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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.

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.

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

D-DIMER 4800,
TLC- 16000.

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

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.

– 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.