(a) A 25 year old female has presented to the medicine OPD with complaints of excessive tiredness, cold intolerance and menstrual…

Part (a)

(i) Thyroid Disorder The clinical presentation of excessive tiredness, cold intolerance, and menstrual irregularities (typically menorrhagia or oligomenorrhea) in a 25-year-old female is characteristic of Primary Hypothyroidism, most commonly caused by autoimmune thyroiditis (Hashimoto's Thyroiditis).

(ii) Cardiovascular Manifestations

| Parameter | Hypothyroidism | Hyperthyroidism | | :--- | :--- | :--- | | Heart Rate & Rhythm | Sinus bradycardia | Sinus tachycardia, Atrial fibrillation | | Blood Pressure | Diastolic hypertension (increased SVR) | Systolic hypertension, wide pulse pressure | | Cardiac Output | Decreased (reduced inotropy/chronotropy) | Increased (hyperdynamic circulation) | | Myocardial & Pericardial| Weak heart sounds, Pericardial effusion | Loud S1, flow murmurs, high-output failure | | Lipid Profile | Hypercholesterolemia, accelerated CAD | Decreased total and LDL cholesterol |

(iii) Pharmacological Management and Monitoring

• Hypothyroidism: Tablet Levothyroxine (T4) is the drug of choice, initiated at 1.6 µg/kg/day orally on an empty stomach 30–60 minutes before breakfast. Titrate dose by 12.5–25 µg every 6–8 weeks.
• Hyperthyroidism:
• Antithyroid Drugs (ATDs): Carbimazole/Methimazole (10–30 mg/day); Propylthiouracil (PTU, 100–300 mg/day, preferred in the first trimester of pregnancy and thyroid storm).
• Symptomatic control: Beta-blockers (e.g., Propranolol 20–40 mg thrice daily).
• Definitive therapy: Radioactive Iodine (¹³¹I) or total/subtotal thyroidectomy for refractory cases or toxic multinodular goitre.
• Monitoring Investigations:
• Hypothyroidism: Serum TSH (target: 0.5–2.5 mIU/L) measured every 6–8 weeks post-dose adjustment, then annually once euthyroid. Free T4 is measured in secondary/central hypothyroidism.
• Hyperthyroidism: Serum Free T4 and Free T3 measured every 4–6 weeks during ATD titration, as TSH may remain suppressed for months. Complete Blood Count (to detect agranulocytosis) and Liver Function Tests prior to and during ATD therapy.

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Part (b)

(i) Assessment and Classification (IMNCI for Young Infants aged 0–2 months) Assessment involves checking for the following danger signs: history of convulsions, fast breathing (≥ 60 breaths/min), severe chest indrawing, nasal flaring, grunting, hypothermia (<35.5^circC) or fever (≥ 37.5^circC), bulging fontanelle, umbilical redness extending to the skin or draining pus, extensive skin pustules (>10 or bullae), lethargy or unconsciousness, and inability to feed.

• Possible Serious Bacterial Infection (PSBI): Classified if any one of the following is present: convulsions, fast breathing, severe chest indrawing, grunting, fever/hypothermia, bulging fontanelle, >10 skin pustules or large bullae, umbilical redness extending to periumbilical skin, lethargy/unconsciousness, or not feeding well/unable to feed.
• Local Bacterial Infection: Classified if there is umbilicus red or draining pus (not extending to skin), or fewer than 10 skin pustules, without any PSBI danger signs.

(ii) Treatment Protocols as per IMNCI

• Possible Serious Bacterial Infection (PSBI):
• Give first dose of intramuscular antibiotics: Inj. Ampicillin (50 mg/kg IM) plus Inj. Gentamicin (5 mg/kg IM).
• Prevent hypoglycemia: provide expressed breast milk or 10% dextrose orally/nasogastrically.
• Keep the infant warm during transport (Kangaroo Mother Care/wrapping).
• Urgent referral to a First Referral Unit (FRU) or tertiary hospital.
• If referral is not feasible: Outpatient management with Inj. Gentamicin (5 mg/kg IM once daily for 7 days) plus oral Amoxicillin (50 mg/kg/day in 2 divided doses for 7 days).
• Local Bacterial Infection:
• Prescribe oral Amoxicillin (50 mg/kg/day divided into 2 doses) for 5 days.
• Apply topical 0.5% Gentian Violet to umbilical discharge or skin pustules twice daily.
• Advise the mother on home care, exclusive breastfeeding, and keeping the infant warm.
• Schedule a mandatory follow-up visit in 2 days.

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Part (c)

(i) Differential Diagnosis

1. Stevens-Johnson Syndrome (SJS) / Toxic Epidermal Necrolysis (TEN) Spectrum (Lamotrigine-induced; primary diagnosis given mucosal involvement, purpuric macules, bullae, and skin tenderness).
2. Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Syndrome.
3. Erythema Multiforme Major (often secondary to infections like HSV/Mycoplasma, with limited body surface involvement).
4. Autoimmune Bullous Dermatoses (e.g., Bullous Pemphigoid, Pemphigus Vulgaris).
5. Staphylococcal Scalded Skin Syndrome (SSSS) (less likely in adults; spares mucous membranes).

(ii) Management

• Immediate Drug Withdrawal: Promptly and permanently discontinue Lamotrigine; document adverse drug reaction.
• Supportive & Intensive Care:
• Admit to an ICU or specialised Burn Unit with sterile barrier nursing and strict thermoregulation (ambient temperature 30–32°C).
• Fluid and Electrolyte Management: Administer IV crystalloids (e.g., Ringer's Lactate) titrated to maintain a urine output of 0.5–1 mL/kg/hour.
• Nutritional Support: High-calorie, high-protein enteral feeding via nasogastric tube.
• Wound Care: Non-adherent dressings (e.g., petroleum gauze); avoid aggressive debridement.
• Organ-Specific Measures:
• Ophthalmology consult: Frequent preservative-free lubricant eye drops, topical antibiotics, and sweeping of fornices to prevent symblepharon and corneal scarring.
• Oral/Mucosal care: Antiseptic mouth rinses (chlorhexidine) and topical analgesics.
• Targeted/Immunomodulatory Therapy:
• Consider early administration of IV Immunoglobulin (IVIG) (2–3 g/kg over 3–5 days) or Cyclosporine (3–5 mg/kg/day) to arrest epidermal detachment.
• Systemic antibiotics only if clinical signs of secondary sepsis arise, guided by wound cultures. Avoid prophylactic antibiotics.