A 5 5 -Y EA R - O L D M A N

WITH
P R OT R AC T EC D VO M I T I N G A N D
GENERALIZED WEAKNESS
Dr. Tasnim Tamanna
FCPS-II Trainee
Medicine Unit-10
Dhaka Medical College Hospital
 PA RTIC U LA RS O F T H E PATIEN T
• Name : Mr. X
• Age : 55 Years
• Sex : Male
• Address : Pirojpur,
Barisal
• Marital Status : Divorced
• Occupation : Businessman

• Religion : Islam
• Date of admission: 21-10-
 CHIEF CO M P L A I N T S

•Severe protracted vomiting for 1 month

•Generalized weakness for 1 month
 H ISTO RY O F T H E PRESENT ILLN ESS

According to the statement of the patient he was reasonably

well 1 month back. Then he developed severe protracted
vomiting which was non projectile. Vomitus contained mixed
food materials which was 30-40 times /day, 50-60 mL in
amount, non bile stained, not contain any blood, not self
induced and partially subsided by antiemetic. He complained of
loss of appetite as well.
 Present Illness Contd.
He has been suffering from generalized weakness and dizziness .
dizziness was more marked in standing position. He complained of
constipation and cold intolerance. On query he mentioned that his
sexual desire was reduced and also gave history of weight loss which
was not significant. There was no history of fever, headache, blurring
of vision, cough, burning sensation during micturation, excessive
sweating and palpitation .
History of past illness: He was a diagnosed case of Hypothyroidism
for 1 year . He gave history of two time admission into SBMCH for
several times vomiting followed by unconsciousness in 15 days
interval on 2023. There was no previous history of TB or contact
with TB patient, abdominal trauma, surgery, unprotected sexual
exposure or abuse of any intravenous drug .
• Family history: There was no history of such illness in his
family.
• Socio-economic history : He lives in tinshed house.

• Personal history : Betel nut chewer ,non smoker

and non alcoholic.

• Drug and Treatment history: He is taking 50 microgram

Thyrox for 1 year. On query he gave history of steroid intake
for 2 weeks (tab Deflazit 6mg) due to knee joint pain 1 year
• Allergic history : He is allergic to prawn and beef.
• History of Immunization : He is immunized as per EPI
schedule and he received two dose of Covid-19 vaccination.
 GENERAL E X A M I NATI ON

•Appearance : Pale and •Anemia : (+)

apathetic •Jaundice : Absent
•Body-built : Average •Cyanosis : Absent
•Decubitus : On lying • Pigmentation: several
position hypopigmented spots
•Co-operation : Co- on lower back and both
operative thighs.
•Nutritional
•Body hair : Axillary •Koilonychia : Absent
and pubic hair
•Leukonychia : Absent
reduced
•BP :100/60 mmHg •Edema : Absent
on lying position and •Dehydration : Moderate
80/50 mmHg on
•Bony tenderness: Absent
standing position
•Pulse : 82 b/m •Lymph Node and Thyroid
•Temperature : Normal gland: Not palpable
•Bed side urine test:
•RR : 16 breath/m
Revealed no abnormal
•JVP : Not raised finidings.
•Clubbing: Absent
SYSTEMIC EXAMINATION
 ABDOMINAL EXAMINATION
• Inspection: Normal in shape, umbilicus is inverted and central
in position, no scar mark present.
• Palpation: Abdomen is soft and non tender . Liver, Spleen,
Kidneys and bladder are non-palpable. Para-aortic, inguinal and
axillary lymph nodes are not palpable.
• Percussion: Tympanic and no shifting dullness present.
• Auscultation: Bowel sound is present.
 NERVOUS SYSTEM EXAMINATION
• Higher psychic function: Normal.

• Cranial nerves: Intact.

• Neck rigidity: Absent.

• Pupil: Equal on both sides and reactive to light.

• Motor function: Normal.

• Sensory function : Intact.

• Fundoscopy: Normal.
 CARDIOVASCULAR SYSTEM EXAMINATION
• Inspection: No visible impulse or scar mark is present.
• Palpation: Apex beat is normal in position. No thrill or palpable
impulse is present.
• Auscultation: First & second heart sounds are normal with no
murmur or added sounds.
 RESPIRATORY SYSTEM EXAMINATION
• Inspection : Chest is normal in shape, respiratory rate and
pattern is normal, no scar mark is present.
• Palpation : Trachea is central in position, chest expansibility and
vocal fremitus are normal.
• Percussion : Resonant on both lung fields.
• Auscultation : Breath sound is vesicular on both lung fields. No
added sound is present, vocal resonance is normal.
 SALIENT FEATURE

Mr. X 55-year old nonsmoker, non diabetic , muslim and

known hypothyroid businessman hailing from Pirojpur,
Barishal admitted into DMCH through emergency on 21-
10-2024 with the complaints of non-projectile,
protracted vomiting for 1 month. Vomitus contained
mixed(undigested and digested) food materials, which
was 30-40 times/ day, approximately 50-60 ml in amount,
non bile stained, not containing any blood, not self
induced and partially subsided by antiemetic medication.
 Salient feature contd.

He complained of loss of appetite as well. He has been suffering

from generalized weakness and dizziness . Dizziness was more
marked in standing position. He complained of cold intolerance
and constipation. On query, he mentioned that he had lost libido
and complained of weight loss which was not significant . There
was no history of fever , headache , blurring of vision, cough,
dysuria, excessive sweating and palpitation.
 Salient feature contd.

He is a diagnosed case of hypothyroidism and taking Tab Levothyroxine

(50 microgram) for 1 year .He gave history of two times admission(in

15 days interval) into SBMCH for severe vomiting followed by

unconsciousness on 2023. On query he gave history of steroid intake for

2 weeks (tab Deflazacort 6mg) due to his knee joint pain 1 year back.
 Salient feature contd.

There was no previous history of TB or contact with TB patient,

abdominal trauma , surgery, unprotected sexual exposure or
abuse of any intravenous drug . He was allergic to prawn and
beef. He was immunized as per EPI schedule and received two
doses of Covid-19 vaccination . There was no history of such
illness in his family. ...
 Salient feature contd.

On general examination my patient was pale and apathetic, with

average body built. Decubitus was on lying position. He was mildly

anaemic with moderate dehydration. Postural hypotension was

evidenced by 100/60 mmHg BP on lying and 80/50mmHg BP on

standing position. His pulse was 88 b/m, temperature was normal,

respiratory rate was 16 br/m.

 Salient feature contd.

There were several hypopigmented spots present on lower back

and both thighs without any buccal or palmar crease
pigmentation . His axillary and pubic hair were reduced. There
was no jaundice, cyanosis, clubbing, koilonychia, leukonychia,
edema or bony tenderness. No lymph node was enlarged,
thyroid gland was not palpable and JVP was not raised . Bed side
urine test was normal.
 Salient feature contd.
Systemic examinations revealed no significant
abnormality
 PROBLEM LIST
Protracted
Reduced
vomiting for
axillary and
1 month
pubic hair

55 year-
old man
Hypopigmentation Generalized
on lower back and weakness
both thighs Loss of for 1 month
libido
?
 PROVISIONAL DIAGNOSIS

Panhyopopituitarism (Hypothyroidism with

adrenocortical insufficiency)
 DIFFERENTIAL DIAGNOSIS

•Hypothyroidism with secondary Adrenal insufficiency

due to Steroid withdrawl.

•Type- 2 APS.
INVESTIGATION PROFILE
 CBC 22-10-24
WBC 2.60K/µL
Neutrophil 1.82K/µL
RBC 3.78 million/L
Hemoglobin 9.60 g/dl
MCV 72.2fl
MCH 25.4pg
ESR 9 mm in 1st hour
 24-6-23 5-7-23 22-10-24
RBS 4.16 3.75 9.71
 Result Ref value
S. creatinine 1.10 .7-1.30mg/dl
S. Uric acid 5.5 3.4-7.0mg/dl
S. bilirubin 1.1 .2-1.2mg/dl
SGPT 38 <40U/L
SGOT 30 8-45U/L
Urine R/E 22-10-24
Epithelial 1-3
RBC nil
pus cell nil
Protein nil
Sugar nil
Serum 24-6-23 27-7-23 22-10-24 31-10-24 Ref value
electrolyt
e
Na 117 125 114 137 136-145mmol/l

K 3.47 3.61 3.79 4.2 3.4-5mm0l/l

Cl 85 95.6 89 105 98-107mmol/l

CO2 16 24.6 20-51mmol/l

HCO3 14 22-28mmol/l
 24-10-2024 Result Ref. Value

24 hours U. Na+ 319 40-22 mmol/L

24 hours U. K+ 26 25-125
mmol/L
24 hours U. Cl 356.2 110-250
24 hours U. volume 2600 ml/24
hours
 1-5-23 26-10-24 Ref value

TSH 55 24.79 0.55-4.78mIU/l

FT4 3.02 9.13 9.0-19.05pmol/l
FT3 1.93 2.89-4.88pmol/l
Cortisol 63 Before 10am:101.2-
535 after 5pm:79-477

ACTH 3.673 4.7-48.8pg/ml

26-10-2024 Result Ref. Value
GH 0.687 0.06-5.0 ng/mL
FSH 3.15 0.70-11 mIU/mL
LH 6.55 1.50-9.30
mIU/mL
 30-10-2024 Result
Anti TPO Ab >1000 IU/mL
ANA Negative
31-10-2024 Result Ref. Value
Calcium 8.1 8.2-10.4mg/dl
Albumin 37 32-48 gm/L
S. PO4 2.0 2.4-5.1 mg/dl

PTH 54 18.5-88 pg/ml

 02-11-2024 Result Ref. Value
Testosterone 612 212-755 ng/dL
Prolactin 22.65 2.10-17.70 ng/dL
C peptide 4.90 1.10-4.50 ng/dL
(Fasting)
• ECG: Normal findings.
• Chest x-ray: Normal.
• USG of whole abdomen: Normal sonographic study. (previously
done).
• Endoscocopy of upper of GIT: Normal upper G.I.T. at
endoscopy.(previously done)
Dynamic MRI of Pituitary and Hypothalamus
Impression: Normal MRI findings of
pituitary gland.
 C O N F I R M AT O R Y D I A G N O S I S

Autoimmune hypothyroidism with ?secondary

adrenocortical insufficiency due to steroid withdrawl .
 Treatment
Inf N/S 1L+Inf 5%DNS 1L

Inj Emistat (8mg)

Tab Thyrox (50µg)
Inj Hydrocortisone (100mg)

Cap Omeprazole (20mg)

Patient condition was improved after getting
hydrocortisone.
Patient was discharged with Tab Levothyroxine(75µg)
with tapering doses of steroid and asked for next visit 1
month later for follow up.
THANK YOU