Rabindra sangeet Piano cover-JAZZ STYLE!!!

Introduction:

The name of this song is "Dariye acho tumi amar" written and composed by Rabindranath Tagore. It's a very famous song and one of my favorite too. I arranged it in piano using circle of fifth chord progression on G Major scale and using some experimental chord substitution. It took a lot of hard work to create this type of sound specially for a beginner like me. 

Lyrics and chords of this song:

To watch my more videos subscribe to my youtube channel   by clicking here "Pianodreams"

Butterfly rash-in an Indian housewife

"Butterfly like Malar rash" and Alopecia in a case of SLE

"Deep purple"- Urine of an old lady

Those who have not seen anything like this must be thinking whether it is real or not. I was surprised too when I saw this for the first time. Here is the story..

Once during my PG days while I was taking morning round just like other days, I discovered it. The color of the urine catheter bag was so prominent that it immediately caught my attention. In the corner of our female medicine ward I saw an old lady lying in the bed. Her urinary catheter and the drainage bag both deep purple. At the first instance, I could not believe my eyes. The patient was admitted under some other unit so I did not have any clues about disease she was having. I checked her file and found that she had a history of stroke one month back and now she has been admitted with unexplained drowsiness. She was a known diabetic and hypertensive patient and she was on multiple medications.

I started to recapitulate the conditions that can cause purple-like urinary discoloration. Only one condition known to me that can cause this type of urine discoloration was Porphyria. In day to day practice some common causes of discolored urine are-

1. Drugs- Antitubercular drugs, among which rifampicin commonly causes orange colored urine. riboflavin and excessive ingestion of carrots can also cause orange urine. Nitrofurantoin and Metronidazole less commonly causes brown urine.
2. Porphyria- urine turns to purple on exposure to light
3. Myoglobinuria- chocolate colored urine
4. Acute tubular necrosis- can cause "muddy brown urine".

Well, none of the above conditions were fitting properly in the clinical background of our patient. So, before starting evaluating her for some rare possibility, I send her urine sample for routine and culture sensitivity testing which is simple and time saving. Her urine report showed alkaline urine with plenty of pus cells in absence of  RBCs and any abnormal pigments. After 48 hours of incubation, growth of Proteus mirabilis was detected with colony count >10^5 c.f.u.

I went through the literature to search for the conditions associated with purple colored urine and found a entity named "Purple urinary bag syndrome" which matched perfectly with our patient. 

But what exactly does it mean?

Actually, it's a very rarely seen condition where the urine collection bag and/or catheter color changes to purple (the urine color remains unchanged). It's mostly seen in old aged, chronic debilitated, dementic patients with prolonged or permanent urinary catheterization as they remain very vulnerable of acquiring urinary tract infection. Many gram negative bacteria including E.Coli, Klebsiella, Providentia could cause it but the Proteus mirabilis is the most frequently found organism to cause purple urinary bag syndrome. 

What is the pathogenesis?

As such it's a benign condition unless associated with severe underlying urosepsis just like our patient. Treatment is cullture sensitivity guided antibiotics and change of urine catheter & urine collection bag.

Disability-Story of a boy with huge calfs

This 13 years old boy came to our hospital from a rural background with the c/o jaundice and pain 

abdomen. On the post admission day morning round when I saw him for the first time, it was like an ordinary case of acute viral hepatitis which is very common in  the tropics. But his father appeared too much worried and depressed about the health issue of his son. He expressed his frustration by telling "Sir, we are extremely poor! moreover, our son is physically challenged!" I was like surprised because at the first instance the boy appeared quite normal, lying in the bed like other patients. But when I heard the  phrase "Physically challenged", I kept staring at the face of the boy. At first, my heart was denying the truth that I had just heard but inside my mind I was sure that this case is not an "ordinary" anymore. So, I went deeper further questioning the father about his son. 

According to him, his son was absolutely normal at birth and had achieved all the developmental milestone normally as he grown up.  But at around the age of 7 years gradually his child became weaker than his peers as evidenced by the inability to walk for a longer time, difficulty in getting up from sitting or supine posture and the loss of ability to walk upstairs. Eventually, the weakness has progressed to the stage where his son has to depend on wheelchair but not on his own leg for moving even for a short distance. He had initially visited to some local practitioners with a hope for the cure of his son's disease but it was unsatisfactory. Being a poor and uneducated person he took it as a curse over their family and left his all hope to explore further options for the better treatment of his child. 

At that time, I was imagining how painful the situation must have been through which he went on experiencing all the stages of grief starting from the "Denial" to end with the "Acceptance"! He took out a torn piece of paper wrapped in plastic from his wallet and hold it in front of me telling "Sir, see it's the disability certificate for my son!".... I acted like reading it very carefully but inside my mind I was busy in analyzing the deeper emotions hidden in his last sentence. May be he tries consoles himself with that "Torn piece of paper" which is not just a paper but a proof of the least he could do for his son or somehow deep inside he feels the word "Disability"mentioned in that certificate point towards his own failure to fight for his child. 

Witnessing all the emotional story along with the medical history, I started examining the patient. The boy was fully conscious and oriented with an average built. Pallor,cyanosis, clubing, oedema were absent but icterus was present. He was a bit tachypnic and tachycardic with normal blood pressure and temperature. On examination of the nervous system, his speech and higher mental functions were within the normal limits, cranium and spine looked fine and all the cranial nerves were functioning properly. In the motor system examination, his both legs were lying helplessly in the bed rotated externally at the hip joint, flexed at the knee joint (Frog-like posture) and plantiflexed at the ankle joint. There was no obvious thinning of any limbs or muscle instead, there was strikingly huge hypertrophied like calf muscles in his both legs. His muscle tone was grossly diminished (more on the lower limbs) and the power was of grade-1 in his both legs and grade-4 in his upper limbs. His huge calf muscles were very firm and non-elastic on palpation like "Pseudohypertrophy" though it's difficult to say for sure without the help of ultrasound (heterogenous muscle echointensities due to intermixed fibrous tissues in case of pseudohypertrophy). Heel contracture was there bilaterally. No abnormal involuntary movements were found clinically. His tendon jerks were grossly diminished in all 4 limbs and plantar response were absent bilaterally. His sensory system and bladder-bowel functions were absolutely normal. Other system examinations were almost normal except for the few crackles heard in both of his lung base.

No investigation reports were available. We did routine blood test which came normal except for the mild jaundice (bilirubin-3.5 mg/dl) and raised ALT (136 iu/l) & AST (148 iu/l). His serum CPK was normal (35 u/l). EMG-NCV, MRI-spine and muscle biopsy was planned but on the next day he suddenly developed progressively increasing shortness of breath (?respiratory muscles weakness) leading to CO2  retention for which he had to be shifted to the ICU for starting BiPAP ventilation. He had not shown any signs of improvement even after 24 hours, so his father became very anxious and finally decided to take his child out from our hospital to a higher facility for better management. We supported his decision and referred the boy to a neurological institute with a wish for his speedy recovery and thus our story ends here without having any formal diagnosis.

...

Do you have any clues? if yes, then please mention it on the comment section.

To me the possible differentials would be-

1. Duchenne muscular dystrophy (though unlikely to have normal CPK)
2. Juvenile SMA type-3 (Kugelberg-welander disease)
3. Limb-girdle muscle dystrophy
4. Hoffman's disease (Hypothyroid myopathy)

Droopy eyes-Mystry solved!

This young female patient came to the ER with the c/o severe generalized weakness, double vision, drooping of eyelids. She first went to some local eye doctor thinking of it as conjunctivitis or stye but the doctor could not quite make out the diagnosis and advised her to get a CT scan of brain. But due to the increasing severity of her disease one day she came to our hospital emergency room. Fortunately, I was on duty at that time, so, I got the opportunity to examine the patient at the first visit. She had bilateral asymmetrical ptosis along with near total ophthalmoplegia in her both eye. Her power in the upper limb was of grade-3+ and in the lower limb grade-2+. Her muscle tone and tendon jerks were diminished in the both upper & lower limb but bladder bowel function was unaltered. She had an intact sensory system functioning and her cranial nerves other than IIIrd, IVth & Vth was absolutely normal. She neither had diabetes/hypertension nor any major illness in the past. There was no h/o snake bite or intake of adulterated food in the recent past. To rule out any gross intracranial pathology, I asked her immediately to get a CT scan of brain which came completely normal. At this stage I was a bit puzzled. What could be the diagnosis??

 But then one possibility clicked in my mind, I gave her Neostigmine (Myostigmine) injection test dose 1.5 mg IM along with inj. Atropine 0.4 mg IV stat. After a while, when I was busy in attending other patients, her husband came through and asked me to have a look at her wife. I was totally shocked when I saw her sitting in the bed, smiling and looking brightly at me. Her ptosis, ophthalmoplegia, limb weakness were seemed to have vanished like a magic. She and her husband both were very happy and expressed their gratitude to me. She was then admitted in the ward and on further evaluation her N-Ach receptor Antibody titre was found to be highly elevated, electrodiagnostic test with RNST was also corroborative with the diagnosis. CECT of mediastinum was done too in which thymoma was detected. So, we got the diagnosis now, it is Myasthenia gravis.

She was started on Tab Gravitor 60 mg TDS along with Tab. Prednisolone 30 mg OD. She improved eventually and was referred to a specialized center for thymectomy surgery.