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This blog was prepared with the help of valuable inputs and under the guidance of Dr. Zain sir, Dr. Aashitha ma'am, Dr. Manasa ma'am, and Dr. Vamsi Krishna sir
Chief complaints
A 46 / F who is a housewife by occupation and is a native of West Bengal came with
•c/o weakness of lower limbs since 3 months
•c/o inability to walk since 1 & 1/2month
•c/o pain and inability to extend her right lower limb since 1&1/2 months
History of present illness:
- Patient-reported to have noticed a thyroid swelling 18 yrs ago, which was initially 1 x 1 cm in size, gradually increased to its current size of 5 x 7 cm
- 3 months ago she started having difficulty in positioning her feet while walking and even had slippage of footwear.
- 2 months ago she slipped and fell in the bathroom and fractured her right ankle joint for which she received treatment from a local hospital
- 1 month prior to admission patient lost her ability to walk and has been using a wheelchair since then to get around.
- The patient complains of both upper and lower back pain radiating to her hip joints with the stiffness of muscles of the inner part of both thighs associated with dragging type of pain radiating along the inner part of thigh more while stretching her lower limbs and more on the right side.
- The patient also complained of inability to lie down in a supine position as it caused pain in her lower limbs and cannot sit for a long time in the same position
- She is not able to extend her right lower limb completely and her lower limbs have become thinner as compared to 2 months ago
- The patient also gave of history of constipation and passing bloody stools when straining to pass hard stools
- h/o recent weight loss of 1-2 kg in last 2 months
- The patient also gave a history of unable to bear cold temperatures
Past history :
•Patient has had similar complaints of both upper and lower back pain radiating to both hip joints since 1&1/2 yrs ago and has been using over the counter pain relief medications
•Patient had gallstone removal surgery 6 yrs ago
Personal history :
- Appetite - normal
- Diet - mixed
- Bowel and bladder movements - constipation+, inability to feel while passing urine
- Sleep - reduced quality of sleep for the past 2 months due to pain
- Addictions - patient consumes 2 pans per day for the past 6 yrs
Family history
- The patient's maternal grandmother also had a ? goitrous thyroid swelling and her mother had also died at a comparatively younger age (~45-50 y/o) of some unknown disease
GENERAL EXAMINATION
The patient is conscious, cooperative, coherent, and well oriented to time, place, and person
Pallor +, no icterus, cyanosis, clubbing, or generalized lymphadenopathy
Vitals
Afebrile
BP 100/70 mmHg
PR 78 bpm
Spo2 99 % @ room temperature
GRBS 119 mg/dl
CNS EXAMINATION
Patient is conscious
Higher mental functions are intact
Speech is intact
Signs of meningeal irritation are absent
Cranial nerves - NFAD
MOTOR SYSTEM
Upper limb. R. L
TONE N. N
POWER
DELTOID. 4+. 4+
BICEPS. 5+. 5+
TRICEPS. 5+. 5+
Lumbricals. 5+. 5+
REFLEXES
B 3+. 3+
T. 3+. 3+
S. 2+. ABSENT
lower limbs. R. L
TONE. ↓↓ ↓↓
POWER
EXTENSORS OF HIP. 3+. 3+
FLEXORS OF KNEE 3+. 3+
EXTENSORS OF KNEE. 3+. 3+
PLANTAR FLEXION 3+. 3+
DORSI FLEXION. 3+. 3+
REFLEXES
KNEE JERK. 3+. 4+
ANKLE JERK 4+. 4+
(ankle clonus present)
PLANTAR. Extensor Extensor
ABDOMINAL REFLEX - ABSENT BELOW UMBLICUS
SENSORY SYSTEM.
UL. LL
R. L. R. L
FINE TOUCH. N. N. ↓ ↓
CRUDE TOUCH N. N. ↓ ↓
TEMP. N N. ↓ ↓
( Patient's attender gave a h/o incidentally finding that patient's response to warm temperature was delayed when they placed a cup of hot tea on her ankle)
PAIN. N. N. ↓ ↓
PROPRIOCEPTION -LOST UP TO HIP JOINT
VIBRATION R. L
Medial malleolus. 6 sec. 5 sec
Lateral malleolus. 3.38 sec 4 sec
Patella. 5 sec. 7 sec
Radial prominence. 6 sec. 6 sec
Clavicle. 4 sec. 6 sec
On palpation stiffening of muscles of medial and posterior compartments of both thighs
spinal tenderness present at D12 level
Gait could not be assessed
Thyroid swelling present on the left side of the neck
CVS : S1, S2 HEARD
RR : BAE +, NVBS
P/A : SOFT, NT
PROVISIONAL DIAGNOSIS
COMPRESSIVE MYELOPATHY 2° to vertebral metastasis secondary to? Thyroid malignancy
INVESTIGATIONS
OUTSIDE REPORTS
Outside MRI REPORT
HB - 10
Tlc - 6200
MCV - 30.9
MCH - 65.7
MCHC - 32.4
PLT COUNT - 1.10
SMEAR - microcytic hypochromic anaemia
Cr. : 0.7
Urea : 19
Na+ 140
K+ 4.1
Cl- 102
TB : 0.86
DB : 0.20
AST : 28
ALT : 18
ALP - 147
TP : 7.0
ALB: 3.8
RBS : 107
SEROLOGY : -VE
Surgery opinion taken
SOAP NOTES 13/9/21
S
•c/o weakness of lower limbs
•c/o inability to walk
•c/o pain and inability to extend her right lower limb
O
Pt is c/c/c
BP 120/80
PR 82
CVS -S1,S2 +
R/S - NVBS+
P/A - SOFT
CNS - HMF - NORMAL
SPEECH -NORMAL
POWER R. L
UL 4/5. 4/5
LL. 3/5. 3/5
TONE
UL N. N
LL ↓↓. ↓↓
REFLEXES
B. T. S. A. K. P
R. 3+. 2+ +. 3+. 3+. Extensor
L. 3+. 2+ +. 3+. 3+. Extensor
A
Compressive myelopathy 2° to ? Thyroid malignancy
P
USG NECK DONE
FNAC DONE - results awaited
X RAYS
CHEST
FNAC slides
SOAP NOTES 14/9/21
S
•c/o weakness of lower limbs
•c/o inability to walk
•c/o pain and inability to extend her right lower limb
• However patient feels better in terms of pain relief
O
Pt is c/c/c
BP 120/80
PR 82
CVS -S1,S2 +
R/S - NVBS+
P/A - SOFT
CNS - HMF - NORMAL
SPEECH -NORMAL
POWER R. L
UL 4/5. 4/5
LL. 3/5. 3/5
TONE
UL N. N
LL ↓↓. ↓↓
REFLEXES
B. T. S. A. K. P
R. 3+. 2+ +. 3+. 3+. Extensor
L. 3+. 2+ +. 3+. 3+. Extensor
A
Compressive myelopathy 2° to vertebral metastasis secondary to? Thyroid malignancy
P
USG NECK DONE
FNAC DONE - results awaited
Orthopedic surgeon opinion taken
Surgery review opinion
SOAP NOTES 15/9/21
S
•c/o weakness of lower limbs
•c/o inability to walk
•c/o pain and inability to extend her right lower limb
O
Pt is c/c/c
BP 120/80
PR 82
CVS -S1,S2 +
R/S - NVBS+
P/A - SOFT
CNS - HMF - NORMAL
SPEECH -NORMAL
POWER R. L
UL 4/5. 4/5
LL. 3/5. 3/5
TONE
UL N. N
LL ↓↓. ↓↓
REFLEXES
B. T. S. A. K. P
R. 3+. 2+ +. 3+. 3+. Extensor
L. 3+. 2+ +. 3+. 3+. Extensor
A
Compressive myelopathy 2° vertebral lesions at the level of T12 2° to? Thyroid malignancy
P
Oncologist opinion taken
USG ABDOMEN DONE
Microscopic picture of thyroid papillary follicular structure
Giant cell with multiple nuclei
Hypercellularity
Chewing gum colloid - classic of papillary
carcinoma thyroid
SOAP NOTES 16/9/21
S
•c/o weakness of lower limbs
•c/o inability to walk
•c/o pain and inability to extend her right lower limb
O
Pt is c/c/c
BP 120/80
PR 82
CVS -S1,S2 +
R/S - NVBS+
P/A - SOFT
CNS - HMF - NORMAL
SPEECH -NORMAL
POWER R. L
UL 4/5. 4/5
LL. 3/5. 3/5
TONE
UL N. N
LL ↓↓. ↓↓
REFLEXES
B. T. S. A. K. P
R. 3+. 2+ +. 3+. 3+. Extensor
L. 3+. 2+ +. 3+. 3+. Extensor
A
Compressive myelopathy 2° to vertebral lesions at the level of T12 2° to? Thyroid malignancy
P
FNAC REPORT
A gynecological review was taken
20/9/21
The patient consulted with a surgical oncologist who asked for a neurosurgeon opinion.
A neurosurgery opinion was taken and pt was advised for decompression surgery but the patient was unwilling and opted for palliative care.
The patient is being referred to MNJ for palliative care with a plan of radiotherapy then Total thyroidectomy after which Radioactive Iodine therapy shall be planned.
Follow up journey at MNJ hospital
After the consult, the patient was started on pain management medication
- Morphine inj 2mg on 21/9/21, tablet 10 mg on 22/9/10
- T.Dulcolax
- T.ketorolac
2/10/21
The patient received EBRT total dose 30 Cy ---> 3Cy/ # from 22/9/21 to 2/10/21
Patient tolerated well
4/10/21
The patient got a pre-anesthetic checkup (PAC) done prior to total thyroidectomy
5/10/21
Surgical profile was done
6/10/21
7/10/21
A cardiology opinion was taken to get a 2D ECHO and fitness to undergo surgery
CT scan was done
9/10/21
USG neck was repeated
10/10/21
S. Ca level - 9.7
12/10/21
The patient underwent total thyroidectomy with full neck dissection
CECT revealed
- a lytic lesion with soft tissue component @ D4 + D12 + sternum
- lung metastasis
- 3 x 3 x 2 cm on left lobe
- level IV node enlarged to size 4.4 x 3 x 2 cm
Advised
- 200 mCi I-131 in the first week of December
- T.Eltroxin 125 mcg OD from next day
- Stop T.Eltroxin in the first week of November
- T.Wysolone 10 mg tid - start in last week of November
13/10/21 & 14/10/21
POD -2 notes
20/10/21
Post thyroidectomy histopathological report of the biopsy specimen
S Ca2+ - 8 mg/dl
21/10/21
S. Ca2+ - 7.1 mg/dl
6/12/21
Discharge Date
Date: 14/12/21
Ward: ss
Unit:5
Name of Treating Faculty
DR.AASHITHA KASHYAP(PGY3), DR. VAISHNAVI (PGY3), DR.SAI CHARAN(PGY2)
DR.ARVIND REDDY(SR)
Diagnosis
PAPILLARY CARCINOMA THYROID S/P TOTAL THYROIDECTOMY + RADIOTHERAPY
COMPRESSIVE MYELOPATHY SECONDARY TO VERTEBRAL METS WITH RIGHT HUMEROUS
FRACTURE
Case History and Clinical Findings
A 46 / F who is a housewife by occupation and is a native of West Bengal came with
•c/o weakness of lower limbs since 3 months
•c/o inability to walk since 1 &1/2month
•c/o pain and inability to extend her right lower limb since 1&1/2 months
HISTORY OF PRESENTING ILLNESS:
Patient-reported to have noticed a thyroid swelling 18 yrs ago, which was initially 1 x 1 cm in size,
gradually increased to its current size of 5 x 7 cm.
3 months ago she started having difficulty in positioning her feet while walking and even had slippage
of footwear.
2 months ago she slipped and fell in the bathroom and fractured her right ankle joint for which she
received treatment from a local hospital
1 month prior to admission patient lost her ability to walk and has been using a wheelchair since then
to get around.
The patient complains of both upper and lower back pain radiating to her hip joints with the stiffness
of muscles of the inner part of both thighs associated with dragging type of pain radiating along the
inner part of thigh more while stretching her lower limbs and more on the right side.
The patient also complained of inability to lie down in a supine position as it caused pain in her lower
limbs and cannot sit for a long time in the same positionShe is not able to extend her right lower limb
completely and her lower limbs have become thinner as compared to 2 months ago
The patient also gave of history of constipation and passing bloody stools when straining to pass hard
stools
h/o recent weight loss of 1-2 kg in last 2 months
The patient also gave a history of unable to bear cold temperatures.
HISTORY OF PAST ILLNESS:
•Patient has had similar complaints of both upper and lower back pain radiating to both hip joints
since 1&1/2 yrs ago and has been using over the counter pain relief medications
•Patient had gallstone removal surgery 6 yrs ago.
PERSONAL EXAMINATION:
Appetite - normal
Diet - mixed
Bowel and bladder movements - constipation+, inability to feel while passing urine
Sleep - reduced quality of sleep for the past 2 months due to pain
Addictions - patient consumes 2 pans per day for the past 6 yrs
Family history:
The patient's maternal grandmother also had a ? goitrous thyroid swelling and her mother had also
died at a comparatively younger age (~45-50 y/o)
of some unknown disease.
GENERAL EXAMINATION:
The patient is conscious, cooperative, coherent, and well oriented to time, place, and person
Pallor +, no icterus, cyanosis, clubbing, or generalized lymphadenopathy
Vitals
Afebrile
BP 100/70 mmHg
PR 78 bpm
Spo2 99 % @ room temperature
GRBS 119 mg/dl
CNS EXAMINATION
Patient is conscious
Higher mental functions are intact
Speech is intact
Signs of meningeal irritation are absent
Cranial nerves - NFAD
MOTOR SYSTEM
Upper limb. R. L
TONE N. N
POWER
DELTOID. 4+. 4+
BICEPS. 5+. 5+
TRICEPS. 5+. 5+
Lumbricals. 5+. 5+
REFLEXES
B 3+. 3+
T. 3+. 3+
S. 2+. ABSENT
lower limbs. R. L
TONE.
POWER
EXTENSORS OF HIP. 3+. 3+
FLEXORS OF KNEE 3+. 3+
EXTENSORS OF KNEE. 3+. 3+
PLANTAR FLEXION 3+. 3+
DORSI FLEXION. 3+. 3+
REFLEXES
KNEE JERK. 3+. 4+
ANKLE JERK 4+. 4+
(ankle clonus present)
PLANTAR. Extensor Extensor
ABDOMINAL REFLEX - ABSENT BELOW UMBLICUS
SENSORY SYSTEM:
UL. LL
R. L. R. L
FINE TOUCH. N. N.
CRUDE TOUCH N. N.
TEMP. N N.
( Patient's attender gave a h/o incidentally finding that patient's response to warm temperature was
delayed when they placed a cup of hot tea on her ankle)
PAIN. N. N.
PROPRIOCEPTION -LOST UP TO HIP JOINT
VIBRATION R. L
Medial malleolus. 6 sec. 5 sec
Lateral malleolus. 3.38 sec 4 sec
Patella. 5 sec. 7 sec
Radial prominence. 6 sec. 6 sec
Clavicle. 4 sec. 6 sec
On palpation stiffening of muscles of medial and posterior compartments of both thighs
spinal tenderness present at D12 level
Gait could not be assessed
Thyroid swelling present on the left side of the neck.
CVS : S1, S2 HEARD
RR : BAE +, NVBS
P/A : SOFT, NT
S. Ca2+ - 7.1 mg/dl
Investigation
HB - 10
Tlc - 6200
MCV - 30.9
MCH - 65.7
MCHC - 32.4
PLT COUNT - 1.10
SMEAR - microcytic hypochromic anaemia
Cr. : 0.7
Urea : 19
Na+ 140
K+ 4.1
Cl- 102
TB : 0.86
DB : 0.20
AST : 28
ALT : 18
ALP - 147
TP : 7.0
ALB: 3.8
RBS : 107
SEROLOGY : -VE
Treatment Given(Enter only Generic Name)
1. TAB.THYRONOM 125 MCG OD
2. TAB.MORPHINE 20 MG OD
3. TAB.CCM 200 MG OD
4. TAB. PAN 40MG OD
5. TAB.WYSOLON 20 MG OD FOR 3 DAYS FOLLOWED BY 10 MG OD FOR 1 WEEK
PATIENT AND ATTENDERS HAVE BEEN EXPLAINED ABOUT THE DIAGNOSIS AND
PROGNOSIS AND RISK ASOCIATED WITH IT. HOWEVER PATIENTS ARE WILLING TO GO
,DISCHARGE AT REQUEST.
Advice at Discharge
1. TAB.THYRONOM 125 MCG OD
2. TAB.MORPHINE 20 MG OD
3. TAB.CCM 200 MG OD
4. TAB. PAN 40MG OD
5. TAB.WYSOLON 20 MG OD FOR 3 DAYS FOLLOWED BY 10 MG OD FOR 1 WEEK
Follow Up
IN CASE OF EMERGENCY VISIT GM OPD
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR
ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:
08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed
and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been
explained to me in my own language
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