Spot Diagnosis - IV

Recreate, revise & use your discretion, its a mental exercise & and learn how to diagnose clinically a case.Improve your clinical acumen.It is better for medical student, house surgeon, PG students & junior doctors.

1. A patient has been referred with abdominal board like rigidity with obliterated liver dullness.
2. A patient 60 yrs of age has many sebaceous cyst on his scalp one of which has become ulcerated,what is the name of the tumour?
3. A patient becomes extremely ill, there is abrupt proptosis, visual impairment & occulomotor paresis.
4. A patient with greatly enlarged hard liver, who wore a glass eye for many years.
5. what is that syndrome with hypertension diabetes mellitus, osteoporosis, moon faces.
6. What is that syndrome with ascitis, plural effusion & pericardial effusion in the case of female.
7. Haematuria during every mensturation is known as ........
8. Keratoconjunctivitis, sicca, xerostomia in rheumatoid arthritis.
 9. Symmetrical enlargement of all salivary gland with narrowing of the palpibral fissure & parchment dryness of mouth.
10. A known case of Hodgekins disease has developed, enlargement of lacrymal in salivary gland with narrowing of palpibral fissure and dryness of mouth.
11. Polyarticular rheumatoid arthritis in children associated with enlargement of spleen & lymph node.
12. A febrile patient with  palpable spleen & cardiac murmurs.

Spot Diagnosis -III

1. Slightly enlarged spleen with ascites.
2. A very hard and nodular liver.
3. A pulsatile liver with ascites.
4. A diffused abdominal swelling with loss of PSOAS margin.
5. An irregular and elevated right side of diaphragm with intercoaster tenderness.
6. In a febrile patient flaccid paraplegia rapidly developed. the symptoms are localized pain in the back of chest in the midline and with percussion and palpation often with radicular radiation.
7. the sudden appearance of obscure lumbar pain in patient receiving anticoagulant.

what is the nature of the growth?
1. A patient had a hard, irregular and fixed lump. Patient says, "it reduces in size at times.".
2. A patient had a static painless lump for long years but it has developed pain recently.
3. A patient had mixed perotid tumour for long years. Very recently he has developed facial palsy of that side.
4. A patient had hard small nodules on the lateral side of his nose which has become ulcerated with beaded margin but no lymphatic enlargement.

Spot Diagnosis - II

what is your clinical diagnosis when

1.  in a febrile patient there is throbbing pain in the perineum.
2.  on straining the flow of urine increases.
3.  on straining the flow of urine decreases or stops.
4.  the serum acid phosphotase rises.
5.  the serum alkaline phosphotase rises.
6.  in which carcinoma the secondary in the bone becomes osteosclerotic.
7.  when in an adult male urine is acidic in nature, contains pus cells & sterile on ordinary cultures.
8.  a known patient of hydroneprosis has developed fever with chill.
9.  a patient has a fistula over the ramus of mandible. he gives the history of watery discharge at the times of meals.
10. a patient has a painless whitlow.
11. neurolipomatosis is associated with which disease?

Spot Diagnosis

Can you diagnose only on a few given points??

1.    Irregular fever of months together with TC 2000

2.    Huge enlargement of spleen with sternal tenderness

3.    Respiratory discomfort with basal crepts

4.    A dead patient with reddish froth in the mouth n nose

5.    Prolonged fever with heart murmur and splenic enlargement

6.    Heart murmur, paetechial haemorrhage and fever developed after IV drips

7.    A man has gangrene of fingers, heart is normal.

8.    Gangrene of finger, heart is normal and there is no cervical rib after X-ray

9.    A patient has protruding tongue, gives the history of taking phenothiazine derivative for vomiting.

10.  What is this condition known as when clubbing of fingers with clubbing of lower end of radius ulna, tibia and fibula?

11.  What is the name of the triangle which is formed with hepatic artery, cystic artery and cystic duct, and its content and its surgical importance??

I never desire a kingdom.

One day one Politician friend of mine Sh. Rajdev Singh visited me in my clinic with his ailing neighbour and told me to help and treat free of cost, although his neighbour was  a useless, worthless and helpless man, he was good for nothing  in his opinion which he whispered into my years. I told him, “Look here, gentleman, no person is as bad that his life should be neglected.

People say that the cost of life even of the worst of the worthless persons is never less than a lakh of rupees and I personally believe that the cost of life of a kind and helpful person like you is more than a crore of rupees.”

Mr.Singh is a very jovial fellow, he always keeps on smiling and cracks jokes at times. He remarked, “Doctor, you do not know the cost of life of Doctors who are not only kind and helpful but sincere, sympathetic and economical like you is always more than a million dollars.”

Another gentleman Sh.A.K.Jha, a senior officer in the state government who was awaiting me in my clinic for treatment supported Mr.Singh in Toto. Mr.Jha told me, “Doctor when I am all okay I feel jealous of you because I have a bigger car, a bigger bungalow and a much higher scale than you even then when I stand before you I find myself much smaller”.

Mr.Jha continued, “whenever I fell ill I always found you as a good clinician but very recently when my son was very serious and hopeless, strangely enough, whenever I needed your help and presence, I always found you on my back with a touch of love, a few words of sympathy, assurance and very seldom with a change with costlier medicines & costlier test. It is strange to find that you are a man with a few words, a physician with a few medicines and a surgeon with a few instruments. It is peculiar that you always prescribe effective, safe and economical drugs. You never go by skillful advertisement and appreciation by the agent. Now I have started believing that God is nothing extra than doctors like you.” I told him, “this is nothing but it speaks of the height of your greatness and simple mindedness.”

One robust layman Kalu Yadav a dreaded name in Diara was in the clinic for the treatment of his ailing wife who was listening to these talks. He failed to hold his tongue and interrupted in between, “Doctor, now only I could understand why people are mad after the life of Doctors. Had I known it earlier, I would have been a far richer person by now. It exited a great laughter and I could not but order for tea for all, in spite of the strict order of my wife – “No tea in the clinic” as my blood sugar runs unstable and I have been forced a fixed tea-quota.

Everybody was rejoicing at tea while I became sentimental and became silent. Tears welled up in my eyes. Mr.Singh remarked, "Doctor why are you so moved.”

Only a few lines my tongue could utter.

I have yet to improve a lot.

May God bestow upon my fingers the power of healing,
So that I maybe of some use to the useless, of some worth to the worthless and of some good for the good-for-nothing.
If this happens then only the purpose of my taking birth as a man and also being a doctor are served.
I dont want to make myself a heartless, money- making- machine by cheating ignorant and innocent people.

I want to be called the doctor of the poor, doctor of the commons.
I never desire a kingdom.

A few of my experiences with Extra-Pyramidal syndrome

I was a house-surgeon in medicine in P.M.C.H. under Dr. B.Dhar, a great man in medicine. Unfortunately he left India for Great Britain and settled there long years ago. Dr. S. N. Arya was junior to him and both were working in the same ward.

Once, Dr. B.Dhar admitted one case in the ward.  Dr. S. N. Arya examined the case and said politely, “sir! this case seems to be extrapyramidal syndrome”. If my diagnosis will be correct I will take a four-ana-coin from you.” Dr. Dhar agreed and gave him a four-ana-coin.

On this grand success we requested and rather compelled him for a grand tea-party in the college canteen. Soon after the round was completed, we left for tea-party and enjoyed a lot.

About twenty years back I was posted in Sadar Hospital Saharsa. One day coming after Ward-rounds, I saw a big crowd in the Deputy-Superintendent’s Chamber. All doctors and staff were present there surrounding a patient, son of the Medical Officer-In-Charge, Bariyahi, Kahra PHC.

The patient was standing with his tongue protruding out with salivation. All the doctors were silent-expectators with a blank look and speech round.

In those days many experienced Surgeons & Physicians who were M.D., M.S., MRCP & FRCS were there at Sadar Hospital Saharsa. The hospital looked like and gave the pleasure of a tiny medical college, the P.M.C.H. of Koshi. We had occasional healthy discussions over some interesting patients.

I asked, have you taken Siquil?’’ The patient nodded his head and said, ”Only one tablet sir.” I said, ”I have made my diagnosis.” Then,  Dr. Sarawgi bounced on me and said, ”Doctor you have just come and didn’t examine the case  even for a second and say that I have made my diagnosis. Do you think diagnosis a joke? This is a very complicated case of medicine.” Dr. Sarawgi was an M.R.C.P having hot temperament and was senior to me. I replied him, ”Sir, this is a case of Extrapyramidal Syndrome”. “You are a surgeon how you could say that”, Dr Sarawgi said as if he was the only authorized person to diagnose the difficult cases. He did not know that medicine is never taught. One learns it if he has interest in medicine and he didn’t know the line of Sushruta, the father of modern surgery – that a man can’t be a true surgeon without the knowledge of medicine.

There has never been a greater teacher than a keen interest.

You can’t limit medicine by your degree alone. Keen observation is also a very important thing which counts.

I am a peace-loving person and believe in simplicity. I said very politely, ”Sir, protrusion of tongue after taking even a single tablet of Phenothiazine group of drugs is a definite sign that patient has developed extrapyramidal syndrome.” “Even one tablet!” Dr.Sarawgi remarked, As if one tablet was not enough in his opinion. I told if the patient is hyper-sensitive or the patient is de-hydrated due to repeated vomiting or he has kidney failure. Sir the steel man, master of judo karate, Bruslee of Hongkong died of taking a single tablet of analgesic. All doctors present there agreed with me and called a very brilliant spot-diagnosis by Dr.Jha. Dr.K.S.Mishra (M.D.) and Dr.R.P.Yadav (MS, FRCS) were very happy and congratulated me like anything.

Very recently I was sent for to see a very critical patient in a junior doctor’s clinic and examined the case and asked the doctor “which drug have you given?” The doctor told about all the drugs and Serenace (haloperidol) - Antipsychotic drug 1 ample i.m. injection b.d for three days. I stopped all drugs and prescribed a few ones and whispered in the doctor’s ear, “It is all due to your drug Serenace. It is Extrapyramidal Syndrome.”

Recently I stayed with a close friend of mine at Sahibganj due to some personal work. A boy in his neighborhood used to come and go time without numbers. I asked about him as he seemed a mental case. They said, “He is under treatment of a Psychiatrist at Ranchi.” I found tremor in his fingers, rigidity of limb muscles and Akathecia (means the patient wants to move, can’t stay at one place). I said he is suffering from Extrapyramidal Syndrome due to Antipsychotic drug.

History taking is not so simple as it looks, if the patient is not educated, intelligent and co-operative it becomes rather tedious to take correct history. The patient makes his own diagnosis and tries to co-relate things in his own way. Many patients do not feel the importance of giving correct history especially the drug history because such a good and costly drug cannot do harm in his opinion. Only wise and experienced doctor can get correct history by asking twisted question. Even doctors ignore that such a common drug can cause any harm.

They think some big and common disease like the police who always think of some noted and listed criminals for any mischief in his area.     Another misguiding feature is high fever which leads and compels us to diagnose encephalitis.

In children the heat regulating Centre is not well developed and if there is malnutrition then the heat regulating Centre virtually leaves to work. So, any change in temperature due to any simple infection and reasons leads to hyperpyrexia, convulsions, stupor and coma and compels us to diagnose encephalitis.

Some time we search our lost spectacles and we have to search the whole house. Better we close our eyes and look and see where I have used it the last moment and where I could have left it. Things become easy if we think with close eyes for any diagnosis. The great philosopher, John Hemphered has said, “Eyes do not see which mind does not know”.

I have seen the cases only on the T.V. flashes and the epidemic of encephalitis is happening continuously for more than 15 years, and on repeated culture no virus is seen. This epidemic is being repeated not only at Muzaffarpur but at many places in India which compelled me to think about drug disaster - Phenothiazine disaster like Thalidomide Disaster in West Germany and Great Britain in the year 1960-61. Not easy to diagnose and much more harder to eradicate in the present  scenario where (a) New drugs introduction in the market is so easy (b)The pharmaceutical companies are growing like wild fire. (c) Quackery is so prevalent and has become a good source of earning and honour. (d) All drugs are available without prescription. (e)Corruption is on its top. (f) Administration is deaf and dumb. If you look carefully and take the history properly about 30% cases admitted in medical colleges are due to iatrogenic (due to drugs and doctors) causes.

These types of cases where diagnosis seems to be at fault should be flashed in detail on TV Channels so that doctors sitting at a distance should use their discretion and make a common and correct opinion after discussion among themselves.

Drugs and Encephalitis

The epidemic of encephalitis is being repeated every year, not  only at Muzaffapur but at many places in India. The govt and the health authority are sitting tight, only because they say its viral encephalitis and viruses are never found in the culture. They should take lesson from the history  , about fifty  years back there was an epidemic of phocomelia in west Germany. Phocomelia means sealed extremities, it is a congenital deformity. Until 1961 the public took a largely romantic interest in development and introduction of new drugs.

In 1961 a major breakthrough did occur, a man discovered that introduction was more hazardous then he has previously believed, the thalidomide disaster aroused public opinion, forced government to intervene in the process of drug introduction and all concerned with this process got a salutary shock , our attitude to casual use of drugs.Drugs can never be the same since thalidomide.

I feel there maybe some error in the new drug introduction in the market. Most west German clinic had no cases for 10 years since 1959 , in 1959 in 10 clinics 17 were seen, in 1960 126, in 1961 477.The outbreak seemed confined to Germany and this steady increase made a virus infection such a s rubella seem unlikely as a cause. Radioactive fallout was considered and so was X-ray exposure of the mother,hormone, food, food preservative and contraceptive.

One doctor investigating his patient retrospectively with a questionnaire found that 20% reported taking  thalidomide in early pregnancy. He questioned the patients again and then 50% admitted taking it. In our day to day practice we find that patient seldom speaks the truth, they focus on different point because they think this was not the causative factor, so taking proper history is not always possible. In 1961 in a paediatric conference somebody whispered that an unnamed drug can be a causative factor and all conscious doctor started looking at the past drug history of their patient. In a series of 46 cases of phocomelia, it was found that 41 mothers had certainly taken thalidomide and of 300 mothers of normal babies none had taken thalidomide between the 4^thand 9^th week of pregnancy.

So we must think of some drugs and probably they are some tranquilizers and anti-psychotic drugs.