This 33 yr female was referred to me for generalised anasarca for 2 years. She has gained 50 kg weight and now was not able to do routine activity due to breathlessness on exertion. O/E Pulse 70/min, BP 170/100, SPO2 95%(RA), generalised pitting edema ( from face to toe). She was comfortable in lying position. CXR-B/L blunt CP ANGLE . ECHO -WNL, grade -2,diastolic dysfunction. She was being treated for
hypothyroidism (50mcg eltroxin), hypertension ( amlodipine-10 mg), dytor 40 mg tds . Her albumin level was 3.5 gm%.
So as suggested by most of you we did send CBC-N,LFT-N,RFT-N, Na118, K 4.2,URINE-R/M,(Albumin nil,-3-4 cells, No RBCs).Albumin 3.5
gm% total protein 6.5gm%. ECHO-N, USG -Normal kidney- B/L Pleural effusion, free fluid in abdominal wall and 3rd spaces. TSH > 100, FREE
T4- LOW, Random cortisol low. Antithyroid Antibody positive very high. Anti -TPO antibody positive.
Based on above finding our dx was autoimmune thyroiditis with severe hypothyroidism anad hypocortisolism. We 1st gave 100 mg
hydrocortisone and 300 MCG eltroxin. Next day we have started on 200mcg eltroxin, wysolone 10mg ,CILINDAPINE, RAMIRIL AND
TEORSEMIDE . She was send home and came back after 14 days. She has lost 40 kg water in 14 days. We needed to stop antihypertensive
and diruretics. Now she is doing well on 200mcg of eltroxin and 7.5 mg wysolone.
This 43 yr female, from affluent class, came to for second opinion 5month ago. She was suffering from bachache since last two month. No fever,no loss of apetite, no weight loss and pain was localised to lower back. She was seen by neurologist, orthopedics, rheumatologist, spine surgeons & OB&G. CBC,CT & MRI were normal. ESR 35.Reason for my opinoin was non relieving pain by all measures and she was advised ovarian cyst surgery for pain. As I was I was not convinced with small folicular cyst and pain relation I asked to go to other OB&G, where he said this may due to LS joint TB. As pateint has local tenderness. He send patient back to me. She had local tenderness. I got her montoux, which was positive (20*20). Usg neck abdomen normal. Repeat ESR-40. CRP 32.
I was of the opinion to start AKT. But patient wanted confirmation, so I advised PET-CT, which showed increased uptake in LS Joint, pancreas and small lesion at Right lung apex area. To get bug and culture it I advised to go LS joint biopsy and cs or navigation-MR guided needle aspiration at clevland USA. Patient went to spine surgeon for biposy where he not only advised against biposy but said it is nothing . Got HLADR27, brucella and ANA profile which was negative. He advised patient to go to ID. As patient was from very affluent class well to lots of supersepecialst ,they took opinion from many concerned superspecialist and everyone advised against AKT.
She was put on NEOCOXIA AND MINOCYCLINE THINKING that it is PID and even PET CT , MONTOUX , ESR AND CRP ALL WERE IGNORED. She GOT SYMPTOMATICALLY BETTER.
After 6 month they came back to me with more sevre pain, fever low grade and incresed CRP ,ESR. This time same ID person advised that she should be given trail. Repeat HRCT -THORAX ,increased lung invlovement, medustinal LN positive. Now last 15 day she is on full AKT.
Though I persued this patient so much and was so confident for dx which I could see well before time, but was not endorsed by other seniors so treatment got delayed for 6 moth only.
The 28 yr Female, known case of SLE, was is remission due to pregnancy. She underwent cesarian, which uneventful. After 48 hr patient became tachypneic, tachycardia, diaphoretic, hypotensive. Oxygen saturation dropped to 85% on RA. How to approach and manage this patient. Was shifted to me 10 litre oxygen, and dopamine drip.
Once patient came to us our clinical diagnosis was moderate to massive Pulmonary embolism. We did ECHO and usg chest which confirmed our diagnosis OF DVT with PE. As patient underwent major surgery thrombolysis was out of question. PE thrombolectomy catheter is not available. We decided to give enoxaparin 0.1 mg /KG BD , NIV support and Noradrenaline. As patient was non acidotic and RV function was good she was more of case of moderate PE. We expected her to get better with regimen. She did bleed in her surgical site for which we had to open it and pack it. She recovered in 7 days. Later we had put her on warf.
Lesson-1-Pregnancy with SLE and autoimmune disease must be screened for DVT ANAD APPROPRIATE DVT prevention / treatment PRECAUTION SHOULD BEE TAKEN before and after cesarian.
2- moderate PE IN POST OP condition can be managed without thrombolysis with appropriate supportive care and LMWH or conventional heparinisation. They need very close monitoring and hemodynamic management.
24 years, the married female took 4 tablets of celphas. She went to primary physicians after 2 hours, he did gastric lavage, gave 100ML coconut oil through RT, and send the patient to me as she was hypotensive. The patient came with, hr-130, BP100/50 ON DOPA AND NORADR, RR 24, SPO2 95% ON RA, Her ABG- ph-7.30, PCO2-24,HCO3-12. It is total 5 hours since she took celphas.
This is our 15th case who survived after taking such a high dose and despite hypotension. Only key to survival was referral in time and aggressive CRRT. Only treatment which makes difference in outcome is high volume continues renal replacement therapy at a dose of 35 to 40 ml / kg / hour along with other supportive treatment like adrenaline, noradrenaline, and mgso4. CRRT helps in correcting acidosis, maintaining homeostasis and avoid fluid overload. Most of the time patient needs 36 to 48 hrs of CRRT, and after that most of the patients recover.
What I have found with time that starting CRRT within 2 hours of taking the drug saves most of the patients. That means early referral for doing high volume CRRT can salvage most of the patient.
So my approach for this patient was pain abdomen ,without signs of localisation with anaemia without blood loss. Further evaluation I found, Serum Iron normal, TIBC low, Ferritin Normal, ESR 40, CRP 20, Absolute reticulocyte 7.5%, Total Bilirubin 1.8, ( Indirect 0.9),LDH 340.
To further narrow it down we were now having additional finding of low TIBC. This lead to DD Of, Chronic lead toxicity, Anaemia of chronic disease, haemoglobinopathy, and other chronic haemolytic anaemic .
Lab results showed -Serum lead 73 MCG /DL ( very high)
We got Cap DMSA ( Succimer ) imported and has started the treatment today. Addition finding in this patient is he is taking AYURVEDIC treatment for infertility ( decreased motility ). Blue gum line -Photo attached .
- I was called to see a patient (60 year Male ), who was being treated for sepsis, AKI on CKD, with antibiotics, HD, and NIV. REASON TO CALL ME WAS - LOW HB ( 5GM%), LOW PLATELETS ( 1000) AND HIGH COUNT 24000. Thrombocytopenia was not responding to platelets transfusions.
History : Patient was known case of HT, DM ( on treatment ). He has complaint of fever since last one month. He came 5 days ago to the hospital with breathing difficuty and decreasing urine out output. For one month he was tretaed at local place with mutples doctors but no response .
To begin with his HB WAS 10GM%, PLT 76K, TLC 24K. CREAT 5 MG%, ABG 7.36, PCO24, HCO3 22. His platelets dropped rapidly over 5 days to 1000. LFT normal; LDH Normal. Fever still concern. Procalcitonin 20.USG ABDOMEN- B/L CONTRCATED KIDNEYS
Patient alert ,needs NIV, and HD . No response to pitazo and .
Looking to history and course I asked for ESR ,CRP, ANA PROFILE , TOTAL PROTEIN , LDH, FRAGMENTED RBCS , LFT , BLOOD CS, ECHO and repeat USG ABDOMEN.
ONE FINDING WHICH WAS CONSITENT THAT DESPITE ALL THE PROBLEMS - HE WAS NOT HYPOTENSIVE , HE WAS NOT ACIDOTIC AND HIS SOFA SCORE WAS CONSISTENT .
FOLLOWING RESULT CAME - ESR 145, CRP 30, TOTAL PROTEIN 9GM%
ASKED FOR PROTEIN ELECTROPHORESIS - DX CONFIRMED MULTIPLE MYELOMA.
( EXPLANED HIS NORMAL ABG )
PATIENT WENT DAMA DUE TO COST ISSUES.
The 28 yr female ,has compliant of pain in abdomen since last 2 year. Pain is associated with continuous sensation of nausea , no vomiting . Last two she has gone to the best centres of gastro in Ahmedabad, mumbai & Hyderabad . Underwent upper G I Scopy , colonoscopy and biopsy and Usg abdomen and CT abdomen three times. All these test did not conclude any diagnosis. Work up for Crohn's was non conclusive . Antacid ,antiemetics and
messaline trails fail to improve her condition.
Last 6 month pain has increased so much that it, it affected her sleep and appetite.
Came to me for diagnostics work up 4 days ago. After analysing all her reports, findings were - generalised abdominal tenderness, eosinophils 5-6%, weight loss 4 kg.
So one of the most exciting case for me to find out the cause - Case was diffuse tenderness , eosinophilia and raised CRP.
DD WAS - AUTOIMMUNE PERITONITIS, OCCULT TB-( CHRONIC PERITINEAL SEROSITIS), VASCULITIS, GLUTEN INTELORANCE, IBD( CROHNS) AND PRIMARY ADDISSON DISEASE.
INVESTIGATION REVEALED - 6 am cortisol 2 ( VERY LOW), ACTH ( 49-HIGH ).
PATIENT DID MENTION - EXCESSIVE TIREDNESS, FASCIAL PIGMENTATION AND MOOD SWING.
And then miracles happened - 20 mg wysolone - and patient was relived of her pain of 2 years.
Fairly preserved Sort ACTH test shows that patient will need very low dose steroid for life time.
62 yr Female, DM,HT, was on BIPAP at home , She was being managed at the best hospital of Ahmedabad. She needed frequent ICU admission due to breathlessness . She was diagnosed to be asthmatics , was send from hospital to home after 20 days of admission. Relative called me to see her home as she was breathless at home while seating or lying . Was not able to say a single word.
In my visit to her home I found her breathless, coughing continuously ,HR 120, BP 140/90 ( AMLODIPINE 10 MG, MINIPRESS XL(TDS) & OLMIN-H40, SPO2-92% (RA) and BIPAP, RBS WAS VARYING ( 300-450) ON OHA AND LANTUS, ,B/L TENSE PEDAL EDEMA
FOR ASTHMA SHE WAS ADVISED - MEDROL 6MG, FORACORT PUMP, IPRAVENT PUMP, AND BIPAP, DERIPHYLLINE TABS.
SO SHE WAS SO SICLE AT THE TIME OF DISCHARGE, STILL SHE WAS SEND HOME, AND THAT IS REASON CALLED ME KNOW IF I CAN DO ANYTHING OR PATIENT IS DESTINED
THID COURSE ONLY.
My 1 st target was to confirm diagnosis, find the severity of the problem, look for cause and find precipitating factors.
Adv- PFT, CBC, LFT,RFT,URIC ACID , D-DIMER, PRO BNP, ALLRGIC TEST ,IGE,.SPTUTUM EXAMINATION
ALL THESE REPORTS I GOT DONE AT HOME ONLY.
PFT confirmed severe reversible airway obstruction , PEFR 0.60-( CRTICAL RESPIRATORY FAILURE)
ABG- CONSITENT WITH HYPOXIC RESIRATORY FAILURE AND PCO 49- ( VERY HIGH IN ASTHMA AS THEY HAVR LOW PCO2), pH-7.34
SPUTUM POSITIVE FOR FUNGAL HYPHAE - ASPERGILOUS
PRO-BNP 400,URIC ACID 7.5.
ALLERGIC TEST POSTIVE -
IGE HIGH ( 435 IU)
For Asthma- I STOPPED BIPAP AND PUT HER ON HOME OXYGEN THERAPY.
We have started on nebulizer( as patient in not candidate for inhaler or rotacap)-duoline, budicot, foracort and tab wysolone 20 mg.. Tobamist , montigress -LC, ACEBROPHYLLINE & VONAZ (200MG BD).
AS IGE WAS HIGH - I HAVE PUT HER ON SC DOSE OF BOLSTRAN AS PER BODY WEIGHT AND IGE.
HER BP WAS HIGH ON THREE DRUG DUE TO RESPIRATORY DISTRESS. WE CHANGE TO CILINDAPINE 10MG BD, OLMINE H 40 . I COULD STOP HER MINIPRESS XL.
FOR DM -WE HAVE PUT HER LANTUS -3 DOSE AND NOVARAPID AAER PER SCALE. AFTER 7 DAYS -her PEFR rose to 1.25, cough decreased to 50%, could walk and speak.
We started home rehabilitation program for her and after 4 week, her PEFR ROSE 1.85-2.0. COUGH GONE. SUGAR CONTROL AND BP CONTROL.
DX- INTRACTABLE ASTHMA, WITH ASPERGILLOUS INFECTION, UNCONTROLLED DM, AND HYPERTENSION.
NOW I AM WAITING HER PEFR TO IMPROVE TO 2.25 SO I CAN GO FOR BRONCHIAL THROMOPLASTY
This 45 year female , came to me from Bahrain for the complaints of giddiness ,vertigo and ataxia since last 2 years . The problem started suddenly one night , when she fell down due to sudden onset sustains vertigo, She is not a known case go DM, HT or smoker. She underwent treatment for infertility and has three uneventful pregnancy.
The current problem is so severe that she became wheelchair bound . In last two year she was seen by multiple docs at UAE and India. Multiple CT ,and MRI of head and spine, nystagmogram, audiogram , could not diagnose her problems.
She has continuous ringing sensation in both ear , sleep disturbances, vomiting sensation and nystagmus in looking upwards and lateral side. There is history of evening rise fever since last 3 month. No weight loss.
Positive findings in her blood reports - Hb 8.5 gm ( confirm iron deficiency -replacement started). Heavy and prolong menstrual losses.
My 1st approach was to rule out local pathology, for which I took help of ENT & Neurophysician. We did repeat ,MRI brain & cervical spine which was normal . MRI PNS -fluid filled collected in maxillary and ethmoid sinuses.
Audiometry was normal . Nystagmus in upward gaze - ( indicates systemic disease ). So clinical diagnosis was Ataxia with upward gaze without localising signs.
So I needed to look for systemic causes and clue was from Low Hb & sinus involvement . Though the anaemia was of iron deficiency ,but causes of heavy menstrual loss could not be ascertained in view if normal ovary and uterus.
MY 1st clinical impression was RES system involvement . S I examined the patient and found mild splenomegaly with Left Supraclavicular Lymphadenopathy . USG -Abdomen confirmed the abdominal lymphadenopathy with hepatospleenomegaly . Lymph node biopsy confirmed low grade follicular lymphoma. PET -CT confirmed the extensive uptake of hot area in thorax & abdomen. After 1st dose of chemo -patient’s ataxia is gone while sitting and lying.
On literature review I found that lymphoma presenting as nystagmus /ataxia is very rare . Case explained is autoimmune antibody against balance system.
Her CSF,BONE MARROW IS UNREMARKABLE.
This 74 yr female was reffered to me for incerasing breathing difficulty and b/l pedal edema, loss of apettite and frequent diarrhea (4-5 /day) since last 6 month .
She is known as a case of hypertension ( 5yrs-on ARB), hypothyroidism ( well controlled on 100mcg) since last 5 years
She was evaluated for these ailments -HRCT AND CTPA- NORMAL. ECHO TR with RA /RV DILATED ( PASP 54)
OTHER ROUTINE BLOOD REPORTS NORMAL.
SHE IS ON ECOSPRIN, CLOPIDOGREL, AND ROSUVASTATIN AS WELL.
NO SIGNS OF BRONCHOSPASM.
B/L TENSE NON-PITTING EDEMA
B/L PLEURAL EFFUSION -TAPPING -TRANSUDATE .
LAST 15 DAYS HER URINE OUTPUT IC DECREASED TO LESS THAN 400ML
SHE IS HAVING DIARRHEA AT LEAST 5-6 TIMES.
After a careful history and examination what I found that Hypertension and hypothyroidism were detected almost together, edema was non-pitting, she has blackish tongue & cheek discoloration, breathing difficulty seems to be more related to chronic fluid overload rather pulmonary or cardiac. Tachycardia was due high Eltroxin dose ( 100mcg- TSH <0.03 MCG/DL).
As rule of thumb whenever I see hypothyroidism associated hypoadrenalism I would like to rule out. Relative hypoadrenalism get worse if Eltroxin is given without steroid replacement. Other clues were tongue pigmentation, relative low Na(128) and high K 4.5( despite on diuretics, explained abdominal pain and diarrhea.
I asked for anti-microsomal / thyroid antibody (>1200) which was high, ACTH 58(23-48) high, 6 am cortisol 18 ( should have been above 30 in view of high ACTH. Short -SYN ACTH test confirmed relative adrenaline insufficiency.
Telmisartan has a tendency to affect renal perfusion -so it was stopped. amlodipine causes pedal edema so it was stopped.
Tab Hydrocortisone 40 mg started and Eltroxin reduced to 88.5 mcg. In three days time, she lost 4 kg weight, breathing difficulty reduced by >60%, diarrhea stopped. A surprising finding is that she does not need antihypertensive now.
Dx - autoimmune thyroiditis, relative adrenaline insufficiency with secondary hypertension.
The 74 year, male, tobacco chewer, veterinary Doctor was under treatment for diabetes and hypertension since last 5 years by a diabetologist. Four months ago his sugar control went out of control. 24-hour sugar study was done by diabetologist blood reports. As per the reports has baseline sugar fluctuations has increased, HbA1c 7.5%, ESR 75. As per his diabetologist opinion, he was started on three OHA -(GLICLAZIDE, METFORMIN, SITAGLIPTIN AND ONE DOSE INSULIN TRESIBA 8 UNITS.)
As the patient was known, so came to me with reports for casual second opinion at the same time 4 month ago for getting endorsed that all is well. I wish to get some more reports which his diabetologist said no, saying that all these changes are due to uncontrolled diabetes and once diabetes gets under control all the reports will be ok.
So I wanted to find out the reason for high ESR and fluctuating uncontrolled sugar. TB and malignancy were high in my card so I ask them to get a screening PET -CT has done. The request was turned down by diabetologist and he was very particular in saying that let us wait till sugar in under control and ESR will come down and ESR is a non-specific test.
Then two month ago, on three antidiabetic drugs and tresiba his sugar got under control, HbA1c =6.5 and ESR CAME DOWN TO 45. I was still persistent for PET CT- Request declined.
A week ago a patient came with 5 kg weight loss, SGPT 95, ALK PHOSPHATASE 154, BILIRUBIN 1.8. ESR again rose to 74. ( All these reports patient was getting it done himself -in view of routine checks)
I got his CA-19-9( 38- high normal) MDCT abdomen and MRCP done, which showed an inoperable CA Pancreas. Endoscopic USG biopsy showed high-grade Adenocarcinoma.
Lesson - 1-High ESR in diabetes is not a normal finding.
2-Whenever sugar goes out of control in well-managed diabetes find the treatable causes and precipitating factors rather adding three or four drugs.
21 Year young male, went to his physician with compliant DOE and palpitation. Pateint was send to Cardilologist for ECHO. ECHO finding were suggestive of Pulmonary embolism , RA RV Dilated with normal LV function.Immediate CTPA- WAS done which confirmed PE. Pateint was given 18 mg reteplase bolus. At that time ,HR130, BP 130/80, SPO2 85% (RA). blood reports came after reteplase was given which showed platelet count 14,000, and HB 10GM%. REST of the routine reports were normal. Now patient was shifted under my care after these report came. when patient came to me His Heart rate 132, BP 120/70, SPO282%( RA) but patient is breathing comfortably ( RR-24).
This patient fall in category of chronic sub massive ( moderate PE). As he was not in shock, not acidotic, not in perarrest condition, not severe RV Dysfuction. Evidence do not support use of thrombolytics in MODERATE PE( clinicaly stable patient. Thogh thrombocytopenia report came later but retrospectively it look the pateint was just lucky that he did not bleed with such a low platelet count.
As he was shifted to my care immedietely post thromolysis ,there was neither any clinical improvementt or deterioration.
Post thromolytic ECHO showed RA/RV Dilated , PASP (50 ), WITH NORMAL LV function.
when patient came to me His Heart rate 132, BP 120/70, SPO282%( RA) but patient is breathing comfortably ( RR-24).
Patient responded to Oxygen ( 15litre NRVM) ,SPO2 99%, As he was non acidotic , and hemodynamicaly stable , we planned to manage further with LMWH . Workup sarted for thrombocytopenia and thrombophilia. He was found to have (APLA & ACLA) postive with ADsDNA postive . Steroid and HCQs was strtaed for same . His platelet stated improving after 24 hour. He was started on warf after 48 hours. It look 7 days to achieve INR OF 3.5 Then sropped LMWH. Platelets came to normal after 5 days.
With retrospective history ,he gave history of Cough and DOE since last 2 months.
We have discharged this patient on warf ( target INR :3.75-4.5), HCQS, WYSOLONE & Mycophenilate mofetil.
At discahge his HR-90, SPO2 (92%-94% ) on RA, BP 120/80, RR 18. PASP 40.
I am watchful , but it way be possible this Chronic , submassive PE patient may need surgical thrombectomy . I am not sure when I will advise for that . I believe to give 3 month trail of controlling SLE, AND MAITAINING INR of (3.75 to 4.5).
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