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Diagnosis case diary
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Provisional Diagnosis - ? 10.5? 9.75 platelets-15/5 50.0, 17/5 71.2, 19/5 126.0,21/5/ 455, ESR 8 ANA-ve, CK 383, D. dimmer? 2.9m, LDH 1235, lipase? 256 (N. 21-67), Amylase 99.8, Ca.7.6, P. 1.6, Bil.T.2.3/D-1.2, SGOT 867, SGPT 772, Viral markers-HbsAg, anti HCV, IgM HEV & IgM HAV all –ve, Blood cultures No growth, MRI stroke protocol N. study (19/5/09) Coom,s-ve PT with INR & APTT N
Final Diagnosis - 1.IBD/ 2. TTP (Thrombotic Thrombocytopenic Purpura) 3. acute pancreatitis 4. viral hepatitis (? Varicellazoster virus) Dramatic improvement on pulse dose of methyl Prednisolone (1000mg od x 3), supportive treatment-pancreatic enzymes/PPIs/Ijn.Acyclovir with antibiotics & oral steroids after pulse dose.
History and Findings - Ref. from GE Med.DOA 15/5/09, DOD 25/5/09. k/c/om IBD on steroids., admitted with chicken-pox, presented with abd.pain/slurring of speech/Ataxia/microscopic hematuria, Hb.11.7
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Provisional Diagnosis - ? Vasculitis? ADEM. Ref. from, Neurology., (ANA +ve). ESR 28, Hb. 12 G., plat. 455.6, Toxo plasma IgM+ve, 13/5/09-0.230
Final Diagnosis - Toxo plasma vasculitis brain Pt.was given full Rx. For 6 wks. Improvement being assessed by Neurology
History and Findings - k/c/o SIADH/multiple cerebral bleed. MRI Brain
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Provisional Diagnosis - T2 DM/HTN, thyroid swelling, worked up at Guruvayoor Saturday OPD
Final Diagnosis - FNAC-follicular neoplasm Lt.lobe thyroid. Ref. to HNS total thyroidecromy 31/5/09, I-131 therapy Nuclear Med. On 6/7/09
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Provisional Diagnosis - ? NSAID induced. HPR-Ac.active colitis, ANA-ve,CEA & ASCA IgA-ve, B2 microglobulins? 5.10 ng/L., Kappa light chain, ? 55.6 ng/L., Lambda N., A/G 3/6.7G.
Final Diagnosis - Serum protein EP strong +ve M.band. B.marrow smear & biopsy 8/5/09, 28% plasma cells, 9/5/09-biopsy consistent with plasma cell myeloma. Transferred to Med. Omcology on 8/5/09
History and Findings - k/c/o OCD/Dep.Illness/Dyspepsia/Melena/recurrent LRTI (Invest). Hb. 6.9, ESR 90, P.smear hypochronic microcytic with Polychromasia, Uric acid 7.2, USG abd.-fatty liver, Echo mN.colonoscopy on 8/5/09,Transverse colon ulcer
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Provisional Diagnosis - k/c/o duct carcinoma Lt. breast MRM 2005 RCC Tvm. Syst.HTN on Rx. Presented with fullness abd./dyspepsia/loss of wt
Final Diagnosis - USG abd. Multiple hypoechoeic lesions-liver Breast Ca. with liver mets ref.to oncology 29/4/09.HPR 8/05/09,Metastatic Ca-on chemo
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Provisional Diagnosis - ? Synovitis Lt.knee (Post traumatic) K/C/O bipolar illness (MDP) on antipsychotics. Invest ESR 100 ANA+ve 46.80, ds-DNA 118+ve, CRP 68.109 antihistone ab++, antineukleosomen++, RA-ve.
Final Diagnosis - Synovial biopsy knee (Ortho) 6.6.09, chr. Granulomatous Synpvitis (TB)./ SLE (? Drug induced) MTB PCR-ve. On ATT wef. 22/6/09 Responded very well to 6 months ATT with no steroids
History and Findings - Polyarthritis/
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Provisional Diagnosis - ABPA/Chlamydial urethritis/Fitz-Hugcurtis syn. Rxed. Recurrence of cough/dyspnoea/PUO since 1 month, Wt. loss. USG neck 16/4/09 significant C.adenopathy FNA-inadequate. CT chest 21/4/09 multiple discreate L.nodes B/L.lungs more in apices AFB culture BAL 29/4/09 report 6/5/09 AFB +ve
Final Diagnosis - On ATT w.e.f. 8/5/09 Pt.responded very well to 6 months ATT. Symptom-free now. Atypical features –hyper calcemia,. A/G reversal increased ACE levels. For follow up
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Provisional Diagnosis -
Final Diagnosis - ? MRM Lt. with axillary dissection (Omcosurgery) on 2/5/09 now on chemo. Old Gen. Med.admission DOA 15/4/08 DOD 6/5/08 Dermatomyositis associated with ? internal malignancy. (breast or ovary)
History and Findings - k/c/o sermatomyositis on tapering steroids, relapse on low dose steroid Pt. responded to increase in steroid dose. Breast lump re-evaluated. 9/4/09 USG Breast highly suspicious of Malignancy. True cut biopsy-infiltrating duct carcinoma 15/4/09. Oncology earlier evaluation 12/2/08 FNA-ve for malignancy. Pt. underwent LAVH +BSO on6/11/08 for doubtful malignancy Rt. Ovary-HPR mucinous cyst.adenoma (ovary
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Provisional Diagnosis - Neurasthenia/Microscopic hematuria/h/o. chronic tonsillitis-ASOT?
Final Diagnosis - PSGN
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Provisional Diagnosis - ? SLE – Past h/o. Genital ulcers. On Omnacortil 20 mg. od wef 26/1/09. VDRL/TPHA –ve, RA –ve, ANA +ve, ds DNA-ve, C3 & C4 N., ANA Profile- Anticentromere ab. +ve , HSV IgM & IgG +ve, Biopsy Oral ulcers-neutrophilic microabscesses.
Final Diagnosis - 1.CREST Syn.
2.HSV Oro-labialis
3.FNA thyroid? Folicular Neoplasam
Pt. improved on Famciclor (valaciclor), Ref.HNS? Lt. hemi-thyroidectomy 5/10/09 HPR no e/o malignancy on Rx.for CREST.
History and Findings - Ref. from HNS-recurrent oral ulcers & vesicles, polyarthritis, Raynauds +ve, esophageal dysmotility. Outside diagnosis- collagen disease
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