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Honourable Sir,

You are a part of one of the finest medical institutions, and I have personally experienced your excellence during the treatment of Shri Banna Lal Ji.
I was present with him when he underwent bypass surgery at the Asian Institute of Heart, Mumbai, and we used to visit the Institute regularly—initially every three months, and later every six months.

When I speak about Dr. Ramakant Panda, I must say he is undoubtedly among the best in Asia.
Similarly, you, Sir, are the finest in the field of Intensive Care. Your values, ethics, and compassionate consideration for a patient’s financial condition are truly admirable—I have personally witnessed this.

Though I am elder to you by age, I still remember the day I touched your feet as a mark of respect for your profound knowledge, humility, and the way you treat your patients.
I have very few words to express my gratitude for your noble service and my deep appreciation for the care you provided to Shri Banna Lal J

Under your supervision, he has been treated successfully for the past four years. Even during the most critical phase, when he suffered from a severe lung infection and admitted at Hardik hospital,your expertise and timely intervention cured him completely.
You are a confident, knowledgeable, and ever-learning doctor—one who constantly updates himself with new technologies, engages in advanced medical discussions, and continues to read and learn every day.

It is this passion and dedication that makes Dr. Rajesh Mishra Sir a truly renowned personality—not only in Ahmedabad but across Asia.

We consider ourselves truly fortunate to have you as our doctor and guide.

With heartfelt regards and immense respect

Vijesh choubisa

A 35-year-old male presents with severe bilateral burning sensation in both lower limbs, persistent for the past 6 months, significantly affecting sleep, daily function, and work performance. Pain is continuous, non-position dependent, and poorly responsive to all standard neuropathic pain agents tried so far.

He has been evaluated by multiple neurologists. Nerve conduction study and EMG are normal. MRI brain and spine are unremarkable. Vitamin B12 levels normal. No relief with pregabalin, gabapentin, duloxetine, nor tricyclic antidepressants. Psychiatry consultation considered somatoform disorder, but psychotherapy and medications yielded no improvement.

Past medical history includes dyspepsia, currently on regular PPI therapy. On statins for hypercholesterolemia (with strong family history) — lipid profile currently well-controlled. No diabetes, no thyroid disorder, no alcohol or toxin exposure.
Blood investigations, heavy metal screen, porphyria workup, and autoimmune profile are normal. How to go about this case further ??

This 16 year old Female, D/O well known pediatricians (both parents) has come to me for compliant of nausea, vomiting since last 15 days. This problem was there since last twelve month during her periods and used to get better afterwards. Since last 10 days she has anorexia, strong distaste for food and whatever she eats vomits immediately so she stopped eating. She was taking water and juices since last 3 days that too she was vomiting often. Last 24 hours she has complaint of giddiness and was feeling very weak so they came to me. She was seen by couple of physicians & OBG. She came with normal USG abdomen, CBC and prolactin reports. O/E I found her dull weak and does not even want to see food. Pulse 120/min , BP 90/60, RR 14, SPO2 100%, RBS 80. Other general and systemic examination are unremarkable. No response to antacids and antiemetics. Mother has RA negative small joint arthritis and DM.

My approach after history and examination was to find organic cause before labeling it psychogenic . As history was related to perimenstrual period and there was no significant weight loss my though was to look for hormonal cause 1st and then go for other metabolic disturbance . In this list corticosteroid deficiency , prolactinoma, porphyria, DKA, Insulinoma hypothyroidism/ hyperthyroidism comes. We got cortisol, ACTH, TSH, insulin, Na, K, insulin level . 6 am. Cortisol level was < 1 micrgram / dL & ACTH 5 pg/M L . Sort syncthen test confirmed the diagnosis of adrenal suppression .Got her MRI & CT abdomen done( normal) . Endocrinologist diagnose this ADRENAL FATIGUE. Started on tab hydrocortisone and patient responded immediately .

DX -Relative adrenal insufficiency ( Adrenal fatigue)

Case 2- This 46 year young gentleman came to me with complaints of backache and fluctuating pain in both the calf and thigh muscles since last 6 months. He has been seen by spine surgeon who has advised to get MRI LS SPINE. Two times MRI done in last six month is unremarkable . Patient was given steroid injection two times which could not relieve the pain. He has problem of constipation , anorexia despite that his weight is static . He is taking thyronorm 100 mcg, metoprolol 25 mg . A month ago he has complaint of urinary retention for which he needed urethroscopy and was prescribed doxy for 6 weeks ( could not understand why). Only reason to come to me was unbearable backache, leg pain which is giving sleeplessness night . O/E he is able to squate , and able to touch his both the toes. He has come with book of reports which was showing ESR ( 20-30), CRP 15-20) , TSH very low rest of the reports were normal. MRI LS spine was showing mild protrusion protrusion at L5 S1 which as per opinion of spine surgeon was normal. His vital are normal and despite anorexia and severe constipation he has gained weight 3 kg in last 6 months.

After examination my initial thought was to to find the cause . His blood reports were showing high eosinophils , ESR & low TSH . One of the rule of thumb which I always follow is whenever someone is on thyroxin tablets , ( TFT is so well control that TSH is low ) and patient is having paradoxical symptoms I will look for cortisol level . I also wanted to rule autoimmune and neuromuscular problems. I have asked for 6 a.m. cortisol , ANA,RA, NCV& EMG . Cortisol level came < 0.5 •μgm/dl and rest of the report were normal. Sort synacthen test confirmed the reports of severe adrenal insufficiency of adrenal origin . On retrospective questioning he has confirmed that he was taking Aurvedic medicine for weight gain . Steroid replacement has made him better. I have also reduced eltroxin dose to half.

Dx was secondary adrenal insufficiency . He needed 20 mg of wysolne to relieve his symptoms.

A 22 yr Female, P2, last baby 1year old has complaint of sudden onset purpuric spot in both the lower limbs which bled occasionally. She was seen by her local physician who has diagnosed her a case dengue (Platelets 60 K & IgG positive). Next day her platelets dropped to 30 k and Hb dropped to 6 gm. She was given 2 SDP and 2 PCV. Next day reports Hb 5 gm%. Platelets 10,000 , LFT normal . She was send to district place where she was treated as dengue only and they gave 3 more PCV, 2 SDP, & 10 PLATELETS but her Hb & Platelets was dropping, on 5th day Doctor noticed abdominal distension, USG abdomen done which shoed intrabdominal bleeding with pelvic collection of collected hematoma. She shifted to us with Tachycardia (HR 160), BP 120/70), RR 35, SPO2 80% RA, and passing good amount of urine. She was carrying blood reports (Hb 2 gm%, Plt 5000, TLS 13000, PT& aPTT Normal, Na 122, K 2.3) Apart from this no other report was done.

This patient came to me at 10:30 pm, and we got these reports done (CBC- Hb 2 gm%, TLC 17000,Platelets- 3000, PT- INR 1.20, aPTT-35/30, LFT-Bilirubin 1.8, RFT-Normal, ANA profile Positive for scl1, ferritin-Normal, Triglyceride Normal, USG abdomen- collection in pelvis adnexal mass hepato-spleenomegaly, Beta-HCG normal, Smear for fragmented RBCs- Absent , MP -QBC/antigen- Negative Dengue IgG titer- normal , Scrub typhus antigen -negative , Direct coombs test positive, ABG pH-7.50, PCO2-26, PaO2-110/10 liter O2, HCO3-22,. These reports came to me 1230 midnight , by that time I had arranged 4 PCV & 1 SDP.

My clinical diagnosis was ITP , on further history relative told me that patient used to have these kinds of purpuric bleed in past but it used to resolve . Before blood transfusion we gave 1 gm methyl prednisolone and 50 gm IVIG ( 10 vials of 5 gm) and then transfused the 4 PCV & 1 SDP. By morning patient got stabilized. We got BMA / Biopsy done next day which confirmed the diagnosis of ITP. Next day we again repeated the 1 gm methyl prednisolone and 50 gm IVIG ( 10 vials of 5 gm) and 1 SDP. She did not need any more PCV transfusion and Platelets transfusion . We gave her methyl prednisolone (1gm) for 5 days . Her platelets started improving on 3rd day and 5th day it came to 1 lakh. We got USG abdomen & CT abdomen which showed resolving hematoma.

We sent her home on 6th day on steroid, HCQs.

Fulminant ITP ANA (ScL) associated.

38 year, Male was referred to me for evaluation of pain in abdomen since 1month. He has postprandial heaviness since last three month . For pain abdomen he was seen and evaluated since last one month at different hospitals. He was admitted for this where his Upper G I Scopy, biopsy, H pylori test were normal. CECT abdomen normal .Complete blood profile was done multiple times. PosItive reports were HB 8.9 GM%, ESR 35. Rest of the blood, urine,stool reports are normal. Seen by more experts and they advised colonoscopy and bone marrow examination. Then he came to me for further diagnosis as cause is yet to be found.

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 .

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.

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.

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.