EACH PATIENT - AN OPEN BOOK Interesting Clinical Cases

1
EACH PATIENT - AN OPEN
BOOKInteresting Clinical Cases

• Dr. R.V.S.N.Sarma., M.D., M.Sc., (Canada)
• 5 Jayanagar, Tiruvallur 602 001
• Mobile [phone]
• Visit us at www.drsarma.in

2
Marked weight loss
Case 1

• Clinical Examination
• Head Master
• 56 yrs. Male, smoker
• ? of 18 kg in 2 yrs.
• No dyspepsia
• No diarrhoea
• No fever, Mild cough
• Not a known diabetic

• Evaluations
• FBG 135, PPBG 205
• Chest PA - bronchitis
• CBC N, ECG HR 120
• Stool occult blood -ve
• USG - Normal
• UGI Endo - Normal
• FT4 ?? - TSH ???

3
Classical Thyrotoxicosis
Case 1

• Managed with Neomercazole
• Started with 5 mg TID
• Increased to 10 mg TID
• Finally stabilized at 15 mg TID
• Present weight gain 20 kgs
• Periodic TC and DC - Agranulocytosis
• Watch over correction and hypothyroidism
• May precipitate IHD due to weight gain

4
Unexplained weight loss
Case 2

• Clinical Presentation
• Young Lady of 32 yrs
• Weight loss of 11 kg
• Over one year
• Had ATT 12 yrs. ago
• No fever, cough
• Presented to a GP
• Ref to Chest Specialist

• Investigations
• CXR opacity rt. U.L
• ESR 18 mm 1 hr.
• Sputum neg. for AFB
• FBG, PPBG - N
• ATT given - 6 months
• Lost further 5 kgs.
• What is wrong ?

5
Thyrotoxicosis is missed
Case 2

• Clinical features of primary hyperthyrodism
• Her TSH is negligibly low
• Both FT3 and FT4 are elevated very high
• Thyroid scan and RAIU done
• Confirmed to have diffuse toxic goitre, No Ca
• Started on Neomercazole 5 to10 mg TID
• Present weight gain 20 kgs
• Her periods became regular
• Now looks ugly with her 74 kgs weight

6
Unexplained weight loss
Case 3

• Clinical Presentation
• Middle aged ?
• Weight loss of 10 kg
• Clinically nil significant

• Investigations
• Free T4 is Normal
• TSH is very low
• Free T3 ??
• What is this ?
• How do we treat ?

7
About T3 Toxicosis
Case 3

• TSH will be very low
• Free T4 will be normal
• Free T3 will be elevated
• Clinical signs of moderate hyperthyroidism
• Ophthalmic manifestations absent
• Anti thyroid drugs Neomercazole
• Thyroid storm is very common

8
Young girl with convulsions
Case 4

• 15 year old girl
• Unmarried
• Tonic / clonic convulsions
• B.P 150/90
• Pedal edema
• What is the likely cause ?
• What was the diagnosis ?

9
Young lady abdominal pain
Case 5

• 30 year old lady
• Mother of 2 children
• Acute abdominal pain - right iliac fossa
• Appendicitis was diagnosed, operation advised
• Came for second opinion
• B.P 70/?, pallor , Patient is in shock
• What is the likely cause ?
• What has clinched the diagnosis ?

10
Sudden death of a man
Case 6

• 42 year old police constable
• Known hypertensive
• As usual obese and he is a smoker too
• Suffered hemiplegia 4 months ago
• Treated at SRMC for his stroke
• Brought with chest pain at 9 a.m. sharp
• ECG showed NSTEMI, advised ICU care
• About to be taken to MMM, dropped dead in toilet
• This death could have been averted how ?

11
Sweet sixteen with head ache
Case 7

• 16 year old plus 2 girl head ache for one year
• She is 72 kg, excess weight of 17 kg for her
  height
• Round and chubby, Variously treated
• Neuro, ENT, Eye, CT brain are normal
• What could be he cause ?
• What investigations are needed ?
• What were the results of tests done by us ?
• Head ache not always neurological / ENT /Oph

12
Her Evaluation revealed
Case 7

• FBG 143, PPBG 210
• B.P 120/78, No IHD in ECG
• LDLc is 181, Total Cholesterol is 276
• Abdominal circumference 36
• USG Abdomen - PCOS
• What does she have ?
• She confesses that co students make fun of her
• Head ache occurs because of the teasings
• How to manage ?

13
Young man with polyuria
Case 8

• 20 year man presents with polyuria
• What could be the likely cause ?
• How to go about evaluating him ?
• What is this present case ?

14
Aged man with mass on the chest
Case 9

• 65 years old man presents on 27th instant
• Huge swelling of 8 x 6 on the left chest
• Long standing in nature, painless,
  non-inflammatory
• Attached to the muscle plane
• Not from the breast tissue
• Presents now with dyspnea and cough
• Needs evaluation

15
Case 9
Munuswamy 65 yrs.
16
Lady with MI
Case 10

• 55 years old woman referred for ECG by our friend
• Her 12 lead ECG has no evidence of IHD or MI
• Patient appeared to be in agony and is sweating
• ECG has right axis deviation with out RVH or RAH
• What is the catch here ?
• It is a case of dextrocardia and so the Right
  Axis
• Right sided chest leads showed classical MI
• She was sent to ICU- SRMC
• Died the same evening

17
Lady with Chest pain
Case 10

• 35 years lady referred for CXR by our friend
• She has mild pleural effusion on right side
• But, her pain, she sure is on the left lower
  chest
• Aspiration of the right side effusion is blood
  stained
• 2 days later she developed severe pain right LL
• Right Ankle and foot pulsations are very feeble
• Sent for further investigations
• She had splenic infarct so the left chest pain
• She had embolic occlusion of right popleteal
  artery
• The pleural effusion right side was due to
  infarct
• Her echo showed left atrial myxoma the culprit
  for all

18
Misery of a lady
Case 11

• 40 years lady suffered severe bilateral
  broncho-pneumonia in May 05 and was treated -
  recovered
• Barely two months later she fell down from a
  scooter while her son was about ride her to
  market
• First few hours no significant symptoms routine
  work
• By evening 5 she has excruciating pain left lower
  chest
• USG revealed fluid in peritoneal cavity, spleen
  outline ?
• CT by 8 p.m. revealed splenic rupture and liver
  LL tear
• Emergency splenectomy, liver, mescentric tear
  repair
• Is there any thing underlying her miseries ?
• Is it the manifestation of some thing more
  serious ?