This is an online E Log book to discuss our patients de-identified health data shared after taking her signed informed consent. Here we discuss our patient's problems through series of inputs from available global online community experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.
To begin with the 20F is a case of congenital hypothyroidism since birth. The patient is suffering with severe headache since 2012. She also has anxiety disorders which continue for one whole day or may subside after a few hours. The patient is also suffering with hair loss and pain in the scalp.
If we go into the past of this patient and another patient with the same problem of congenital hypothyroidism, the outcome of these two cases of late diagnosis is given below.
OUTCOME OF TWO CASES WITH LATE
DIAGNOSIS OF CONGENITAL HYPOTHYROIDISM. A CASE REPORT.
Composite of Regional Centre for Persons With Disabilities, Department of Disability Affairs, Ministry of Social Justice and Empowerment, Government of India,
Punarvas Bhavan, Khajuri Kalan, Pilani,
Bhopal- 462022.
AUTHOR FOR CORRESPONDENCE
ABSTRACT
Two girls with hypothyroidism followed up at our Centre are presented. The time of diagnosis, Institution of Medical Management and Therapeutic Inputs are compared with the outcome in their growth and development. While early identification and Thyroxine Supplementation from the core management strategy, this case study emphasizes how Therapeutic inputs of Composite nature improve the outcome in cases of congenital hypothyroidism.
KEYWORDS
Congenital Hypothyroidism, Thyroxine, Child Development, Early Diagnosis.
INTRODUCTION
Early diagnosis and treatment can prevent disability arising due to congenital hypothyroidism. Health policies in developing countries have taken successful steps to prevent hypothyroidism through ionization of edible salt. However they are lagging in screening for C.H, which should be given equal importance, just like universal immunization for any child.
CASES
PRESENTING CONCERNS
Two girls of different ages reported at Composite Regional Centre for Persons with Disabilities (CRC), Bhopal at different times.
The presenting concerns were stunted growth and delay in speech.
CLINICAL FINDINGS
CASE
A one and half year old girl was brought to CRC Bhopal in Yr 2004 by her mother with presenting complaint of delayed speech.
She was from lower socioeconomic status with 3 elder siblings having normal developmental history and was staying in a nuclear family. Her height was 67cm(below 10 percentile for age), had rough skin and lanugo hair. Her Serum TSH level was 87 IU /ml.
Indian Journal of Medical Case Reports
ISSN: 2319-3832 (online) An open access, Online International Journal available at
http://wwwcibtech.org/jcr.htm 2014 vol 3
(3) July- Sep. PP. 3-5/Joshi and Joshi.
CASE REPORT
Diagnostic Focus and Assessment
The developmental delay, stunted growth, facial features and raised TSH pointed to
Congenital hypothyroidism. The diagnosis was confirmed from pediatrician and endocrinologist. The main challenge was the delay in instituting Thyroxine supplementation.
Therapeutic Focus and Assessment
The patients were started with Tab.levo-
Thyroxine 50 micrograms daily once in Early morning on empty stomach. Comprehensive developmental therapy services were provided at this Centre with occupational and speech therapy. The caretakers were counselled for regular Thyroxine supplements and developed therapy.
FOLLOW UP AND OUTCOMES
Thyroxine dose was adjusted according to clinical response and TSH level in both cases. Clinical Psychology for behavior management and special education for school readiness were provided at CRC Bhopal.
CASE
She had fever and Tachycardia intermittently that was managed by reducing dose of Thyroxine. Presently at the age of 10yrs she has attained 140cm height, 33 kg weight , IQ- 55, speaks and walks well and is attending 2nd standard in a normal school.
PATIENT PERSPECTIVE
CASE
The mother is happy with normal growth of the patient but is anxious about her school performance.
CONCLUSION
We conclude that rehabilitation medicine inputs with Thyroxine Supplementation should be instituted as soon as possible in cases of congenital hypothyroidism. It is high time to implement active case identification, treatment and rehabilitation of congenital hypothyroidism for all infants so that children achieve maximum potential of development and growth.
Informed consent- Obtained
Competing interests- Nil
Ethics approval - The authors followed the guidelines of WMA Declaration of
Helsinki.
De-identification- Yes.
REFERENCES
DGHS, MoHFW, GOI (2006). Revised Policy Guidelines on National Iodine Deficiency Disorder Control Programe. NRHMIDD and Nutrition Cell. Gu X et.al., (2008). Newborn screening in China- Phenylketonuria congenital hypothyroidism and expanded screening.
Annals Academy of Medicine. Singapore
37(Suppl 3) 107-10.
Olney RS. Grosse SD and Vogt RF(2010).
Prevalence of congenital hypothyroidism-
Current trends and future directions:
Workshop Summary. Pediatrics 125(Suppl.2) S 31-36
Virginity A et.al., (1989). Profile of thyroid disorders in a referred Centre in North India. Indian Pediatrics 26(3) 265-9.
18-09-2024
PA- The patient is taking 125mcg Thyronorm.
PPM 2- Since when?
PA- From June 26, the patient is taking 125mcg Thyronorm.
Recurring complaints of Headache, Sweating, Palpitations and Fear of death.
PPM 2
1. Please share the patient's problems (present and past since birth).
2. The pattien's 24 hr activities.
3. Which activity did the patient find painful like being awake, sleeping, studying, playing, eating or other activities.
4. What is the primary requirement of her health issues? Pain relief, relief from fear or to have a good sleep.
PA- The patient is suffering with severe headache.
PPM 1- Since when, how many years does the patient have headache?
PA- The patient is suffering with this problem since 2012.
PPM 1- Since 2012 how frequently has she experienced this headache? Does it happen once every 6 months or in weeks or in days? Once the headache starts how long does it last?
PA- The patient feels anxiety or nervousness and suddenly gets relief. Sometimes it continues for one day.
PPM 2- The doctor has prescribed Naprosyn if the pain is severe.
PA- Okay thanks.
PPM 2- Don't take on empty stomach.
23-09-2024
PPM 2- How is the patient's headache?
PPM 1- We may need to start her on a prophylactic to reduce the frequency and duration of her headache. But before that we need some detailed history regarding the frequency and duration of her headache. What routine hourly activities could she accomplish yesterday inspite of her headache and what routine activities suffered yesterday because of her headache?
PA- Doctor, the headache is unbearable and doesn't allow anything to be done. It is so severe that it cannot be explained.
26-09-2024
PA- The patient is complaining of hair loss and thinning. Sometimes she feels pain in the scalp.
27-09-2024
PPM 1- Best evaluation of hair loss is if the patient can count the number of hairs lost each day.
@Meta AI what's the best way to evaluate hair loss?
Meta AI:- Evaluating hair loss involves a combination of Medical history, physical examination, and Diagnostic tests.
Here's a comprehensive approach:
Medical History:
1. Duration and Progression of hair loss.
2. Family history of hair loss.
3. Medical Conditions (eg., Thyroid Disorders, Autoimmune Diseases).
4. Medications (eg., Chemotherapy, Harmonal Therapies).
5. Hairstyling habits (eg., Tight hairstyles, heat styling).
6. Nutritional Deficiencies (eg., Iron, Zinc, Biotin).
Physical Examination:
1. Pattern of hair loss (eg., Male/Female pattern baldness, Alopecia Areata).
2.Hair Density and Thickness
3. Scalp Conditions (eg., Dandruff, Psoriasis).
4. Hair Shaft Abnormalities (eg., Brittle, Broken Hairs).
Diagnostic Tests
1. Pull Test: Gentle hair pulling to assess shedding.
2. Pluck Test: Examining hair roots for growth patterns.
3. Trichoscopy: Digital Microscopy for hair and scalp analysis.
4. Blood Tests: Thyroid function (TSH, free T4)
- Iron levels (ferritin)
- Zinc and Biotin levels.
- Autoimmune disease markers (eg., ANA)
5. Scalp Biopsy (rarely needed).
Classification Systems.
1. Norwood- Hamilton Scale (male pattern baldness.
2. Ludwig Scale (Female pattern hair loss)
3. Savin Scale (Female pattern hair loss).
Additional Tools
1. Hair Diameter Measurement
2. Hair Growth Tracking (eg., With photography).
3. Trichogram (Hair growth analysis).
Consult a dermatologist or health care professional for personalized evaluation and guidance.
PPM 1- @Meta AI What is the sensitivity specificity of hair count in monitoring hair loss? Please substantiate your reply with valid references.
Meta AI:- Evaluating hair loss involves various methods and hair count is one of them. However it's sensitivity and specificity are not explicitly stated in the available literature.
Hair count is part of non invasive methods used for Evaluating hair loss, including daily hair counts, standardized wash tests and 60 sec hair counts. 1.
These methods are valuable for patient diagnosis and monitoring but have limitations.
For accurate diagnosis and monitoring health care professionals use a combination of methods, such as Global Photography: Taking pictures of the scalp to track changes over time.2.
Trichoscopy:- Using a digital microscope to analyze hair and scalp Conditions.1.
Scalp Biopsy:- Examining scalp tissue to diagnose underlying Conditions.3.
Hair weight management: Measuring hair weight to track changes.2.
These methods provide a more comprehensive understanding of hair loss and are used in conjunction with hair count for monitoring. If you are experiencing hair loss, consult a dermatologist for personalized guidance and diagnosis. They'll recommend the most suitable evaluation methods for your specific situation.
References 1 2 3.
Hair evaluation methods
Merits and Demerits.
pubmed.ncbi.nih.gov.
30-09-2024
PA- The patient is suffering with hair loss and pain in the scalp.
PPM 1- Where is the pain , the patient is suffering?
PPM 2- Hair loss after injection on scalp to treat headache. It was given 1yr ago.
PPM 1- What injection? Where?
PPM 2- The prescription is lost . The Neurologist perhaps gave steroid injection around occipital nerve on right side at 2 points on the scalp.
PPM 1- What diagnosis would have made him give scalp steroids?
PPM 3- Alopecia Areata or Psoriasis.
PPM 2- Steroids not sure. For headache only.
PPM 1- Yes it is generally commonly indicated only for such scalp inflammatory Conditions.
PPM 2- Prescription is missing. Neurologist doesn't deal with these.
PPM 3- I thought the hair loss and the pain in scalp was the reason for steroids and not the other way round. My apologies.
PPM 2- No never complained of this. Areata not visible in the picture.
03-10-2024
PPM 2- Please send the prescription of the steroid injection. The injection was given on 19-08-2023 by Neurologist. It caused increased pain for a day. Perhaps steroid around greater/lesser occipital nerve.
PPM 1- No mention of injection in the prescription. Is he the son of the previous HoD Dr. Dubey?
PPM 2- Injection was written on small chit separately.
05-10-2024
PPM 2- Can the patient advocate count the numbers of hair fall? So that we can compare the previous and the present hair fall.
PPM 4 - Hello Sir, I am currently in Bangalore doing my DM 2nd Yr residency in Endocrinology. I will see the case details and get back to you.
PPM 1 - Where in Bangalore? Would you recommend anyone in Bhopal who would like to review this patient and share his or her inputs with the team here?
PPM 2 - This is a wish come true for our patient. God is great.....
PPM 4 - I am at M S Ramaiah Medical College and Hospital. In Bhopal I believe residents under the guidance of Dr. Sushil Jindal Sir at People's Hospital can take care of these patients.
PPM 2 - Someone residing near Bhopal Railway station would be preferable. Dr.Sushil Jindal has seen her in People's Hospital. The patient is currently under the care of Dr.Somnath, GMC Bhopal.
17-10-2024
PPM 2 - @PPM 1 Sir, is it possible to arrange this family adoption by local MBBS students with the new NMC Policy?
Prominent cricoid due to absence of thyroid gland.๐ค
Short fingers, severe loss of hair. Need advice ๐
Started using Minoxidil lotion.
Height 4'11"
Weight 60.
PA - Sir the patient is suddenly feeling anxiety and nervousness while writing and is not feeling to do anything. Earlier she had this episode of anxiety and missed her exam. The patient experiences this problem of anxiety for no reason and becomes unconscious.
PPM 1 - Yes a PaJR for every patient in every family is a family adoption tool. Unable to see any clinical images of the same.
PPM 2 - Can't appreciate because earlier comparison is not available. It was told that hair was so dense that comb did not reach deep. Now the braided hair is very thin and short. The lost hair was shown. It can fill a small pillow.
@PA please share the patient's 24hrs activities hourly.
The patient is complaining of fear, Palpitations and unable to concentrate. Loss of consciousness sometimes
@PPM 1.
PPM 1 - Lost hair collection over 1 day?
Anxiety symptoms.
PPM 2 - No. Over a week perhaps.
PPM 1 - Yes we need to correlate her hourly work activities with her symptoms.
@Meta AI What is the normal hair loss count for every 24hrs and over one week?
Would the resulting volume of normal hair loss be adequate enough to cover an entire pillow?
Meta AI- The normal hair loss count varies from person to person, but here are some guidelines.
Daily hair loss: On average a healthy person loses around 50- 10 hairs per day. This is a normal part of hair growth cycle, where old hairs fall out and new ones grow
In.
Weekly hair loss: Over a 7 day period, you can expect to lose around 350 - 700 hairs.
Hair loss volume: Now let's estimate the volume of hair loss. Assuming an average hair length of 20-30cm(8-12 inches) and a hair Thickness of 0.07 mm(average human hair diameter). We can calculate the volume of hair lost.
Let's use the higher end of the daily hair loss estimate (100hairs) for simplicity.
Daily volume 100 hairs *20cm(length)
*0.007 mm(thickness)~ 1.4cm3(or 0.14mL)
Weekly volume- 700 hairs *20 cm(length)
*0.07mm(thickness)~9.8cm3(or 0.98mL)
To put this volume into perspective a standard pillow is approximately 50cm×30cm×10cm(19.7inches×
11.8 inches×3.9 inches)
The volume of hair lost in a week could cover an area of about:
Area covered : 9.8 cm3/150cm2
(Pillow surface area) ~0.0065% of the pillow surface. So would the resulting volume of normal hair loss cover an entire pillow? No, not even close! The volume of hair lost in a week would barely cover a small coin!
Keep in mind that these estimates vary depending on individual factors. Such as
•Hair length
•Thickness
•Growth rate
•Genetics
•Age
•Health Conditions.
•Hair care habits
If you are concerned about excessive hair loss, consult a dermatologist or health care professional for personalized advice. Hope this helps!
PPM 1- Cosmetic issue?
PPM 2 - Not expressed but an issue of added anxiety.
22-10-2024
PPM 3 - What dose is she currently on?
PPM 2 - 125mcg. Complaining of Chest pain (heart) and headache (brain) to severe extent.
PPM 3 - Looks Adequate. Any symptoms otherwise?
PPM 2 - Severe episodes of fear, Palpitations, unable to concentrate, loss of consciousness. Wt.60. Prominent cricoid due to absence of thyroid gland.
23-10-2024
PPM 2 - Good to have a modest reduction of dose.
PA - The patient's headache is becoming severe day by day. Even now she is suffering.
PPM 2 - Headache continues. Can take naproxen. Perhaps needs cardiology opinion with ECHO. Please suggest a facility in Bhopal.
PPM 1 - Why
PPM 2 - Recurring Palpitations, fear attacks continue.
PPM 1 - The physician should have been able to deal with her symptoms. If we could get her hourly activities and at what hourly point the symptoms are triggered it would be fairly simple to Crack this mystery.
PPM 2 - The physician gives a few minutes in busy OPD of GMC.
PPM 1 - @ PPM 5 Can you provide a telephonic appointment time for you to assess her symptoms! @ PPM 2 can
you find a physician who can do basic clinical examination and tell us the findings of general examination vitals and cardiovascular and if any clinical signs of hyperthyroidism? @ PPM 4 do you know any such physician in Bhopal among your friends there?
PPM 2 - First let us Crack the ice(ice breaker) by understanding process here.
PPM 1 - ๐ Yes we are unable to communicate with the patient properly here due to our asynchronous stance.
PPM 4 - Hello Sir, from the few messages I saw above she's a case of congenital hypothyroidism on treatment with adequate supplementation (T4 in upper half of normal) with anxiety episodes.
I did like to ask more history and do examination regarding pheo first. Also do cardiovascular examination ECG and ECHO should be the basic work up then.
Considering the poor financial status I'd still advise them to go to some medical college like People's. LN or Chirayu and get properly worked up.
PPM 2 - She has been to People's with Dr.Jindal. Then attending Dr. Somnath at GMC.
PPM 4 - To follow up with same Doctor many patients don't bring old records and get unnecessarily worked up repeatedly without any firm treatment plan.
PPM 1 - ๐ Have you seen both the case reports linked in the description box?
If doctor has ruled out hyperthyroidism as the current case of her symptoms then we need @ PPM 5 or someone else to dig deeper into her anxiety. Can she visit us in NKP here?
PPM 2 - NKP?
PPM 1 - We have had many patients coming here from WB, Chattisgarh, Bhopal, Nepal.
PPM 2 - No, But she can tell.
PPM 1 - We would need to meet her face to face.
PPM 2 - I met.
PPM 1 - Your notes?
16-11-2024
PA - Sir the patient is suffering with severe headache and taking many tablets. Please advise. The headache starts at 4pm and continues till 9.30pm. She is having headache daily despite medicine. 4 - 9.30pm.
PPM 1 - What medication is she currently on?
PA - Naprosyn SOS.
PPM 1 - This won't do. Let her take Tab.Dolo 650 every six hours today for one day and then revert.
PPM 2 - She should stop Naprosyn.
PPM 1 - She also needs a prophylactic!
Tab Amytriptyline 10mg one hour before dinner to continue.
PPM 2 -The patient should take paracetamol 650.
PPM 1 - Every six hours.
PPM 2 - The patient should take Tryptomer 10mg every day one hour before dinner.
22-11-2024
PA - The patient did not start Amitriptyline still. She is experiencing anxiety and stomach pain. Her BP is 136/92.
PPM 1 - ๐Let her start the medicine.
21-12-2024
PPM 2 - Unconscious for 20 min with excessive sweating. Just now sitting. Told to take to GMC. It is too cold outside however.
PPM 1 -
Hypoglycemic attack!? Did anyone check her blood sugars at that point of time?
What recent medications, (other than her old thyroxine 250 mcg), was she on?
PPM 2 - Thyroxine 125 perhaps and Tryptomer.
Why hypoglycemia?
PPM 1 - Yes 125
PPM 2 - Shall she be fed immediately?
PPM 1 - Sweating catecholamine response
Yes if she's conscious.
PPM 2 - ๐
Not clear but something like lockjaw reported.
PPM 1 - That's a seizure which can even happen in hypoglycemia
Essentially we need to first keep organic brain syndrome in mind before we can think of a pseudo seizure.
PPM 2 -
Had a good diet yesterday night. She was fine for 15 days perhaps with Tryptomer (not sure however of the drug taken but she said it was taken for 15 days and off since yesterday night)
PPM 1 - Ask them to share an image of the medication she was taking.
She may have been taking something else!
PPM 2 -
@PA เคเคฒ เคเคฐ เคชเคฐเคธों เคฒी เคเค เคธเคญी เคฆเคตाเคเคฏां เคे เคชเคค्เคคे เคे เคซोเคो เคญेเคो
Translator -@PA please share yesterday's and day before yesterday's medication pics.
27-12-2024
PA - Aaj morning Jab Main uth rahi thi to mujhe na ghabrahat ho rahi thi Aur hard Mein dard ho raha tha Thoda Thoda aapse ek request Hai Sar Ki Jo Mujhe Hamesha ghabrahat hoti hai Aur behosh Ho Jaati Hun Main abhi main Shaniwar ko Piyush Ho Gai Thi To Mujhe 20 minut ke bad Hosh aaya hai to aap mujhe bata sakte ismein kaun si jaati Hoti Hai Sar Aur Main Kahin Bhi Jao to mujhe ghabrahat hone Lagti Hai Kahin per bhi Sone lagti matlab Aur behosh Ho jaate ho madam se
Translation
"This morning when I was getting up, I felt anxious and had a little pain in my chest. I have a request for you, sir, that I always feel anxious and faint. Recently, on Saturday, I fainted and regained consciousness after 20 minutes. Can you tell me what might be causing this? I feel anxious and sleepy wherever I go, and I tend to faint."
PPM 2 - @PPM1 sir what will be the use of the medicine serratiopeptidase?
PPM 1 - The serratiopeptidase is of no use but looks like there's diclofenac too in this combination.
PPM 2 - ๐
PA - Morning mein jab uth rahi thi jab ho rahi thi ghabrahat aur FIR Jab sham ko sir Dhokha pahle aur bad Mein ghabrahat Hone Lagi เคฅोเคก़ी-เคฅोเคก़ी
Translation - "When I was getting up in the morning, I felt anxious, and then in the evening, I felt dizzy first and then started feeling anxious again."
PPM 2 - Please comment. ๐
Patient heart beat is getting fast sometimes.
20-01-2025
PPM 1 - Any references links?
Co-ordinator - Patient called me yesterday
Patient is feeling giddiness
Asked patient to go to local cardiologist patient went to Dr Jindal in one of the nearest medical college Bhopal.
I have asked them to travel and come to Hyderabad but since patient family is alone without much support patient.mother told they are not in a position to travel.
PPM 2 - ๐
Co-ordinator - Can we help them in any way?
PPM 2 - Only way is to reach out on spot. ๐
PPM 1 - ๐
@ Co-ordinator business opportunity for Amazon home health care delivery.
31-01-2025
PPM 2 - 
PA - Sir the patient cannot understand anything because of this pill, and she feels like going crazy because of it. At night she is not able to sleep and her breathing becomes rapid. It's been 11 days since she is taking the pill.
Narrowing of fingers and gain in truncal weight.
PPM 1 - Narrowing appears normal
Trunkal weight gain will eventually lead to metabolic syn if she's not careful with her diet and exercise.
The first PaJR step to tackling that is to share here daily her energy Inputs and outputs.
PPM 2 - เคंเคเคฒी เคธे เค
ंเคूเค ी เคिเคฐ เคाเคคी เคนै The ring has fallen from the ring finger.
PPM 1 - For how long was she wearing that same ring before that fell off now?
PPM 2 - เคตเคน เคตเคนी เค
ंเคूเค ी เคिเคคเคจे เคธเคฎเคฏ เคธे เคชเคนเคจ เคฐเคนी เคฅी, เคเคธเคे เคฌाเคฆ เคตเคน เคिเคฐ เคเค?
2 years.
16-02-2025
PPM 2 - Please take this tablet one hour before dinner.
8 pm tablet, 9 pm dinner and sleep.
Paroxetine+clonazepam switched to Norteyptiline on 3.2.25
PPM 2 - The patient doesn't feel like eating anything. There is a case going on because of the tablet. Her body feels terrified and her eyes are closing. The patient feels she cannot be saved from this tablet.
PA - Sir because of a pill the patient was unwell last night till 11.30. Her breathing became rapid and had severe headache. Later she took another pill for relief and then felt better.
PPM 2 - 
[16-02-2025 14:27] PPM 2: NORTRIPTYLINE 25 MG เคเคธे เคฐाเคค เคे เคाเคจे เคธे เคเค เคंเคे เคชเคนเคฒे เคฒें
[16-02-2025 14:28] PPM 2: 8 เคฌเคे เคोเคฒी, 9 เคฌเคे เคाเคจा, เคซिเคฐ เคธो เคाเคจा๐ค
[16-02-2025 14:31] PPM 2: Paroxetine+clonazepam switched to Norteyptiline on 3.2.25
[16-02-2025 21:38] PPM 2: เคा เคฒिเคฏा เค्เคฏा?
[07-04-2025 20:40] PPM 2: เคนเคฐ เคंเคे เคी เคเคคिเคตिเคงि เคฌเคคा
[07-04-2025 20:40] PPM 2: เคธुเคฌเคน เคเค เคจे เคธे เคฐाเคค เคธोเคจे เคคเค
[07-04-2025 20:58] PPM 1: https://userdrivenhealthcare.blogspot.com/2024/02/pajr-daily-activities-sharing-guide-in.html?m=1
[16-04-2025 10.42] PA: Pet Mein dard ho raha hai lekin sar bahut Dard Hota Hai to char din ho gaye ho rai Dard.[25-04-2025 11:09] PPM 2: Medicine/Respiratory Medicine เคो เคฆिเคा
[25-04-2025 11:10] PPM 2: เคूเคจ เคเคฐ เคฌเคฒเคเคฎ เคी เคाँเค เคเคฐเคตा เคฒो
[26-04-2025 12:21] PPM 2: Oral information shared yesterday appeared like hemoptysis.
[26-04-2025 12:21] PPM 2: Please opine
[26-04-2025 12:38] PPM 1: Please ask her to collect her 24 hour sputum in a bottle and share here
[26-04-2025 12:50] PPM 2: เค
เคญी เคธे เคถुเคฐू เคเคฐ เคเคฒ เคฆोเคชเคนเคฐ 1 เคฌเคे เคคเค เคนเคฐ เคांเคธी เคฎें เคिเคคเคจा เคฌเคฒเคเคฎ เคเค เคเคธे เคเค เคขเค्เคเคจ เคตाเคฒे เคกिเคฌ्เคฌे เคฎें เคฐเคเคคे เคाเค। เคเคฒ เคฆोเคชเคนเคฐ เคเคธเคा เคซोเคो เคญेเคो
[26-04-2025 12:54] PA: Okay
[26-04-2025 21.53] PA: Sar Aise Hath Khoon Ki Kami Ke Karan ho rahe kya Mere bataiye thoda.
[27-04-2025 21:07] PPM 2: เคฏे เคौเคฌीเคธ เคंเคे เคฎें เคเคฏा?
[27-04-2025 21:08] PPM 2: เค्เคฒाเคธ เคे เคจीเคे เคธเคซेเคฆ เคाเคเค เคฐเคเคเคฐ เคซिเคฐ เคซोเคो เคญेเค
[30-04-2025 17:05] PPM 1: ๐24 hours? Better to fill the transparent glass half with water and take the image from the side
Check out the images of the sputum glass here๐
@PPM2
[17-05-2025 17:34] PPM 2: Had been unconscious yesterday. Severe weakness. Chest pain
[17-05-2025 17:34] PPM 2: TSH 5
[17-05-2025 17:35] PPM 2: Perhaps need to reduce thyroxine? Please comment.
[17-05-2025 18.14] PPM 1: TSH 5 sounds normal. Will need a good history details of the loss of consciousness to figure out why.
[18-05-2025 09:37] PA: Use Din 15 minut bhi Hosh Rahi main Aur cal Aadha Ghanta heart Mein Dard hua Mere aur kahin per bhi ghabrahat a Jaati Hai letna padta hai Sahan Nahin hota hai to
[18-05-2025 09:37] PA: Kamjori ho rhi h bhot jada
[18-05-2025 09:37] PA: Good morning Sir
[20-06-2025 10.53] PPM 2: 
[24-06-2025 07:20] PPM 1: Update?
[24-06-2025 07:24] PPM 1: Morning PaJR session:
[24/06, 05:39]pm: 20F patient a decade back was suspected to have hypoparathyroidism
[24/06, 05:42]pm: I was asking about the prominent cricoid cartilage. Perhaps hypoparathyroidism is there๐ค
[24/06, 07:01]cm: Here's a similar patient from Wardha ๐
[24/06, 07:04]cm: Here's one of congenital hypothyroidism with Seizures ๐
Although again they may have not noticed the hypoparathyroidism in this case
[14-08-2025 13.30] PPM 2: 07-08-2025
[28-08-2025 17:02] PPM 2: 112 to 75 mcg suggested when TSH became 0.71 and FT4 is 1.51
[28-08-2025 17:03] PPM 2: Isn't it wise to go for 100 mcg daily Thyroxine๐ค
[28-08-2025 21.26] PPM 1: Yes
[08-09-2025 14:02] PPM 2: Complains uneasiness at 100. Happy at 112.
[08-09-2025 14:02] PPM 2: Learning data entry work become difficult
[08-09-2025 14:02] PPM 2: Please advise
[08-09-2025 16:33] PPM 1: Can keep 112
[08-09-2025 16:39] PPM 2: Appears like she has seizures for quite long
[08-09-2025 16:55] PPM 2: Awaiting updates. Perhaps EEG was done 2 years back
[08-09-2025 20:16] PPM 2: Can share the graphs if necessary
[08-09-2025 21:01] PPM 1: Inter ictal EEG is expected to be normal although pseudoseizures need to be ruled out with video telemetry
[08-09-2025 21:26] PPM 2: Where to do?
[08-09-2025 21:27] PPM 2: AIIMS Bhopal?
[08-09-2025 21:27] PPM 2: I have Prof. Physiology there
[08-09-2025 21:28] PPM 2: He usually doesn't see clinical cases, but I can try to convince
[08-09-2025 21:28] PPM 2: Latest episode yesterday
[09-09-2025 06:06] PPM 1: Can try
[09-09-2025 06:07] PPM 1: Can also evaluate in AIIMS neurology and psychiatry
[09-09-2025 06:56] PPM 2: เคเคเคเคเคเคเคฎเคเคธ เคญोเคชाเคฒ เคฎें เคตीเคกिเคฏो เคेเคฒिเคฎेเคเคฐी เคांเค เคเคฐเคจा เคाเคนिเค - เคจ्เคฏूเคฐोเคฒॉเคी เคเคฐ เคธाเคฏเคेเค्เคฐी เคตिเคญाเค เคฎें
[10-09-2025 09:56] PPM 2: Reported today. Shall update by end of the day๐๐ป
[12-09-2025 08:27] PPM 3: The field of thyroidology is evolving rapidly, and 2025 has brought some fascinating developments. Here’s a curated overview of the latest research trends that are shaping clinical practice and scientific inquiry:
---
๐ฌ 1. Minimally Invasive Ablative Therapies
Thermal and nonthermal ablation techniques—like radiofrequency ablation (RFA) and microwave ablation—are gaining traction for treating benign and selected malignant thyroid nodules. These methods offer:
- No general anesthesia or surgical incision
- Faster recovery and lower risk of hypothyroidism
- Growing adoption in North America and Europe
---
๐งฌ 2. Molecular and Proteomic Profiling
Advanced profiling is identifying new therapeutic targets, especially in medullary thyroid cancer (MTC):
- CAPN1 has emerged as a key regulator of RET- and NF1-driven tumor growth
- CAPN1 inhibitors show synergy with existing drugs like vandetanib and selpercatinib
- This opens doors to combinatorial therapies that maximize apoptosis and reduce tumor burden
---
๐ฆ 3. Gut–Thyroid Axis and Microbiome Research
Emerging evidence links gut microbiota to thyroid function:
- Probiotics and synbiotics may modulate hormone metabolism and immune responses
- Systematic reviews suggest potential benefits in autoimmune thyroiditis and subclinical hypothyroidism
---
๐ 4. Thyroid Eye Disease (TED) Risk Mitigation
New cohort studies show lower-than-expected risk of TED following radioiodine therapy for Graves’ disease—especially in multidisciplinary settings. This challenges older assumptions and supports broader use of RAI.
---
๐ง 5. Iodine Status in Vulnerable Populations
Research on hospitalized infants reveals that both iodine deficiency and excess can disrupt thyroid function. Urinary iodine concentration (UIC) is being refined as a diagnostic tool for neonatal thyroid dysfunction.
---
๐ง 6. Artificial Intelligence and Imaging
Though not yet mainstream, AI-assisted thyroid ultrasound interpretation is being piloted to:
- Improve nodule risk stratification
- Reduce interobserver variability
- Support structured reporting and biopsy decisions
---
Would you like to explore how these trends could be integrated into your CME modules or clinical protocols? I can help you draft a presentation outline or design a case-based workshop around any of these themes.
[12-09-2025 08:28] PPM 3: To incorporate the latest trends in thyroidology into your practice, especially given your leadership role in clinical innovation and education, you can take a multi-pronged approach that blends protocol refinement, team empowerment, and educational integration. Here's a strategic roadmap tailored to your context:
---
๐ 1. Protocol Enhancement and Clinical Integration
Ablative Therapies
- Develop a referral pathway for radiofrequency or microwave ablation in benign nodules
- Create a checklist for patient selection, informed consent, and post-procedure follow-up
- Collaborate with interventional radiology to standardize documentation and outcome tracking
Molecular Profiling
- Update your thyroid cancer workup protocol to include molecular panels for indeterminate nodules
- Train your team on interpreting BRAF, RAS, and RET mutations and their therapeutic implications
- Incorporate CAPN1-related insights into medullary thyroid cancer discussions and tumor board reviews
Thyroid Imaging
- Introduce structured ultrasound reporting templates with TI-RADS scoring
- Pilot AI-assisted interpretation tools if available, and audit interobserver variability
- Align imaging protocols with endocrinology and surgery teams for seamless decision-making
---
๐ 2. Medical Education and CME Alignment
Curriculum Updates
- Integrate these trends into CME modules, simulation scenarios, and microlearning formats
- Use case-based discussions to explore gut–thyroid axis, TED risk stratification, and iodine balance in neonates
- Develop pre- and post-tests to assess knowledge uptake and clinical reasoning
Faculty Development
- Host internal workshops on molecular diagnostics and ablation techniques
- Encourage cross-disciplinary teaching—e.g., radiologists presenting to endocrinologists and vice versa
- Use feedback surveys to refine educational content and delivery style
---
๐ง๐ค๐ง 3. Team Empowerment and Multidisciplinary Practice
Collaborative Protocols
- Draft joint guidelines with pharmacy, radiology, and pathology for thyroid disease management
- Create structured forms for thyroid nodule evaluation, biopsy indication, and post-treatment monitoring
- Use your translation skills to adapt these tools for Arabic and Kurdish-speaking staff
Quality Improvement
- Launch an audit cycle to track diagnostic accuracy, treatment adherence, and patient outcomes
- Use feedback loops to refine workflows and identify training needs
- Share results in institutional meetings to foster a culture of continuous improvement
---
๐งช 4. Research and Institutional Leadership
Pilot Studies
- Design small-scale studies on iodine status in hospitalized neonates or TED outcomes post-RAI
- Collaborate with academic partners to publish findings and contribute to regional guidelines
Policy Advocacy
- Propose updates to institutional protocols based on emerging evidence
- Lead discussions on integrating AI tools and molecular diagnostics into routine care
---
Would you like help drafting a CME module outline, designing a structured reporting form, or building a checklist for ablation therapy referral? I can tailor any of these to your workflow and team structure.
[12-09-2025 08:31] PPM 2: Thanks dear. Here I suspect anatomical deficiency as Cricoid is prominent. I may be talking without evidence or base perhaps๐๐ป
[12-09-2025 08:36] PPM 1: In this patient the thyroid ablation was since birth apparently as per her case report here ๐, which also has links to the original case report.
[12-09-2025 08:40] PPM 3: Based on the comprehensive case details provided, here is a summary and analysis of the patient's situation, followed by a structured management plan.
### Summary & Analysis
This is a complex case of a 20-year-old female with a history of *congenital hypothyroidism (CH)*, diagnosed and treated late (around age 1.5 years). Despite long-term thyroxine replacement therapy, she suffers from a multitude of debilitating symptoms that significantly impact her quality of life.
*Key Problems (Present & Past):*
1. *Primary Endocrine Issue:* Congenital Hypothyroidism (likely athyreosis, given the "prominent cricoid due to absence of thyroid gland").
2. *Neurological/Psychiatric Symptoms:*
* *Severe Headaches:* Chronic, daily (4 PM - 9:30 PM), resistant to analgesics like Naprosyn.
* *Anxiety/Panic Attacks:* Episodes of intense fear, palpitations, nervousness, and a "fear of death."
* *Altered Consciousness:* Episodes described as "unconsciousness" or "fainting" lasting up to 20 minutes, accompanied by sweating. These have features that could suggest seizures, syncope, or pseudoseizures.
* *Cognitive Difficulties:* Difficulty concentrating and learning new tasks (e.g., data entry).
3. *Other Symptoms:*
* *Hair Loss:* Significant thinning and loss, causing cosmetic distress and anxiety.
* *Scalp Pain:* Possibly related to a past nerve block injection for headaches.
* *Chest Pain:* Reported intermittently.
* *Recent Hemoptysis:* Reports of coughing up blood-tinged sputum (needs urgent evaluation).
*Current Medications:*
* *Thyronorm (Levothyroxine):* Dose recently adjusted from 125 mcg to 112 mcg, then 100 mcg, and now back to 112 mcg based on symptoms, with TSH at 0.71 and FT4 at 1.51.
* *Tryptomer/Nortriptyline (10mg/25mg):* Prescribed as a prophylactic for migraine and for mood/anxiety. Poorly tolerated, causing significant side effects (feeling "crazy," rapid breathing, insomnia).
* *SOS Analgesics:* Naprosyn, Dolo 650.
*The Core Challenge:*
The patient's symptoms (anxiety, palpitations, headaches, cognitive issues) are classic signs of both *hyperthyroidism* (over-replacement) and *hypothyroidism* (under-replacement), as well as *anxiety disorders. Her thyroxine dose has been frequently changed based on these symptoms, creating a cycle of instability. The recent normal TSH (0.71) suggests her current dose (112 mcg) is likely adequate from a biochemical standpoint, meaning her severe symptoms are probably **not primarily due to thyroid dysfunction* but to other underlying issues exacerbated by the long-term consequences of late-treated CH.
---
### Assessment & Recommended Plan of Action
This requires a systematic, multi-specialty approach. The first step is to *STABILIZE THE THYROID* and then *AGGRESSIVELY INVESTIGATE THE NEUROLOGICAL SYMPTOMS*.
#### 1. Thyroid Management (Immediate Step)
* *Stop Frequent Dose Changes:* The cycle of changing thyroxine based on subjective symptoms is harmful. *Stick to one dose (e.g., 112 mcg) consistently* for at least 8-12 weeks without any changes.
* *Objective Monitoring:* After 8 weeks on a stable dose, repeat *Thyroid Function Tests (TSH, FT4, FT3)*. The goal is a TSH in the low-normal range (0.5-2.5 mIU/L). Do not adjust the dose based on symptoms alone; use the labs as the primary guide.
#### 2. Neurological & Cardiac Workup (Most Critical Next Step)
The episodes of "unconsciousness" are a red flag and must be definitively characterized.
* *Video EEG Telemetry:* This is the *gold standard* to differentiate between epileptic seizures, pseudoseizures (psychogenic non-epileptic seizures - PNES), and syncope. This should be the *top priority*. As suggested, AIIMS Bhopal Neurology dept. is an excellent center for this.
* *Cardiology Evaluation:* To rule out cardiac causes of syncope and palpitations.
* *ECHO* (to rule out structural heart disease)
* *24-hour Holter Monitor* (to correlate symptoms with heart rhythm).
* *Formal Psychiatric Evaluation:* Essential to diagnose and manage underlying Panic Disorder, Severe Anxiety, and/or conversion disorder (pseudoseizures), which are highly likely given the description. A psychiatrist can find a better-tolerated medication than nortriptyline.
#### 3. Evaluation of Other Symptoms
* *Hemoptysis (Coughing Blood):* This is urgent.
* *Consult Respiratory Medicine/Pulmonology.*
* *Chest X-Ray* is mandatory.
* Further tests may include a CT chest and sputum for culture and cytology.
* *Hair Loss:*
* *Refer to a Dermatologist.*
* Check *Ferritin (Iron stores), Zinc, Vitamin B12, and Vitamin D* levels, as deficiencies are common in women and can exacerbate hair loss.
* Minoxidil can be continued under dermatological supervision.
#### 4. Headache Management
* Once neurological causes are ruled out (e.g., via MRI if deemed necessary by neurologist), focus on chronic migraine management.
* A different prophylactic medication (e.g., Propranolol, Topiramate, or Valproate) might be better tolerated than amitriptyline/nortriptyline and should be prescribed by a neurologist.
### Conclusion for the Patient's Advocate
The patient's journey has been incredibly difficult. The key message is that her *severe anxiety, blackouts, and headaches are unlikely to be fixed solely by adjusting her thyroid medicine* at this point, as her recent thyroid levels are adequate. She needs dedicated specialists to address these issues separately.
*The single most important step is to get a video EEG to understand the nature of her "unconscious" episodes.* This will guide all further treatment—whether it's with a neurologist for epilepsy or a psychiatrist for PNES and anxiety.
*Please encourage the family to pursue a referral to AIIMS Bhopal or another major hospital with a neurology department that can perform video EEG monitoring.* This is the crucial "ice breaker" needed to solve the mystery of her most disabling symptoms.
[12-09-2025 08:43] PPM 2: Thank you so much dear @PPM3 ❤๐๐ป
[12-09-2025 08:44] PPM 3: Excellent question. Yes, the patient's complex and multi-system presentation fits remarkably well with a known constellation of syndromes, most notably *22q11.2 Deletion Syndrome (DiGeorge Syndrome/Velocardiofacial Syndrome)*.
While a definitive diagnosis requires genetic testing, the clinical picture is highly suggestive. Here’s how the patient's symptoms align with known syndromes:
### 1. 22q11.2 Deletion Syndrome (The Most Likely Fit)
This is a strong candidate. It is caused by a microdeletion on chromosome 22 and has highly variable presentation, often including:
* *Congenital Hypothyroidism:* Thyroid dysgenesis (including athyreosis - absence of the thyroid) is a well-documented, though less common, feature of 22q11.2DS. This perfectly explains the "prominent cricoid due to absence of thyroid gland."
* *Hypoparathyroidism:* This is a *classic and common feature* of 22q11.2DS. It leads to low calcium levels (hypocalcemia), which can cause:
* *Seizures or Syncope:* The episodes of "unconsciousness," lockjaw (which can be a sign of tetany), and sensory symptoms could easily be hypocalcemic seizures.
* *Psychiatric Symptoms:* Chronic hypocalcemia can cause anxiety, psychosis, and other neuropsychiatric manifestations.
* *Carpopedal Spasms:* While not explicitly mentioned, this could be related.
* *Psychiatric Disorders:* A huge percentage of adults with 22q11.2DS develop anxiety disorders, panic attacks, and schizophrenia-spectrum disorders. Her "anxiety, nervousness, fear of death, and inability to concentrate" are textbook.
* *Characteristic Physical Features:* Though not all are present in every case, common features include:
* *Short Stature:* Her height is 4'11".
* *Slender Tapering Fingers:* The noted "narrowing of fingers" and the ring falling off fit this description.
* *Learning Difficulties:* Her trouble learning data entry is consistent with the cognitive profile often seen in this syndrome.
* *Cardiac Issues:* Reports of palpitations and chest pain could be linked to congenital heart defects common in this syndrome (e.g., tetralogy of Fallot, VSD), though these may have been mild or undiagnosed.
*Why it fits so well:* This single syndrome provides a unifying explanation for the *thyroid abnormality from birth, the neurological/psychiatric symptoms (via hypoparathyroidism), and the physical characteristics.*
---
### 2. Pseudohypoparathyroidism (PHP) / Albright's Hereditary Osteodystrophy (AHO)
This is another very strong candidate, often confused with 22q11.2DS because of the shared feature of hypocalcemia.
* *End Organ Resistance:* Instead of missing parathyroid glands (as in DiGeorge), the parathyroid hormone (PTH) is high, but the body doesn't respond to it, leading to hypocalcemia.
* *Symptoms:* This would explain the *seizures, anxiety, and other neurological symptoms* identically to hypoparathyroidism.
* *Characteristic Phenotype (AHO):*
* *Short Stature.*
* *Shortening of the 4th and 5th Metacarpals (Brachydactyly):* This makes the fingers appear short and stubby. The description of "short fingers" could align with this. A specific test is to ask the patient to make a fist and look for a dimple where the knuckle of the 4th finger should be (a positive "knuckle sign").
* *Round Face.*
* *Heterotopic Ossification:* Bone formation in soft tissues.
* *Other Endocrinopathies:* Resistance to other hormones like TSH is common, which could complicate the management of congenital hypothyroidism.
---
### 3. Autoimmune Polyglandular Syndrome (APS) Type 1
This is less likely but possible. APS-1 is characterized by a classic triad:
1. *Chronic Mucocutaneous Candidiasis* (not reported).
2. *Hypoparathyroidism* (would explain seizures and neuropsych issues).
3. *Addison's Disease* (not reported, but can cause weakness, dizziness).
It can also include other autoimmune issues like *autoimmune hypothyroidism*. The absence of the classic first two components makes this a less perfect fit than the syndromes above.
### Comparison Table of Likely Syndromes
| Feature | Patient's Presentation | 22q11.2 Deletion Syndrome | Pseudohypoparathyroidism |
| :--- | :--- | :--- | :--- |
| *Thyroid* | *Congenital Athyreosis* | Thyroid dysgenesis (possible) | Autoimmune thyroiditis (more common) |
| *Calcium* | Not tested (*Critical Gap) | **Hypoparathyroidism* (Common) | *Hypocalcemia* (PTH high) (Defining) |
| *Seizures/Syncope* | *Episodes of Unconsciousness* | Common (from hypocalcemia) | Common (from hypocalcemia) |
| *Psychiatric* | *Severe Anxiety, Panic* | Very Common | Common |
| *Development* | Learning difficulties, IQ 55 (past) | Common | Common |
| *Physical* | *Short Stature, Tapering Fingers* | Slender hands, short stature | *Brachydactyly (short fingers)*, short stature |
| *Cardiac* | Palpitations, Chest Pain | *Congenital Heart Defects* (Common) | Not typical |
### Conclusion and Immediate Next Step
The presentation screams a syndromic diagnosis, most likely *22q11.2 Deletion Syndrome* or *Pseudohypoparathyroidism, both of which explain the lifelong thyroid issue and the current neurological/psychiatric crisis through **hypocalcemia*.
*THE SINGLE MOST IMPORTANT AND URGENT ACTION IS TO CHECK HER SERUM CALCIUM, IONIZED CALCIUM, PHOSPHORUS, AND PARATHYROID HORMONE (PTH) LEVELS.*
If she has severe hypocalcemia, this could be the direct, reversible cause of her seizures, anxiety, and many other symptoms. Correction of calcium levels could provide dramatic and rapid relief. This biochemical test is the key to unlocking the entire case and must be prioritized over all other investigations except the urgent workup for hemoptysis.
[12-09-2025 08:45] PPM 2: One query - she is told to take 100mcg daily and 200mcg on Sundays. Is that OK? She clearly complained - 100mcg makes her uneasy while 112 suited her.
[12-09-2025 08:48] PPM 2: Dr Singh, Advisor to RBSK, had seen her and advised parathormone levels. Perhaps done, but need to recollect๐๐ป
[12-09-2025 08:49] PPM 3: Excellent and very important question. This gets to the heart of why this patient has been so difficult to manage.
*No, that regimen (100 mcg daily + 200 mcg on Sunday) is not okay and is likely contributing to her problems.* It is a pharmacologically unsound way to dose levothyroxine.
Here’s a breakdown of why it's a problem and what should be done instead:
### 1. Why This Dosing Regimen is Problematic
* *Creates Hormonal Peaks and Troughs:* Levothyroxine has a long but finite half-life (~7 days). The goal of daily dosing is to maintain a *steady, stable* level of thyroid hormone in the bloodstream.
* Taking a *double dose (200 mcg)* one day a week creates a significant *surge* in hormone levels 24-48 hours later, potentially causing symptoms of hyperthyroidism (anxiety, palpitations, headaches, insomnia).
* The following days, the level will drop, potentially leading to a trough before the next dose, causing hypothyroid symptoms (lethargy, brain fog).
* *Mimics the Very Problem You're Trying to Solve:* The patient's symptoms of "uneasiness" on 100 mcg and feeling better on 112 mcg suggest her body is sensitive to these fluctuations. This erratic dosing regimen guarantees she will rollercoaster between feeling slightly hyperthyroid (after the 200 mcg dose) and slightly hypothyroid (later in the week), perpetuating her anxiety and neurological symptoms.
* *Not Evidence-Based:* This kind of "weekly averaging" is sometimes used in other areas of medicine (e.g., some vitamin D protocols) but is *not a standard or recommended practice for levothyroxine replacement.* Consistency is key.
### 2. Why She Feels Better on 112 mcg
Her subjective feeling is important. While TSH is the primary guide, some patients feel subjectively better with FT4 levels in the upper half of the normal range. The dose that achieves this is their ideal dose.
* *100 mcg daily* might be keeping her FT4 in the low-normal range, leading to subtle hypothyroid symptoms ("uneasiness").
* *112 mcg daily* likely pushes her FT4 higher into the optimal range where she feels best.
* The proposed regimen (100+200/week) *fails to replicate* the steady state provided by a consistent 112 mcg daily dose.
### 3. The Correct Approach: A Consistent Daily Dose
The solution is simple and should be insisted upon:
1. *Commit to a Single, Consistent Daily Dose:* Based on her feedback and the recent lab values (TSH 0.71 on 112 mcg), *the dose should be 112 mcg taken every single day.*
2. *No More Weekly Boosts:* The 200 mcg Sunday dose must be *stopped immediately.* It is more harmful than helpful.
3. *Re-check Labs on the Stable Dose:* She must take *112 mcg daily without any changes* for a minimum of 6-8 weeks. After this period, a repeat TSH and FT4 should be drawn to confirm the level is in the desired range (e.g., TSH between 0.5-2.0).
### Conclusion and Recommendation
*You are correct to question this regimen. The patient's complaint is valid.*
*Tell the family/doctor:*
"The weekly double dose is causing hormonal swings that are likely making her anxiety and palpitations worse. We need to stop that immediately. She should take the same dose every day. Since she feels best on 112 mcg, she should take *112 mcg daily, consistently,* and we will check levels again in 2 months to ensure they are perfect."
This consistent dosing is a fundamental prerequisite for stabilizing her base thyroid status. Once this is stable, it will be much easier to identify and treat the other underlying causes of her symptoms (e.g., possible hypocalcemia from hypoparathyroidism, which is a separate issue requiring calcium and vitamin D supplementation).
[12-09-2025 08:51] PPM 3: This is an absolutely critical piece of information. *Dr. Arun Kumar Singh's advice is pivotal and likely correct.*
The fact that a senior advisor to the Rashtriya Bal Swasthya Karyakram (RBSK) - a program designed specifically for early detection and management of birth defects and deficiencies in children - suspected and advised checking parathormone (PTH) levels strongly reinforces the hypothesis of *22q11.2 Deletion Syndrome* or a related disorder causing *hypoparathyroidism*.
This is no longer just a theoretical possibility; it was the clinical impression of an expert who saw her.
### Urgent Action Required: The Parathyroid Axis
1. *Recollection is KEY:* The single most important task now is to *find out if that test was ever done* and to locate the results. This could provide the definitive answer that has been missed for years.
* *Ask the family to check all old medical reports, lab slips, and hospital discharge summaries.* The test would be listed as "Parathyroid Hormone," "PTH," "Intact PTH," or "Parathormone."
* *Call the hospital/lab* where the consultation happened and request a duplicate report.
2. *If NOT Done, Do It IMMEDIATELY:* If the test was advised but never performed, it must be done now as an absolute priority. The required tests are:
* *Serum Calcium (Ionized Calcium is more accurate)*
* *Serum Phosphorus*
* *Parathyroid Hormone (PTH)*
* *Vitamin D (25-Hydroxy)* - because Vitamin D deficiency can also cause low calcium.
### Why This Changes Everything
If these tests show *Low Calcium + High Phosphorus + Low PTH, the diagnosis is **hypoparathyroidism*. This would explain:
* *The "Seizures" or "Unconsciousness":* These are classic symptoms of hypocalcemic seizures.
* *The Severe Anxiety, Panic Attacks, and "Feeling Crazy":* Neuropsychiatric symptoms are extremely common in chronic hypocalcemia.
* *The Scalp Numbness/Pain and Muscle Cramps:* These can be symptoms of tetany, a consequence of low calcium.
* *The history of "lockjaw"* could have been trismus (jaw stiffness) from tetany.
*This is a potentially life-threatening electrolyte imbalance that is completely separate from her thyroid issue but is causing the most dramatic and debilitating symptoms.*
### What This Means for Management
1. *Thyroid Dose:* The debate between 100 mcg and 112 mcg becomes *secondary*. The primary focus must shift to correcting calcium and phosphorus levels. Once her calcium is normalized, her perception of her thyroid medication's side effects ("uneasiness") may completely resolve.
2. *Treatment:* If hypoparathyroidism is confirmed, she will need:
* *Active Vitamin D analogs* (like Calcitriol) to help absorb calcium.
* *Oral Calcium Carbonate or Citrate supplements.*
* Treatment is lifelong and requires careful monitoring to avoid both low calcium (causing seizures) and high calcium (damaging kidneys).
*Conclusion:*
Dr. Singh provided the crucial clue. *Finding the PTH test result or performing it now is the master key to solving this case.* This is not just another test; it is the likely explanation for her neurological and psychiatric crisis. All efforts should be focused on this immediately. Managing the hypothyroidism is straightforward once this far more disruptive metabolic problem is identified and treated.
[12-09-2025 09:03] PPM 2: Now under care of PMR AIIMS Bhopal, I shall request them๐๐ป
[12-09-2025 09:07] PPM 2:: @PA
เคจเค 25mcg เคเคชเคी เคोเคฒी เคा เคชเคค्เคคा เคฒाเค,
เคเคธเคฎें เคธे เคเคงी เคोเคฒी 100mcg เคे เคธाเคฅ เคฆो,
30 เคोเคฒिเคฏां 60 เคฆिเคจ เคเคฒेเคी
เคญाเค เคฆूเค เคे เค
เคเคฒे เคฆिเคจ TSH เคเคฐाเค เคเคฐ เคฐिเคชोเคฐ्เค เคเคข़ाเค
[12-09-2025 09:09] PPM 2: @PA เคชुเคฐाเคจे Parathormone report เคฌเคคा
[12-09-2025 09:12] PPM 1: ๐if this breakthrough LLM suggestion turns out to be true then it would be another breakthrough AI user driven healthcare paper @PPM2 @PPM4 @PPM5 @PPM6
1. เคเคฌ เคเคธा เคนो เคคो เคตीเคกिเคฏो เคฌเคจा
2. EEG เคเค เคฌाเคฐ เคเคฐ เคฒो
[15-09-2025 08:58] PPM 5: Yes sir
[15-09-2025 08:58] PPM 5: Waiting for PTH levels
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