Diagnosis case diary
| Provisional Diagnosis | - | Iatrogenic thyrotoxicosis IGT Spondyloarthritis/Osteopenia |
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| Final Diagnosis | - | Granulomatous Cervical L.adenitis On ATT wef 16/11/11 Iatrogenic thyrotoxicosis Spondyloarthritis/Osteopenia IGT |
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| History and Findings | - | Hypothyroidism on Rx LT4 150mcg od last 3yrs.wt loss 72 -62kg,tiredness,body aches,bone pains since 3yrs O/e BP-130/80,Bipedal edema,tachycardia,C.L nodes + non tender,Gr 1/6 ESM at LBA,varicose veins ++,Joints-OA knees shoulders |
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| Investigation | - | Hb-11.3,CRP-1.06,ESR-60,HBA1c-6.7%,FBS-122.7,TSH-0.01,FT3-1.69,TPO-58.96,Blood urea-25.2,creat-0.8,uric-5.3,ca-9.3,P-3.5,A/g-3.59/3.7g,RA-neg,25(OH)vit D-14.73,BMD-Osteopenia,P.Smear-Normocytic normochromic,Skeletal scintigraphy-Hot spots dorsal & lumbar vertebrae-degenerative,L node biopsy AC-2451/11-Granulomatous L.adenitis |
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| Treatment | - | Cap.Rcinex 600 1-0-0,Ethambutol 1000mg 1-0-0,Tab.Benadon 40mg 1/2-0-0,Tab.Risophos 35mg wkly once,Calcirol sachets 1gm in milk wkly once,Tab.Shelcal 0.5g 1-0-1,Tab.Razo 20mg od cm ,Tab.Durajoint GM 0-0-1,Cap.Fefol 0-0-1 x 2months |
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| Follow Up | - | R/a 2 months with LFT/GGT/uric acid/TSH |
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| Provisional Diagnosis | - | Basilar Migraine
?Hyperviscosity syndrome
Neuromyasthenia
Vit D def state | |
| Final Diagnosis | - | Basilar Migraine/Hyperviscosity syndrome
Neuromyasthenia
Vit D def state | |
| History and Findings | - | Referred from Adm office AIMS
Recurrent syncopal episodes >30yrs
H/o headache along with diziness
Previous units
ENT 10/12/10 Rt ear SNHL-minimal,Lt ear-SNHL Mod severe
cardiology-CAG 29/07/05-normal coronaries
Bronchial asthma from age 24 on inhalers from Pulmo
Neurology 12/3/10-NCV normal,3 hr video EEG 4/12/10-N study
GE Med 1/4/04-OGD Normal
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| Investigation | - | Previous Inv:MRI brain with MRA 03/12/10-N study
Electrolytes/LFT/ANA/ACLA(Anti cardiolipine ab),TSH,Hb all normal
Present Inv:Hb-12.6,ESR-36.CRP-1.23,Ca-8.8,P-3.9,TSH-0.46,TPO-2.70,ATg-23.19,HBSAg,anti HCV-Neg,Cryoglobulins-Neg,A/g-4.25/4g,ALP-89.9
ECG-WNl,Echo-25/04/11-N study,25(OH)vit D -9.16,Beta 2 microglobulin-2.93,IgE-1373.72 Other immunoglobulins-N(0.24-1.98) | |
| Treatment | - | Tab.Sibelium 5mg 0-0-1,calcirol sachets + oral Milical,Tab.Fiona 60mg 0-0-1,Tab.Nortryptillin 25mg 0-0-1 increased to 0-0-2 wef 08/08/11,Tab.Montelukast
Ct inhalers as before. | |
| Follow Up | - | No further episodes of syncope
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| Provisional Diagnosis | - | Nonocaseating Cervical L.adenopathy
?Toxoplasmosis?Sarcoidosis
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| Final Diagnosis | - | Toxoplasmosis(Cervical L.adenitis-Biopsy)
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| History and Findings | - | Case referred by Dr.Pavithran Prof.Medical oncology
H/o recurrent throat pain,sputum+,voice change frequently since last 12yrs.H/o Lt sided postr C.L.adenopathy x 1month.Pain Lt shoulder x 1month
Family h/o Sisterx 1-Tuberculosis
O/e Pharyngitis++,Post nasal secretion +,Halitosis+ | |
| Investigation | - | CRP-1.95,Hb-13.7,ESR-10,WBC,Plat-N,ca-8.7,A/g-4.7/3.5,LFT-N,LDH-198.5,Tox IgM 16/03/11+ve (2.362),Brucella IgM Neg,ACE-44 (N),pre op serology(HIV,anti HCV,HBSAg)-neg,Cxr-Rt basal cystic changes,Xray PNS-Max sinusitis B/l,C-ANCA-neg,Mx-Neg,Histopathology C.L Node S11-2290-No Caseating microgranulomas possibility of toxoplasmosis,ENT consultation for nasal endoscopy | |
| Treatment | - | Tab.Rovamycin forte x 6weeks (spiramycin) | |
| Follow Up | - | R/w 03/06/11-Pt asymptomatic
HadENT Rx for sinusitis | |
| Provisional Diagnosis | - | SHTN/Amlo induced edema
Rt Hemicrania (Trigeminal Neuralgia)
?Temporal arteritis
Osteopenia | |
| Final Diagnosis | - | Trigeminal Neuralgia(Inadequate Rx)
SHTN
Vit D Def state
GERD
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| History and Findings | - | Referred by Dr.Rahul Laxman (Pain & Paliative AIMS)
H/o Rt Hemicrania,bone pains,bipedal edema of long duration.K/c/o SHTN on Rx,trigeminal neuralgia x 30yrs no relief on Rx | |
| Investigation | - | Previous inv:MRI Brain 15/1/04-N study,pre op serology-neg,CAG 06/06/06-N study,CT Brain 27/10/07-N study,MRI c spine 03/05/08-Diffuse disc bulge C5,C6,Pap smear Dec 2009-Neg for malignancy,CT Brain Oct 2010-N study,A/g-3.9/2.7,TFT-Normal,RBS-179,Hb-12.5,ESR-30.
present Inv:Hb-11.6,ESR-36,uric-5.5,HBA1c-6%,Ca-9.1,P-3.9,Ck-138,25(OH)vit D-10.92,S.B12-1161,Alb-4.22,Glob-3.26,Total chol-231,Tg-213,LDL-148,HDL-39,urine RE-Blood 1+,8-10 RBCs/HPF,HBSAg Neg,Doppler study temporal arteries-N study,OGD scopy 17/0/11-LA-A esophagitis,Pangastritis | |
| Treatment | - | Rx before present consultation Tab.Ultracet,Imipramine,Evion,Dom DT,Amlong,Gabapentin,artificial saliva
Present Rx:stop Amlodipine & Gabapentin
Tab.Telma 20mg od,Tab.Pregabalin 75mg 0-0-1 increased to 1-0-1,carbamazepine (Mezetol)added subsequently increased to 200mg 1/2-1/2-1,Calcirol sachets 1gm in milk wkly once for 3months & then once monthly,Milical 1000mg 0-0-1,Tab,Pan 40mg od before food | |
| Follow Up | - | Pt V.neuralgia & RT hemicrania improved remarkably with normal sleep & bone pains responded to calcirol & oral calcium | |
| Provisional Diagnosis | - | Ac Pyelonephritis Lt ?Ac choletcystitis To r/o Renal Tuberculosis |
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| Final Diagnosis | - | Ac Pyelonephritis Lt Urine AFB culture automated-Pending |
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| History and Findings | - | Case worked up at GVR Sat clinic on 12/11/11 & later investigated in AIMS H/o Fever around 101*F since 4months,one episode of hematuria.LUTS+,h/o br asthma since 7yrs on inhalers,K/c/o SHTN on Amlodipine 5mg od. past PTB 1988 fully Rxd. Exam revealed tenderness Lt kidney on ballotable test |
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| Investigation | - | ESR-120,Hb-11.6,CRP-23,Urine ACR-1816mg/g,BU-25mg,S.creat-1.27,LFT/GGT-N,Urine Alb +,Gr cast + Dengue IgM & Brucella IgM neg,ANA-Neg,C-ANCA,P-ANCA Neg,PSA-1.1,S.Protein EP-Neg,IgG-1650,IgA-516,IgM-101,Urine BJ protein Neg,IVU study-consistent spasm upper pole calyx Lt kidney clubbed calyx,DMSA scan on 12/12/11-No e/o any cortical scar B/l kidneys to suggest chronic Pylelonephritis,HIDA scan 13/12/11-Preserved hepatobiliary function,no e/o acute/chronic cholecystitis.ECG-Wnl,Cxr-Increased BVm Rt base,urine culture no growth,blood culture-no growth,widal-Neg,MP MF Neg,USG abd-Cholelithiasis,multiple stones largest 6.4mm,fatty liver,Mantoux-Neg,urine AFB culture-pending,urine cytology-Neg,Xray L S spine-spondylitis |
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| Treatment | - | .Zanocin OD 400mg 0-0-1 x 6wks,Tab.Dolo 650mg 1sos,Ct Foracort Inh & Amlodipine as before |
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| Follow Up | - | Pt afebrile 2 wks after starting antibiotics 12/12/11 ESR-60 started attending daily office work R/w with urine AFB culture |
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| Provisional Diagnosis | - | Congenital Rubella syndrome
Post Viral Demyelination
Hypothyroidism/Thyroiditis
T2DM
Iron def anemia/Vit D def state
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| Final Diagnosis | - | Post viral demyelination/Hashimottos Encephalopathy
Hypothyroidism/Thyroiditis
T2DM
Iron & Vit D Def state | |
| History and Findings | - | Photocopy machine work with amma in Vallikavu
H/o Chr cough,scanty sputum
DOE class II last 6months
snoring ++
Day sleepiness ++ for yrs
Deaf & dumb from birth(congenital rubella syndrome),
Speech improved on therapy.H/o PDA closure at 9yrs of age.Organic psychosis Nov/Dec 2008.H/o Hypothyroidism off Rx | |
| Investigation | - | Previous Inv:09/07/04-CT Brain-Demyelinating disease
?Glyomatous cerebral/SSPE.MRI Brain 12/07/04-Viral induced demyelination ?Rubella encephalitis,MRI brain 20/2/07-Viral demyelination,MRI Brain Nov 2009- lesions status quo,B/L symetric white matter hyperintensities.13/09/04 TSH-7.98,20/03/07-TSH-4.60,25/11/08-TSH-6.88,ATg-45.92,ESR-16,Hb-12.2
Present inv:Hb-10.3,MCV MCH low.ESR-22,P.Smear-Microcytic hypochromic anemia,FBS-118,GRBS-196,HBA1c-8.6%,Blood urea-18.2,S.creat-0.7mg,uric-6.1,A/g-4.27/3.3g,ALP-103,GGT-65,Ca-8.5,P-3.6,LFT-N,Ck-81.5,CK MB-8.5,LDH-293,IgE-60.67,CRP-5.01,TSH-14.86,FT4-0.95,TPO-1656.7,25(OH)vit D-5.66ng,C1 INH-17mg (N-11-26),Na-136,K-4.4,S.Iron-24.4,Fe-8.17,TIBC-432.3,ANA-Neg (0.27),ds DNA-22.1,stool fat +ve,OB Neg,ECG-Sinus tachycardia,Cxr-Cardiomegaly,Echo-No RWMA,mild MR/TR,EF-55%,urine RE-Nil | |
| Treatment | - | Diabetic diet.
Tab.Thyronorm 75mcg 1-0-0,Cap.Fefol z 0-0-1,Tab.Rantac 150mg 1-0-1,Cap.GLA 120mg 1-0-0,
Cap.Neuracetam 800mg 1/2-0-1/2,Glycomet SR 0.5g 1-0-0,Cap.Evion 400mg od | |
| Follow Up | - | Pt improving steadily with more mental alertness & able to work without break.Intellectual works better,attention & speech better,day time sleepiness markedly improved
23/06/11-TPO-769.92,Hb-15.3
15/10/11-HBA1c-7.1,TSH-3.62 | |
| Provisional Diagnosis | - | IgE mediated food allergy
Chr fatigue syndrome to r/o Addison's
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| Final Diagnosis | - | Chr fatigue syndrome
IgE mediated food allergy
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| History and Findings | - | H/o Tiredness,lack of allergy,sleepiness during day time especially after food.Occasional feverishness,brachialgia,Gen.oedema picture,paroxysmal palpitation since 1yr
DOE class II x 1month.H/o Lt Cervical rib on physiotherapy,TMT,Echo AIMS cardiology 03/06/10-N study,Chikun gunya July 2009.Ayurvedic Rx for all complaints for 5months from Jan-June 2010
O/e Wt-50kg,BP-100/80 lying,90/80 standing. | |
| Investigation | - | Prior inv in AIMS;FT4-1.15,TSH-2.97(1/06/10)
Dec 2009-RBS-97.2,urea-11.6,creat-0.8,LFT-n,Na-137,K-4.3,Ca-8.7,P-3.7,TSH-3.89,CRP-2.03,ESR-38,Hb-12.6,Cxr-N study
Present inv:Hb-12.1,ESR-28,RP-1.79,ASO <200,RA-Neg,Corrected ca-9.09,Cortisol-7mcg,Post synacthen cortisol-23.7mcg,ANA-0.25,TG IgA- <0.2 neg,Stool fat ++,OB-Neg,stool chymotripsin-13.6,C1 esterase(C1-INH)-17mg N 11-26,OGD scopy 2/07/10-LA-A esophagitis,deep D2 biopsy,colonoscopy-Normal,ileal biopsy.Both HPR-N study,no e/o dysplasia,granuloma,malignancy,malabsorbtion.IgE-845.2 Pulmo food allergy done | |
| Treatment | - | Diet chart avoiding knowm allergens
Cap.Doxepin 25mg 0-0-1 x 3wks & then 1-0-1 x to ct
Tab.Allegra 120mg 1-0-1,Tab.Rantac 150mg 1-0-1
Ensure 2 tsp bd x 3months
R/w after 3 months | |
| Follow Up | - | Pt improving well,no more sedation during day time,energetic,able to attend duties normally,no more angioedema,BP improved 130/80 both lying & standing
27/07/11-IgE-440.9,stool fat-Neg | |
| Provisional Diagnosis | - | Anemia (iron def)
Vit D def state
IgE mediated food allergy
IBD (Crohn's)
Neurasthenia | |
| Final Diagnosis | - | Crohn's disease
Iron & vit D def state
Neurasthenia
IgE mediated food allergy | |
| History and Findings | - | Chief Nursing Officer Incharge AIMS
H/o hypothyroidism 2006-2007 Off Rx after 2007
Anemia,Lack of energy,tiredness,plapitation-Chr
low grade fever x 2yrs
H/o Rx for enteric fever in 2008
Pain neck,brachialgia,eye strain,muscle spasm x 4yrs
Wt-61k BP-130/80
Features of Neurasthenia ++
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| Investigation | - | Inv earlier-MDCT abd/Thorax/Pelvis 24/08/07-N study
MRI Brain 24/08/07-N study,CT Neck 3/12/07-early spondylitis,multiple L.Nodes (Benign),MDCT Thorax 03/12/07-Small pleral tagging,postr basal segment Lt,USG abd-13/06/08-N study,MDCT abd 18/06/08-Bulky ovaru with follicular cyst,colonoscopy & rectal biopsy 12/07/08-Multiple aphthoid ulcers in rectum,biopsy unremarkable,BMFT study 18/07/08-N study,Echo-21/06/08-MVP with AML prolapse
Present Inv:Hb-9.76,ESR-62,MCV & MCH low,stool fat +ve,OB NegS Iron-19.9,fe-7.44,ALP-84.3,Stool chymotripsin-14.1,25(OH)vit D-4.96,S PTH-109.7,Corrected ca-8.6,P-2.3,IgE-406.2,food allergy pulmo done,Urine CCR-0.03,CK-47.4,ASCA IgA-38.5 normal <20,CRP-7.73,ECG-WNl,CXr-increased BVm Rt base C.Spine-C.Spondylosis | |
| Treatment | - | calcirol sachets,Citromacalvit,Dexorange,
Tab.Mesacol,Folvite,Rantac,Cap.Doxepin,Tab.allegra+
Ensure | |
| Follow Up | - | 08/09/10-CRP-6.04,ESR-40,Hb-10g
15/11/10-Hb-10.6
14/5/11-Hb-10.1,ESR-40
07/1/11-CA-125-22.5(N),CRP-5.65,ESR-46,hb-11 | |
| Provisional Diagnosis | - | Cystic lung Disease (from childhood)
recurrent sinoBronchial Infection
Fat Malabsorbtion
?cystic Fibrosis/CFTR mutation study pending
Marfan syndrome | |
| Final Diagnosis | - | Cystic Fibrosis(Recurrent URTI & LRTIs,Cystic Lung Disease & Exocrine pancreatic dysfn),CFTR pending
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| History and Findings | - | Final year MBBS student Karakkonam MCH TVM
Recurrent fever,headache,sinus & throat infection,hyperactive airways,Br asthma,recurrent LRTIs,MVP,AF induced by terbutaline ,C4 cytoenia,Polymyalgia,Polyarthralgia since early childhood.
Under wt-43kg,high arched ppalate,arm length-180cm Ht-169cm,Marfanoid features ++ | |
| Investigation | - | Hb-17g,ESR-2,Creat-1mg,A/g-4.9/3.2g,PT with INR-2.4,APTT-31.8,ACE-34.2,Cortisol-14.72,Stool fat +ve,OB Neg,Stool chymotripsin-11.5(N >13.2)TTg IgG(Tissue Transglutaminase IgG)-Neg,Quantiferon TB gold assay(Gamma Interferon)-Neg,Mantaeux-neg,BMFT-Normal,PFT-Mixed dysfn pattern with minimal reversibility,Cxr-Chest emphysematous,Pul conus prominent,PNS-Mucosal thickenning Max antra,TSH-1.8,FT4-1.9,Aspergilla IgG-Neg,
CT Thorax-Minimal bronchiectatic changes B/l upper & loower lobes.IgG,IgM,IgA-Normal,Serum.Kappa,Lambda freE lite-N,ANA IFA-nEG,C-ANCA,P-ANCA-Neg,Rpt PT with INR(07/11/11)-1.05,APTT-31.9/32.2,S.Amylase-63.9,urine amylase-63.9,Serum Na-141,k-3.9,Cl-103,sweat Na-136.9(N <35)sweat Cl-112.2 (N <46),Vit A-22.9 (N 30-120),Vit D 23.18 (20-30 insufficiency),Echo-Normal chamber,trivial MR & TR | |
| Treatment | - | Chest physiotherapy,steam inhalation
Tab.Mucomix/Duolin & Budicorte Nebulization
Cap.Eldervit ZC,Cap.Evion,Tab.Pancreon,Tab.Montelukast | |
| Follow Up | - | With sputum culture both bacterial & fungal & CFTR mutation study | |
| Provisional Diagnosis | - | SHTN
Hypothyroidism
P.Neuropathy/Pan dysautonomia(ED,atonic bladder,Diarrhoea,Postural hypotension-Frequent falls)
Cardiomyopathy
Iron Def Anemia?Systemic AL Amyloidosis to r/o Carcinoids | |
| Final Diagnosis | - | Systemic AL Amyloidosis(Biopsy proved)
Hypothyroidism | |
| History and Findings | - | Senior project officer from Canada
A K/c/o SHTN since Jan 2010 General Medicine AIMS
P.Neuropathy Jan 2010 seen in AIMS Neurology
Hypothyroidism 3yrs on Rx
Hypertrophic Cardio Myopathy (HCM) Jan 2010 AIMS
Esophagitis/GERD evaluated in Gastro Med AIMS May 2010
Erectile Dysfn & urinary retention since May 2010
presented to mewith loose stools 20-25 times/day associated with tiredness,diziness,presyncopal epiosode with frequent falls,wt loss of 14kg over last 1yr.Admitted in 24/11/10 DOD:21/12/10
MDCT abd contrast 18/05/10-N study,Echo-12/05/10-Hypertrophic cradiomyopathy EF-60% | |
| Investigation | - | Postural Hypotension++,Hb-12.3-10.84,ESR-8,Blood urea-33.2,Creat-1.2,Caorrected ca-9.3,Mg-2mg,Na-135,K-4.6,A/g-4.10/2.2g,LFT/GGT-normal,Ck-64.4,CKMB-7.2,Uric acid-5.1,LDH-147.4,Retics-0.49%,serum.Amylase-66.1,lipase-90,S.iron-7.3,Fe-299.51,HBA1c-5.8,HIV,anti HCV,HBSAg-neg,VDRL-NR,TPHA-Neg,24 hr urine 5HIAA-neg,ACE-18 (N),beta 2 Microglobulin-3.1(High),C-ANCA,P-ANCA-Neg,ASCA IgA-5.24 Neg,IgA-99.65,IgG-785.42,IgM-26.91,S.Kappa free lite-26.95,Lambda-64.7(high,)urine ACR-7.9mg,Beta HCG-<1.20,AFP-0.80,CeA-1.94,PSA-0.565,Urine PBG-Neg,Cryoglobulins-neg,TSH-5.02,FT4-1.47,TPO-88.5,Cortisol-16.4,Urine culture-No growth,Blood culture-Sterile,Stool culture-no Enteropathogenic organism,USG abd-Prostate 20cc,PVR-500ml,OGD scopy-LA-C (GERD),Colonoscvopy-Caecum shows edematous mucosa with nodules.Biopsy 27/11/10-Non Caseating epithelioid granuloma,rectal biopsy-neg for amyloidosis,Echo-25/11/10-Thickenned ventrivular valve longitudinal contactility reduced,Gr I DD, consistent with HCM,Possibility of Amyloidosis.Cardiac MRI contrast 2/12/10-Mod concentric LV Hypertrophy,no features of Myocardial infiltrative desorder,BM aspiration 2/12/11-Cellular marrow with trileneage maturation,BM Biopsy-N,BMFT study-04/12/10-Gastro oesophageal reflux noted,Abd fat pad biopsy 10/12/11-Fibrofatty tissue with few vessel/No e/o inflamation or abnormal deposit,Congo red neg,MRI L-Spine-14/12/10-Early disc degeneration L4/5 & L5 S1,CT Chest contrast HRCT 20/12/10-Minimal central bronchiectatic changes in RML,repeat rectal biopsy 21/12/10-No e/o amylo noted,congo red stain & Kappa Lambda study neg for Amyloidosis & light chain deposition
Skin biopsy-LM & IF-No e/o Amyloidosis special stain(Congo red neg)IF IgG,IgM,IgA,C1q,C3,kappa,Lambda-neg
Urology studies-Significant PVR-500ml,Prostate normal,no e/o BNO,uro flowmetry,Cystometry confirmed atonic bladder for which they advised self catheterisation (CISC)
Neuro consultation-Severe autonomic dysfn considered autoimmune dysautonomia & IVIG 25g/day x 5d given with no benefit.Pt being from Canada schistomial IgG ab on19/12/10 <1.00 (neg),Serum TB IgM was Neg,S,Calcitonin<2pg/ml (Neg),Sural nerve biopsy (Lab no-s-10-13277 NIMHANS)24/12/10-12 nerve fascicles,2-3 of the endoneurial vessels show perivascular pink homogenous material resembling which on congored stain shows apple green birefringence.Kpal stain shows uniform ,selective small fibre loss.Few endoneurial vessels shows hyalinised walls as do the epineural arterioles which also exibit mild perivascular lymphocytic infiltrate.Neovascularisation os also noted
Impression;Amyloid neuropathy,sural nerve
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| Treatment | - | Case referred to medical oncology on 11/01/2011
Tab.Melphalan 5mg bd,Tab.Wysolone 40mg od x 4days to be repeated monthly wef 11/01/11
LT4 112mcg ,Fludrocortisone 100mcg,Bifilacbd,Folvite 5mg ,Lyrica 75mg bd,Nortryptillin 25mg bd,Fefol Z od,Norflox 200mg 1od,Cordorone 100mg 1od,Mododrin 2,5mg 1 sos,Loperamide 2mg TID,Domstal RD 1od | |
| Follow Up | - | since chromogranin A was high in KIMS Hospital TVM (during my leave)pt underwent octreotide scan with PET CT for carcinoids & MIBG scan to r/o Pheochromocytoma both at B'glore were N studies
R/w on 15/03/11-No episode of postural hypotension or syncope,frequency of stools controlled on Loperamide.BP-140/80 lying & standing,CRP-0.50,corrected ca-9.2,creat-1.1,Na-140.K-3.4,ESr-6,Hb-11.2
Continue same management.Pt fit to travel abroad & to join duty,Monthly inv & 3monthly tests as advised | |
