
Drug History
Inj. Ceftazidime
Tab Escitalopram
Multivitamin
Levosulpride
Esomeprazole
NSAIDs
Immunisation/Allergies
Non significant
Family history
Parents are healthy and alive.
There is no family history of Diabetes, Tuberculosis,
Asthma, Hypertension or any cardiac disease.
Menstrual /obs history
Age of menarche 13 yrs
Cycle 6/28
Flow- heavy
She has 5kids (SVD)
Age of last born- 1yr 8 months old
LMP- 31/12/2023
Personal History Socioeconomic History
She had no addictions Own House
Sleep- disturbed 4 people and 1 bread earner
Appetite increased Well ventilated 2 rooms with
Weight loss (around 6- attached bathrooms
Drinks boiled milk and water
7kg)
Summary
A young married female patient admitted
with the complain of fever for 1month, along
with weight loss. She also had pain in her
neck.
ANY DIFFERENTIALS?
EXAMINATION
GPE
Appearance and behaviour
My patient is a young woman
Average height and thin built.
Lying comfortably on bed.
Well oriented to time, place & person.
Vitals:
Radial pulse- 96 bpm and rhythm is regular
RR- 20 breaths/min
BP- 110/70 mm Hg
Temperature-98’F
SO2 99% on RA
SUBVITALS
There is no anemi a, jaundice
On examination of neck,
No palmar erythema, cyanosis,
thyroid was diffusely
edema, dehydration, clubbing.
enlarged, non tender.
Palms were sweatywith fine
There was no cervical
tremors on outstreched hands.
There was no proptosis.
lymphadenopathy.
CVS EXAMINATION
Inspection
Normal looking chest
No scars, no deformity, no visible pulses or no superficial veins
Palpation
Apex beat localised at 5th intercostal space just medial to
midclavicular line
Auscultation
S1 and S2 audible with no added sounds
CHEST EXAMINATION
INSPECTION PALPATION
No visible scar marks, Normal chest
pulsations, swelling, any expansion
bulging or any deformity
PERCUSSION AUSCULTATION
Percussion note was Normal vesicular
resonant bilaterally breathing,normal vocal
resonance, no added sounds
ABDOMINAL EXAMINATION
Inspection
Scaphoid shaped abdomen
Umblicus seems to be central and inverted
No scar marks, no visible pulsations,no stria, no deformity
Palpation
On palpation, abdomen was soft and non tender
No visceromegaly found.
Auscultation
Bowel sounds were audible
CNS EXAMINATION
GCS 15/15
Motor examination normal
Sensory examination normal
Fine tremors present in both hands
Differential diagnosis?
Hyperthyroidism
XDR Enteric fever
Tuberculosis
Neck Abscess
INVESTIGATION
COMPLETE BLOOD COUNT
Ltest Desc Ltest Desc Result Unit Normal Ranges
Result Unit Normal Ranges
CP
12 - 14
RDW-CV 11.3 %
Female: 11.1 - 14.5
10.6 G/di
HAEMOGLOBIN Male: 13.7 - 16.3
4.0 - 11.0
WBC COUNT 10.4 10*9/L
m/cu.mm Female: 3.9 - 5.5
R.B.C. COUNT 4.45
Male: 4.5 - 6.5
40 - 60
NEUTROPHILS 75
VOL% Female: 35.4 - 42.0 % 20 - 40
P.C.V. (HCT) 33.2 LYMPHOCYTES 21
Male: 41.9 - 48.7
M.C.V. 74.8 FL 80 - 96 EOSINOPHILS 1-6
01
MONOCYTES % 2-8
03
27 - 33
M.C.H. 23.8 PG
PLATELET COUNT
334 10*9/L. 150 - 450
G/DL 32 - 35
M.C.H.C. 31.8
REMARKS: HYPOCHROMIC ANEMIA ,ANISOCYTOSIS
HAEMATOLOGY
Ltest Desc Result Unit Normal Ranges
ERYTHROCYTE SEDIMENTATION RATE 117 mm/1hr 4-10
C-reactive protein 93.36 mg/L <06
CHEMICAL PATHOLOGY (BLOOD)
Ltest Desc Result Unit Normal Ranges
CHEMICAL PATHOLOGY (BLOOD)
UREA 18 mg/dI 10 - 50
CREATININE 0.66 mg/dI 0.5 - 1.5
ELECTROLYTES
SODIUM 139 MEQ/L 135 - 145
POTASSIUM 3.1 MEQ/L 3.5 - 5.0
CHLORIDE 102 MEQ/L 98 - 110
BICARBONATE
23 MEQ/L 25 - 29
URINE EXAMINATION
Ltest Desc Result Unit Normal Ranges Ltest Desc Result Unit Normal Ranges
URINE DETAILED REPORT UROBILINOGEN NORMAL
COLOUR YELLOW STRAW - YELLOW BLOOD (OCCULT) NIL
PH 5.0 5-8 NITRITES NIL NIL
SPECIFIC GRAVITY 1.010 1.005 - 1.030 RED CELLS NIL /HPF 0-1
PROTEIN NIL mg % LEUCOCYTES 2-4 /HPF 0-5
GLUCOSE NIL NIL EPITHELIAL CELLS (++) /HPF 0-2
KETONES NIL NIL CASTS NIL /HPF
BILIRUBIN NIL NEGATIVE OTHERS NIL
LIVER FUNCTIONS TEST (LFT)
Ltest Desc Result Unit Normal Ranges
TOTAL BILIRUBIN 0.94 mg/dI 0.1-1.0
DIRECT BILIRUBIN (CONJUGATED) 0.38 mg/dI UPTO 0.3
SGPT (ALANINE TRANSAMINASE) 111 U/L 10 - 50
C. <15 Y: 54-369,F:42-98
ALKALINE PHOSPHATASE (TOTAL) 256 U/L M:53-128
GAMMA GLUTAMYL TRANSPEPTIDASE 84 U/L 15 - 50
MALE:< 35
SGOT (AST) 117 U/L FEMALE:< 31
IMMUNOLOGY & SEROLOGY
Ltest Desc Result Unit Normal Ranges
HEPATITIS Bs ANTIGEN (HBsAg) (ICT)
HBsAg = NON - REACTIVE
HEPATITIS C ANTIBODY (ICT)
H.C.V= NON - REACTIVE
Blood culture
No bacterial growth isolated after 05
days of incubation
Urine culture
No bacteria isolated
Chest Xray
ECG
WHOLE ABDOMEN
LIVER RIGHT KIDNEY
Liver is measuring 11.8 cm, normal in shape, texture, Right kidney is normal in size (10.5 x 4.0 × 0.7 cm) with
echogenicity with regular margins. normal shape and regular margins.
Normal cortical thickness and corticomedullary
No intra hepatic mass or biliary ducts dilatation seen.
distinction.
CBD is 0.2 cm. Portal vein is 0.7 em, hepatic vein and IVC
No stone or hydronephrosis seen.
are normal. LEFT KIDNEY
GALL BLADDER Left kidney is normal in size (10.1 x 5.4 x 1.5 cm) with
Gall bladder is normal in size and walls: normal shape and regular margins.
No stone, sludge or growth seen. Normal cortical thickness and corticomedullary
distinction.
PANCREAS No stone or hydronephresis seen.
Pancreas is normal in size, shape and echo texture.
No pancreatic duct dilation seen. URINARY BLADDER
Partially filled at the time of scan.
SPLEEN
IMPRESSION
Spleen is measuring 10.3 cm and normal in eeho texture.
Normal splenie vein. Normal seen of whole abdomen.
No free fluid or para - aortic lymphi node seen.
THYROID PROFILE
LTEST DESC RESULT UNIT NORMAL RANGES
FREE T4 >7.77 - 0.8-2.0 ng/dL
FREE T3 25.01 pg/ml 2.0-4.4
T.S.H <0.005 Adult 0.35-5.5 uLU/ml
THYROID SCAN
Findings
Scan shows no uptake of the radiotracer in the region of the
thyroid bed.
U/S NECK /THYROID
Thyroid is enlarged. Heterogeneous echotexture of the thyroid.
Multiple well-defined solid looking nodules are seen in both lobes of the thyroid. largest on
right side is measuring I.a 1.9 cm and on left side measuring 1.4 x 1.2 cm. Moderate
amount of flow seen in these nodules, some of them show necrotic centre.
Vaseular structures and trachea are unremarkable. Overlying strap muscles are
unremarkable.
Bilateral jugular vein and carotid arteries identified.
Lymph nodes:
Few lymph nodes are seen in the segmental region, largest is 1.41x06cm with intact fatty
hilum.
DEFINITIVE
DIAGNOSIS ?
HYPERTHYROIDISM
secondary to
THYROIDITIS
DISCUSSION
THYROIDITIS
Thyroiditis refers to
the group of disorders
that cause
inflammation of the
thyroid gland.
PHASES OF THYROIDITIS
Thyroiditis can present with
temporary thyrotoxicosis as part of
a classic triphasic course.
Thyrotoxicosis
Hypothyroidism
Recovery
SUBTYPES OF THYROIDITIS
Painless: Painful:
Hashimoto thyroiditis Subacute
Postpartum Thyroiditis Thyroiditis
Silent Thyroiditis Acute suppurative
Reidel Thyroiditis Thyroiditis
Drug Induced Radiation Induced
Thyroiditis Thyroiditis
DIAGNOSIS
Thyroid antibody test Blood test
Physical exam Thyroid function test
Thyroid ultrasound Radioactive iodine uptake
SUBACUT E THYROIDITIS
Subacute thyroiditis, also called subacute granulomatous or
deQuervain thyroiditis, is a common cause of thyroid pain.
The diagnosis of subacute thyroiditis is based on clinical
history, physical examination, laboratory data and RAIU.
Subacute thyroiditis presents with moderate to severe pain
in the thyroid often radiating to the ears, jaw or throat. The
pain may begin focally and spread from one side to other side
of the gland over several weeks. Patients may have prodrome
of malaise, low grade fever, pharyngitis symptoms, and
fatigue.
Initial thyrotoxic phase due to unregulated release of
preformed thyroid hormone from damaged thyroid folicular
cells.
The serum TSH level is suppressed, and the free T4 level
elevated
the erythrocyte sedimentation rate (ESR) or C-reactive protein
is elevated, and mild anemia and elevation of the WBC count
are common.
RAIU is low, as is uptake on a thyroid scintigram.
Thyroid ultrasonography shows diffuse heterogeneity, focal
hypoechoic areas, and decreased or normal color flow Doppler
The thyrotoxic phase usually lasts 3–6 weeks, ending when
the thyroid stores of preformed hormone are depleted.
About 30% of patients subsequently enter a hypothyroid
phase that can last up to 6 months.
Most patients become euthyroid again within 12 months of
disease onset, although 5%–15% have persistent
hypothyroidism
In addition, recurrence rates of 1%–4% have been reported
TREATMENT
Subacute thyroiditis is treated with β-
blockers and anti-inflammatory
therapy.
Patients who fail to respond to full
doses of NSAIDs over several days
should be treated with corticosteroid
therapy.
References
Davidson's Principles and Practice of Medicine
2016 American Thyroid Association Guidelines for Diagnosis
and Management of Hyperthyroidism and Other Causes of
Thyrotoxicosis
THANK YOU FOR LISTENING
Any Questions??
DISCUSSION
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