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Diagnosis case diary
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Final Diagnosis -
Ref to Cardiology CAG 24/9/09-DVD (LAD & Cx. Disease)-PTCA with stenting to LAD on
History and Findings - k/c/o syst.HTN/Dyslipidemia, not on Rx. Presented with EA Class II-III, TMT +ve, Doppler neck vessels & Echo N.9/9/09
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Provisional Diagnosis - k/c/o syst.HTN/Hypothyroidism on Rx./presented with Polyarthritis, vertigo, tinnitus, Head-ache, 2 episodes of pre-syncope & 1 episode of transient weakness Lt half recently. Invest.:- ESR 40, corrected Ca. 9.1, ANA +ve, anti RO 52+++, SS-A+++, SS-B+, ds DNA-ve, APLA-IgM & IgG-ve, anti TPO ? serum protein EP n., MRI brain with contrast N study, No e/o CP angle Tumour.
Final Diagnosis - 1.Sjogren’s syn
2.Auto immune thyroidits
3.Syst. HTN
4.TIA/vasculitis
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Provisional Diagnosis - k/c/o von recklingausen’s Type 1 presented with severe neck pain & radiculopathy both upper limbs. MRI cervical spine 4/8/09 consistent with von recklingausen’s Type 1 with multiple neuro fibronmata intradural, extra medullary with compressive cervical mylopathy.
Final Diagnosis - Ref to neuro surgery on 3/8/09 Procedure:- C4-TI Laminectomy/Excision of neurofibromata on 7/8/09
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Final Diagnosis - HLAB 27+ve, serum uric acid colonoscopy & Biopsy 30/7/09-s/o crohn’s MRI spine no e/o Ankylosing spondylitis X-ray foot-gouty arthritis
1.IBD with entropathic arthritis
2.Gouty arthritis
3.Steroid induced DM
Pt responded very well on zyloric & colchicines To continue Mesacol and folic acid. Re-evaluated 19/10/09 and 28/01/10, doing very well.
History and Findings - Ref. from GE med. k/c/o Ankylosing spondylitis (Hubli) &IBD(manipal Hospital)onsteroids/Metho trexate indomethacine, Meslamine(mesacol)/, Steroid induced DM non responding peripheral arthritis. ESR 62, CRP 56.6, ANA-ve,CEA & PSA N, skeletal scintigraphy N. BMFT 08/01/10-Duodenal and jejunal diverticuly. No other significant abnormality. Patient a symptomatic now.
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Provisional Diagnosis -
Final Diagnosis - 1.Sjogren’s syn.
2.Ac pancreatitis ? auto immune.
3.basilar migraine
improved on conservative management (GE med.)
History and Findings - k/c/o Sjogren’s syn./migraine diagnose by me in med. 1 OPD/presenting with Ac. Abd. Pain, fever, vomiting, admitted on 9/7/09 S.amylase 284.5, lipase 900, hypocalcemia.
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Provisional Diagnosis - ? hemochromatosis – A/G 4.5 : 3.5, SGPT 127, SGOT 228, GGT 104, PT with INR 0.92., serum ferritin 1698.58, Iron 192.8, TIBC-262.1 Transferrin saturation-73.5%
Final Diagnosis - Ref GE med. For liver biopsy on 7/7/09 HPR consistent with macro vesicular steatosis/ pearl’s highlights-Gr I? in iron stores. Genetics – Heterozygous for C282 y mutation in HFE Gene 01/08/09
History and Findings - Liver dysfn./HCM/OA knees
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Provisional Diagnosis - ? ALP still rising, transaminitis+.Chlamydia IgM ++, pain subsided on azithromycin followed by doxy, liver enzymes + ALP decreasing on Udiliv (dose increased to 300 mg bd.)
Final Diagnosis - CECT chest 31/8/09 outside-few nodular infiltrates Lt. UL/ regression of media stinal & abd. L. nodes.? Hepatomegaly small adrenal mass lt. 1.2 cm.,
1.Sarcodosisrecoveringon steroids (dose tapered).
2.chlamydial urethritis with Fitz-Hugh-curtis syn.
3.Granalomatous hepatitis recovering on Udiliv (hence liver biopsy deferred)
History and Findings - k/c/o Sarcoidosis on steroids (pulmo AIMS) since one yr. Ref.GE med. For evaluation. 1. liver disfn.(SGOT/SGPT/ALP rising). Gilbert’s syn. Detected since 4 yrs., h/o bloody Ejaculations for 1 yr. 2004-05, followed by Uveitis., now having abd pain RUQ
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Provisional Diagnosis - ? carcinoid syn.
Final Diagnosis - 24 hours. Urine 5 HIAA-ve S.chromogranine AN. ASCA IgA ++ 54.4 (N 20 ) diarrhea and fever responded to Rx. For ? Crohn’s disease.
History and Findings - Ref.from GE med.k/c/o extra Hepatic portal venous HTN/cryptogenic cirrhosis liver/T2 DM Chr. Diarrhoea wt loss (50kg-41kg in one yr.), lower abd. Pain & recurrent fever.(invest). Hb.8.16., ESR 84., Plat. 23.5., creatinine 1.4., Alb. 2.24, ANA-ve., AMA-ve., PANCA –ve., anti LKM –ve., Serum ferritin 547.,ceruloplasmin 36.83., old CT abd. 11/12/08, rectal wall thickening with fat stranding & sigmoidoscopy 12/12/08, rectal ulcer-HPR non specific.
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Provisional Diagnosis - Admitted under GE med/ref. to med. Ac abd.pain, distension, dyspnoea cough with fever.(Chr. Alcoholic), ascitis+. Invest. Leucocytosis, ESR 54, CRP 19.6,ANA +ve, serum amylase 200, Lipase 254,chest X-ray Lt. sided pleural effusion, Ca, 7.5.,P. 3.3., Cancer markers-ve, ASCA IgA,LKM ab., & P ANCA all –ve serum ferritin 1158.33 Trasferrin saturation N., LFT-SGOT & SGPT high, A/G reversal, ANA profile anti SS-A/SS-B+++., anti sm +ve4., Schirmer’s +ve.
Final Diagnosis - 1.Sjogren’s syn.
2.Ac. Pancreatitis (? Auto immune) overlap syn.
3.CLD(ethanol related)
Pt. improved very well on steroids for polyserositis.
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Provisional Diagnosis - ?? 593, Pt. responded well to Rx for Toxo plasmosis x 6 wks. Emperical ATT started wef 15/7/09 since pt. opted for excision biopsy at nearby hospital
Final Diagnosis - 1.Toxo plasmosis
2.Recurrence of fever&admission AIMS DOA 25/7/09, DOD 5/8/09, excision biopsy axillary L.node on 31/7/09-Caseating granuloma (TB – L.adenititis), MTB-PCR-ve.,(already on ATT wef 15/7/09.pt. finished ATT on 15/1/2010. Asymptomatic.
History and Findings - PUO/polyarthritis/L.adenopathy invest. ESRT 52, CRP 13.94, RA-ve, anti CCP-ve, P.smear N., ANA-ve, C3 & C4N., IM Latex-ve., brucella IgM-ve, ulcerative Mx., Tox IgM +ve, 0.245, HRCT chest 14/7/09, Rt. Axillary L.nodes with necrosis, FNAC L.node 02/07/09 consistent with Toxo plasmosis. Tox IgG
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