1. www.drsarma.in EACH PATIENT - AN OPEN BOOK Interesting Clinical Cases Dr. R.V.S.N.Sarma., M.D., M.Sc., (Canada) 5 Jayanagar, Tiruvallur 602 001 Mobile 93805 21221 Visit us at : www.drsarma.inwww.drsarma.in

2. Marked weight loss 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 FT 4 ↑↑ - TSH ↓↓↓ Case 1

3. www.drsarma.in Classical Thyrotoxicosis 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 Case 1

4. www.drsarma.in Unexplained weight loss… 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 ? Case 2

5. www.drsarma.in Thyrotoxicosis is missed Clinical features of primary hyperthyrodism ++ Her TSH is negligibly low Both FT 3 and FT 4 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 Case 2

6. www.drsarma.in Unexplained weight loss… Clinical Presentation Middle aged ♂ Weight loss of 10 kg Clinically nil significant Investigations Free T 4 is Normal TSH is very low Free T 3 ♀ ￪ What is this ? How do we treat ? Case 3

7. www.drsarma.in About T 3 Toxicosis TSH will be very low Free T 4 will be normal Free T 3 will be elevated Clinical signs of moderate hyperthyroidism Ophthalmic manifestations absent Anti thyroid drugs – Neomercazole Thyroid storm is very common Case 3

8. www.drsarma.in Young girl with convulsions 15 year old girl Unmarried Tonic / clonic convulsions B.P 150/90 Pedal edema ++ What is the likely cause ? What was the diagnosis ? Case 4

9. www.drsarma.in Young lady – abdominal pain 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 ? Case 5

10. www.drsarma.in Sudden death of a man 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 ? Case 6

11. www.drsarma.in Sweet sixteen with head ache 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 Case 7

12. www.drsarma.in Her Evaluation revealed 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 ? Case 7

13. www.drsarma.in Young man with polyuria 20 year man presents with polyuria What could be the likely cause ? How to go about evaluating him ? What is this present case ? Case 8

14. www.drsarma.in Aged man with mass on the chest 65 years old man presents on 27 th 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 Case 9

15. www.drsarma.in Case 9Munuswamy 65 yrs.

16. www.drsarma.in Lady with MI 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 Case 10

17. www.drsarma.in Lady with Chest pain 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 Case 10

18. www.drsarma.in Misery of a lady 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 ? Case 11