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Diagnosis case diary
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Provisional Diagnosis-Hypothyroidism/Thyroiditis Polymyositis to r/o Multiple Myeloma
Final Diagnosis-Polymyositis(Biopsy proved) Lymphocytic thyroiditis Iron Def anemia
History and Findings-Polyarthritis x 4months,Pain back interscapular area Thyromegaly Rt lobe Wt-44k
Investigation-Hb-8.19,ESR-62,HBA1c-5.2%,creat-0.7,Uric acid-5,Ca-8.6Iron-33.7,Ferritin-162.29,A/g-3.47/4.66,CRP-22.74,TSH-5.23,TPO-30.28 & ATG-54.85(Both high),RAF-Neg,ECG-Normal,CXR-cardiomegaly,Echo-Normal study, FNAC thyroid-lymphocytic thyroiditis,Serum protein EP-No M Band,ANA IFA-+++ Anti Jo antibody +ve,Anti SEL 70 ,Anti RNP +++,Anti SM +ve,ds DNA-Neg,Ck-253,Muscle biopsy(NIMHANS)(No-X3382/11)24/10/11-Inflamatory myopathy with vasculitis(Delay in biopsy & Rx since pt went for ayurvedic trial at ottapalam in between)
Treatment-Thyronorm/Fefol Z/Pan D wef 15/6/11 Wysolone/Milical/Azoran wef 7/12/11(After pt returned leaving ayurvedic trial).
Follow Up-
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Provisional Diagnosis - Moderately severe anemia+renal failure Family h/o early CRF & Dialysis ?Inherited kidney disease
Final Diagnosis -
History and Findings - Tiredness,carpelspasm,leg cramps x 1 1/2yrs H/o Anemia (7g) during pregnancy 3yrs back Family h/o CRF (Father-died at the age of 40yrs after dialysis for CRF x 2yrs). O/e Wt-46k BP-130/80 DNS++Lt Thyyroid N,Pallor++ No Palpable kidneys No facial/Pedal edema
Investigation - Hb-7.9g,Low MCV low MCH,ESR-30,Plat-389.0,Retics-0.49%(low),Absolute retics-14(Low),urine 4-6PC/HPF,BU-115,S.Creatinine-5.5,uric acid-7mg,Ca-9mg,Phos-6.9,Na-132.7,K-4.6,HBA1c-5.8%,A/g-4.65/4g,ALP-67.6,LDH-173.5,Iron-97,Ferritin-53.65,ATg-65.38 normal <4.11,PO-1.36,Lipids normal,24 hr urine protein-247.8,ANA IFA-Neg,C3-86.45(N),C4-25.58(N),ds-DNA-15.1(Neg),Urine Na-51.4,Stool OB/Fat-Neg,ASO-neg,P.Smear-Notmocytic normochromic anemia,C-ANCA,P-ANCA-Neg USG abd-RK 9.9x4cm parenchyma 15mm LK-10.3x4.9cm,Parenchyma 19mm Increased B/l cortical echoes,poor corticomedullary differentiation,multiple simple cortical cyst 8-9mm B/l impression:Chr Renal Parenchymal disease with secondary cystic changes Inv pending-Eye examination for retinitis pigmentosa,Lentoconus & for vasculitis changes/Uremic retinopathy ENT-Puretone audiogram 24 hr urine Ca oxalate
Treatment - Advised-Nephro consultation & Renal biopsy
Follow Up -
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Provisional Diagnosis-Moderately severe anemia+renal failure Family h/o early CRF & Dialysis ?Inherited kidney disease
Final Diagnosis-
History and Findings-Tiredness,carpelspasm,leg cramps x 1 1/2yrs H/o Anemia (7g) during pregnancy 3yrs back Family h/o CRF (Father-died at the age of 40yrs after dialysis for CRF x 2yrs). O/e Wt-46k BP-130/80 DNS++Lt Thyyroid N,Pallor++ No Palpable kidneys No facial/Pedal edema
Investigation-Hb-7.9g,Low MCV low MCH,ESR-30,Plat-389.0,Retics-0.49%(low),Absolute retics-14(Low),urine 4-6PC/HPF,BU-115,S.Creatinine-5.5,uric acid-7mg,Ca-9mg,Phos-6.9,Na-132.7,K-4.6,HBA1c-5.8%,A/g-4.65/4g,ALP-67.6,LDH-173.5,Iron-97,Ferritin-53.65,ATg-65.38 normal <4.11,PO-1.36,Lipids normal,24 hr urine protein-247.8,ANA IFA-Neg,C3-86.45(N),C4-25.58(N),ds-DNA-15.1(Neg),Urine Na-51.4,Stool OB/Fat-Neg,ASO-neg,P.Smear-Notmocytic normochromic anemia,C-ANCA,P-ANCA-Neg USG abd-RK 9.9x4cm parenchyma 15mm LK-10.3x4.9cm,Parenchyma 19mm Increased B/l cortical echoes,poor corticomedullary differentiation,multiple simple cortical cyst 8-9mm B/l impression:Chr Renal Parenchymal disease with secondary cystic changes Inv pending-Eye examination for retinitis pigmentosa,Lentoconus & for vasculitis changes/Uremic retinopathy ENT-Puretone audiogram 24 hr urine Ca oxalate
Treatment-Advised-Nephro consultation & Renal biopsy
Follow Up-
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Provisional Diagnosis-Dyspepsia/Wt loss/upper ab pain/vague mass epigastrium ?GI Malignancy
Final Diagnosis-Adenocarcinoma pancreas with liver METS
History and Findings-SHTN x 1yr,dyspepsia x 2months,upper abd pain,retrosternal burning x1month,Wt loss 60kg-51kg in 2months. O/e vague mass epigastrium tender
Investigation-Hb-10.5,ESR-20,HBA1c-5.8%,S,Creatinine-1.4,Amylase-49.3,Lipase-40,CRP-1.45,CA 125-51.6,CeA-76.33,25(OH)Vit D-19.15,Stool fat +ve,OB neg,OGD scopy 18/11/11-Hiatus hernia,Colonoscopy same day normal study.MDCT abd contrast & CA 19-9 on 18/11/11 scan shows an ill defined irreular marginate mildly enhancing lesions in body & tail of pancreas with proximal dilatation of main pancreatic duct with multiple peripherally enhancing lesions noticed in both lobes of liver s/o METS (CA 19-9)5430.5
Treatment-Referred to RCC TVM on patients request for tissue diagnosis & management
Follow Up-
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Provisional Diagnosis-ITP ?Thrombocytopenia secondary to Hypersplenism Thyroid nodule evaluation to r/o malignancy Work up for inherited thrombophilia
Final Diagnosis-Extra hepatic portal vein obstruction(EHPVO) Portal hypertension & Hypersplenism Papillary carcinima thyroid(S/p Total thyroidectomy) Vit D Def Neurasthenia
History and Findings-Referred by Dr.Pavithran Prof Med oncology A k/c/o ITP on management from CMC Vellore(age 17-27) & from TVM MCH by Dr.Pavithran from age 27 onwards.Off steroids since 2004 h/o Gen Oedema/polyarthritis/Polymyalgia/DOE class II,snoring,sllep apnoea,recurrent throat infection x 4yrs.Past H/o B/l renal calculi & obstructive hydroureteronephrosis in 2006.Ureterolithotomy Rt on 25/08/06 Wt-104kg BMI-37.3,Thyroid nodule Lt lobe+
Investigation-Hb-12.8,ESR-28,plat-150.0,uric-5.9,HBA!c-5.3,LFT N 25(OH)vit D -14.18,IgE-147,TSH-2.03,ATg-0.82,TPO-0.30,ANA-Neg,ACE-53(N),Cortisol-10.1,CA-125-12,CEA-1.94,APLA IgM,IgG-N,AFP-3.38,CA 19-9-21.48,Beta HCG <1.20,PT with INR APTT-n,Thrombophilia work up normal,MDCT abd contrast 04/04/11-Liver volume redistribution with hypertrophy of caudate lobe,no IHBRD,few nodules s/o hemangioma,splenic & portal vein not visualised.Splenic artery aneurysm & multiple spleno renal collaterals,splenomegaly 15mm s/o extrahepatic portal vein obstruction & PHTN OGD scopy 06/04/110-No varices severe Portal hypertensive gastropathy.FNAC Thyroid Lt Lobe 06/04/11-S/o Papillary carcinoma Total thyroidectomy done on 28/04/11(HNS dept).HPR Papillary thyroid carcinoma Lt lobe,no nodes identified
Treatment-On I 131 therapy followed by oral LT4 Oral calcium & calcirol,Zosert,Evion,Razo D
Follow Up-Pt doing well on treatment
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Provisional Diagnosis-ITP ?Thrombocytopenia secondary to Hypersplenism Thyroid nodule evaluation to r/o malignancy Work up for inherited thrombophilia
Final Diagnosis-Extra hepatic portal vein obstruction(EHPVO) Portal hypertension & Hypersplenism Papillary carcinima thyroid(S/p Total thyroidectomy) Vit D Def Neurasthenia
History and Findings-Referred by Dr.Pavithran Prof Med oncology A k/c/o ITP on management from CMC Vellore(age 17-27) & from TVM MCH by Dr.Pavithran from age 27 onwards.Off steroids since 2004 h/o Gen Oedema/polyarthritis/Polymyalgia/DOE class II,snoring,sllep apnoea,recurrent throat infection x 4yrs.Past H/o B/l renal calculi & obstructive hydroureteronephrosis in 2006.Ureterolithotomy Rt on 25/08/06 Wt-104kg BMI-37.3,Thyroid nodule Lt lobe+
Investigation-Hb-12.8,ESR-28,plat-150.0,uric-5.9,HBA!c-5.3,LFT N 25(OH)vit D -14.18,IgE-147,TSH-2.03,ATg-0.82,TPO-0.30,ANA-Neg,ACE-53(N),Cortisol-10.1,CA-125-12,CEA-1.94,APLA IgM,IgG-N,AFP-3.38,CA 19-9-21.48,Beta HCG <1.20,PT with INR APTT-n,Thrombophilia work up normal,MDCT abd contrast 04/04/11-Liver volume redistribution with hypertrophy of caudate lobe,no IHBRD,few nodules s/o hemangioma,splenic & portal vein not visualised.Splenic artery aneurysm & multiple spleno renal collaterals,splenomegaly 15mm s/o extrahepatic portal vein obstruction & PHTN OGD scopy 06/04/110-No varices severe Portal hypertensive gastropathy.FNAC Thyroid Lt Lobe 06/04/11-S/o Papillary carcinoma Total thyroidectomy done on 28/04/11(HNS dept).HPR Papillary thyroid carcinoma Lt lobe,no nodes identified
Treatment-On I 131 therapy followed by oral LT4 Oral calcium & calcirol,Zosert,Evion,Razo D
Follow Up-Pt doing well on treatment
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Provisional Diagnosis-PUO/Mediastinal L.Adenopathy/B/l lower lobe collapse consolidation,High ESR,CRP,ulcerative Mantoeux(ATT Emperical) Hypothyroidism/Thyroiditis Spondyloarthritis/Vit D def?Poncet's disease Liver dysfn(NASH)-liver biopy not done
Final Diagnosis-Tuberculous L.Adenitis (Mediastinal) Thyroiditis Spondyloarthritis/Vit D def NASH
History and Findings-Referred by Dr.Pavithran,Prof Med Oncology Fever >2weeks,Polyarthritis,skin nodules,one episode of syncope on 5.03.11.Past h/o polyarthritis from age 21 not evaluated,h/o migraine
Investigation-Hb-14.3,ESR-52,Pre op serology(HBSAg,anti HCV,HIV)Neg,CRP-205.6,Corrected ca-9.4,creatinine-1mg,ANA neg(0.47),ds DNA-3.7(Neg),GGT-99.8,SGOT-63.8,SGPT-82.5,ALP-92.6,HbA1c-6,4,TSH-4.90,FT4-0.82,RA & ASO neg,LDH-264,Ck-35.5,CK MB-10.9,Na-135,k-4.9,c3-202,C4-64.4,SA-0.620,TPO-3131.2,ACE-27,Uric acid-6.4,Mg-1.8,Anti CCP <0.05 25(OH)Vit D-8.68,HLA B 27 Neg,24hr urine uric acid-472.7,ASCA IgA-6.57,FNAC Thyroid-Hashimottos thyroiditis,IgM Brucella Neg,IgM Mycoplasma-Neg,ECG-Wnl,cxr-Bronchovascular markings Rt base Lt hilar shadow Lt basal patchy haziness.CT chest HRCt 14/03/11-Mediastinal lymph adenopathy B/l segmented basal collapse consolidation.toxoplasma IgM Neg,Bronchoscopy didnot reveal any obvious lesion BAL Cytology Neg for malignancy,AFB Neg,Smear-No atypical cells,Biopsy no granuloma,BAl AFB culture neg for AFB after 6weeks.OGD & Colonoscopy 31/03/11-Normal,Mantaeux strongly +ve & ulcerative,ATT emperically started on 23/02/11 modified regime in view of altered LFT.Repeat CT Chest HRCT 30/4/11-Collapse consolidation resolved mediastinal nodes regressing in size ATT ctd for total 8months with complete remission.Repeat CT chest HRCT on pts arrival from Gulf-Full regression on L.Nodes with mild hepatomegaly Hb-14.8,ESR-16,TSH-6.94,TPO-3328,HBA1c-5,6%,SGOT-57.5,SGPT-75.1,CRP-1.18
Treatment-Inj.Amikacin 750mg IV odx 5months & A/D x 2 months Ethambutol x 8months,Clarythromycin bd x 6months INH reintroduced after LFT became normal with B6,Udiliv,LT4,Citromacalvit,Calcirol,HCQS & Leflunamide
Follow Up-Pt became asymtomatic except for mild spondyloarthritis & mild transaminitis.He is advised to ct Thyronorm,Citromacalvit,HCQS 7 Lefra
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  Provisional Diagnosis - Raynaud's Lt UL ?Thoracic outlelt obstruction yndrome ?Vasculitis Liver Dysfn ?Auto immune
 
  Final Diagnosis - Cryoglobulin induced Raynaud's LUL HCV infection
 
  History and Findings - Shock like pain Lt UL paroxysmal in nature s/o Raynaud's x 12yrs.H/o jaundice 3 epidodes in ths past & also in the family.Premarietal sex+,non alcoholic.MRI LS spine 5/4/11 diffuse annular disc bulge L4 L5,L5 S1 MRI Cervical spine 5/5/11 normal,MRI Brain normal
 
  Investigation - Hb-16.2,ESR-14,platelet-349.0,CRP-2.26,Creat-1mg,uric-6.3,ca-9.7,P-4.24,GGT-153.1,SGPT-120.6,SGOT-47.5,A/g-4.64/3.4,ALP-84,Ck-350.3,TSH-1.88,ATg-0.91,TPO-1,26,HbA1c-5.8%, ANA-neg,ceruloplasmin-38.12(normal)Fe-173.89,HBSAg,anti HCV,HIV screen neg,VDRL NR,TPHA neg,Doppler neck vessel normal,Doppler Lt UL arteries normal,USG neck normal,Cryoglobulins +ve,ECG-Wnl,cxr-Normal,anti HCV ELISA Neg,HCV RNA PCR qualitative+ve,HCV viral load quantitative < 15 +ve
 
  Treatment - Ecospirin/UDCA/Silymarin
 
  Follow Up - Pt asymptomatic/LFT improving
 
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Provisional Diagnosis-Obesity/DLP/Hyperuricemia ?Insulinoma ?Diabetes Insipidus
Final Diagnosis-Psychogenic Polydypsia vit D def
History and Findings-Polyurea,Polydypsia,increased appettite,burning abdominal pain,Sleep disturbance,lethargy,snoring 11yrs duration Wt-89kg BMI-31,acanthosis nigricans+
Investigation-Hb-15.6,ESR-22,HbA1c-5.8%,A/g-4.57/3.44,ALP-69,FBS-83.9,Total Insulin-22.7,serum PTH-90.1(15-68 normal),Serum.Gastrin-162(normal upto 100),Serum.Amylase-56,Lipase-29,urine amylase-88,Creatinine-1.1,Ca-1.4,P-3.8,PSA-2.924,TSH-2.17,25(OH)Vit D-15.54,S.Osmolality-335,urine osmolality-547,Na-141.K-4.3,ECG-Wnl,Cxr-N,MRI Brain-15/09/11-No mass lesion in pituitary region
Treatment-Doxepin/Metformin/Calcirol sachets
Follow Up-
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Provisional Diagnosis-Reactive Hypoglycemia Dyslipidemia Hydradenitis suppurativa GERD
Final Diagnosis-Coeliac disease Reactive Hypoglycemia Hiatus Hernia Hydradenitis suppurativa
History and Findings-Recurrent Hydradenitis axilla,Reactive Hypoglycemia ,Recurrent oral aphthi,High uric acid,reflux symptoms-Chronic OGD 10/05/09-Duodenitis,CLO Neg Colonoscopy 12/06/09-Internal Hemorrhoids
Investigation-Hypertryglyceridemia(481.8)/Hyperuricemia/HbA1c-5.4%,LFT normal,FBS-97.7,Total insulin-9.7 normal 3-35,GRBS 3hr 60mg/dl with hypoglycemic symptoms repeat OGD scopy 19/09/11-hiatus hernia D2 biopsy report 20/09/11-Mild increase in Intra epithelial Lymphocytes 25-30/100 tTg- IgA-11.3+ve (normal < 8) Diagnostic of Coeliac disease
Treatment-Gluten free diet,Acrbose,Mega 3 capsule,Liposem
Follow Up-
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