30th March, 2023
MEDICAL REPORT
J.A , 53YEARS, FEMALE
WCA/1084B/2021
Background information;
Diagnosis; Subacute thyroiditis
Management plan;
·
Do
FBC, TFT, Thyroid scan, Xray neck, ESR, Lipid profile.
Presentation and Neurology;
A 53yr old female who presented with complaints of painful right anterior neck swelling of 3/12 duration which worsened about a month ago.
Pain was initially in the left anterior neck, radiates to the ear, later bilateral but now confined to the right side of the neck and also radiates to the right ear. Pain is said to be worse when she raises her arm, chokes easily while swallowing and with pain.
She noted to have been having arthritis pain in her knee joints, but now worse and impairs her from squatting and exercising.
Imaging and Differential Diagnosis;
ECG shows normal findings, xray cervical shows diffuse hypodense anterior neck swelling.
UPDATE: 30/03/2023
·
FBC; WBC-4.74, RBC-5.19, HBG-11.6,
PLT-278, ESR-72
·
TFT; TSH-0.2, fT3-3.7, fT4-21.2.
·
RBS; 8.82.
·
THYROID USS; Findings indicate/suggest
thyroid goitre.
PLAN:
1. Commence prednisolone 20mg tds for 48hrs
2. Ibuprofen 400mg 6hourly 3/7
3. Augmentine 625mg bd 5/7
4. See in 2/52
5. Repeat TFT in 4/52.
Kindly
revert for further clarifications if need be.
Sincerely Yours,
Dr. ALABI, S.I.
For Team Wellington Clinics