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Diagnosis case diary
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Provisional Diagnosis - Iatrogenic thyrotoxicosis IGT Spondyloarthritis/Osteopenia
Final Diagnosis - Granulomatous Cervical L.adenitis On ATT wef 16/11/11 Iatrogenic thyrotoxicosis Spondyloarthritis/Osteopenia IGT
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
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
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
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
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
Final Diagnosis-Toxoplasmosis(Cervical L.adenitis-Biopsy)
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
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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
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
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Provisional Diagnosis - Ac Pyelonephritis Lt ?Ac choletcystitis To r/o Renal Tuberculosis
Final Diagnosis - Ac Pyelonephritis Lt Urine AFB culture automated-Pending
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
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
Treatment - .Zanocin OD 400mg 0-0-1 x 6wks,Tab.Dolo 650mg 1sos,Ct Foracort Inh & Amlodipine as before
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
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
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Provisional Diagnosis-IgE mediated food allergy Chr fatigue syndrome to r/o Addison's
Final Diagnosis-Chr fatigue syndrome IgE mediated food allergy
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
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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 ++
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
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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
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
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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
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
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