1. A 60-year-old man with weight loss and bilateral leg swelling Dr. Md. Abdul Mumit Sarkar Resident Phase – A(Gastroenterology) Endocrinology Department

2. Patient Information Patient Information Name Mr. M S M Sex Male Age 60 years Address Nogorkanda, Faridpur Occupation Retired police man Date of admission 20-08-2013

3. Presenting complaints Increased frequency of defecation 3 yrs Progressive weight loss 3 yrs Bilateral leg swelling 20 days

4. History of present illness Defaecation 8-10 times/day Semisolid stool Not mixed with blood No relation with foods or drugs Not abdominal pain

5. History of present illness Weight loss Progressive Lost 10kg during his course of illness Normal appetite Associated heat intolerance No associated increased thirst or increased frequency of micturition No H/O fever,cough,haemoptysis or night sweat

6. History of present illness Bilateral leg swelling Swelling of scrotum and prepuce Associated with exertional dyspnoea,orthpnoea & palpitation No H/O chest pain No H/O scanty high coloured uine No past H/O of jaundice

7. History of present illness No H/O contact with known TB patient

8. Past History H/O hospital admission in 1999 with the complaints of fever and black tarry stool. Blood transfusion-1 unit

9. Family history  He is father of 5 children  No H/O thyroid or cardiac disease in the family Socioeconomic history  Low socioeconomic status

10. Personal history Non smoker No H/O alcohol abuse Drinks tube well water Uses sanitary latrine

11. Treatment History Tab-Propranolol(40mg) 1/2  0  1/2 (29/7/13)

12. General Examination(on admission) Anxious looking Cooperative Well oriented to time, place and person Below average body built Mildly anaemic Aanicteric

13. General Examination(on admission) Exophthalmos Swelling of eye lids Fine tremor Thyroid gland-Normal PR - 60beats/min irregularly irregular Pulsus deficit-present

14. General Examination BP 110 / 70 mmHg in sitting position over right arm JVP Raised RR 18 /min Weight 57 kg Temp 98 0 F Oedema ++

15. Systemic Examination Cardiovascular System Apex beat-Lt. 6 th ICS 11cm from midline Thrusting No Lt.parasternal heave No thrill 1st heart sound soft in mitral area Normal 2 nd heart sound Pansystolic murmer-over mitral area No radiation

16. Respiratory System Examination Trachea-central Breath sound-vesicular & reduced from rt.8 th intercostal space and downward Vocal resonance-reduced Percussion note-Dull Fine inspiratory cerpitation over both lung bases

17. Systemic Examination Per abdomen Liver 3cm from rt. Sub costal margin in the mid clavicular line Firm Non tender Smooth surface Rounded border Upper border of liver dullness on rt.5 th intercostal space No hepatic bruit

18. Per abdomen No splenomegaly No para aortic lymphadenopathy No ascites No bruit

19. Other system examination No abnormality

20. Provisional diagnosis Graves’ thyrotoxicosis with ophthalmopathy with CCF with AF

21. Hospital Course Treated with Tab-Asprin(75mg) 0  1  0 Tab-Carvedilol(6.25mg) 1/2  0  1/2 Tab-Spironolactone(25mg) 1  0  0 Cap-Loperamide(2mg) 1  0  1 Tab-Paracetamol(500mg) 1  1  1

22. Investigations Test Name21/08/2013 Hb9.6g/dl ESR70 mm in1 st hr RBC3.77X10 12 /L Platelets120X10 9 /L WBC5X10 9 /L Neutrophil48% Lymphocytes39% Monocytes05% Eosinophils08% basophils00%

23. Investigations Test Name21/08/2013 HCT0.31L/L MCV82.2fl MCH25.5pg MCHC31.0g/dl Blood Film(29/04/2013) RBC: Dimorphic blood picture with microcytes,few elliptical cell and rouleaux formation WBC: Mature with above count and distribution Platelet-Reduced Comment: Bicytopenia

24. InvestigationsResult FPG3.9mmol/L HbA1c5.7% Serum Creatinine0.9 mg/dl Serum Albumin20g/dl SGPT30U/L Total Cholesterol84mg/dl LDL-Cholesterol43mg/dl HDL-Cholesterol32mg/dl Triglyceride45mg/dl

25. Investigations Urine R/M/E (21/08/2013) Pus cells :0-2/hpf RBC : Nil Epithelial Cells: 0-2/hpf Protein : nil Chest Xray(21/08/13) Right sided mild pleural effusion with consolidation

26. Investigations Test Name30/07/201321/08/2013 FT32.13ng/ml FT41.34ng/ml2.67ng/ml TSH0.09mIU/L0.045mIU/L ECG-Atrial fibrillation with lateral ischemia

27. Thyroid Scan Finding Both lobes of thyroid gland are enlarged. There is uniform and increased radio tracer accumulation shown throughout the gland.There is no background activity is seen.

28. USG Of Thyroid Gland Both lobes of thyroid gland are enlarged (AP of right lobe-20.5 mm, AP of left lobe- 22mm).Thyroid parenchyma is heterogenous in echotexture.

29. Problem lists When to start definitive treatment of thyrotoxicosis? Is management of CCF optimum? Is there any role of anticoagulant? What is the cause of bicytopenia? What is the cause of cardiac murmur?

30. THANK YOU THANK YOU