35yrs old male with C/o weakness and numbness of hands and feet for 4-5 months.

*Restless leg syndrome (RLS* ☝ *Today about*☝ Definition Restless leg syndrome (RLS) or Willis-Ekbom disease(WED) is a common cause of painful legs. The leg pain of restless leg syndrome typically eases with motion of the legs and becomes more noticeable at rest. Restless leg syndrome also features worsening of symptoms and leg pain during the early evening or later at night. Restless leg syndrome Restless leg syndrome is often abbreviated RLS; it has also been termed shaking leg syndrome. Night time involuntary jerking of the legs during sleep is also known as periodic leg/limb movement disorder. History The first known medical description of RLS was by Sir Thomas Willis in 1672. Willis emphasized the sleep disruption and limb movements experienced by people with RLS. Initially published in Latin (De Anima Brutorum, 1672) but later translated to English (The London Practice of Physick, 1685), The term “fidgets in the legs” has also been used as early as the early nineteenth century. Subsequently, other descriptions of RLS were published, including those by Francois Boissier de Sauvages (1763), Magnus Huss (1849), Theodur Wittmaack (1861), George Miller Beard (1880), Georges Gilles de la Tourette (1898), Hermann Oppenheim (1923) and Frederick Gerard Allison (1943). However, it was not until almost three centuries after Willis, in 1945, that Karl-Axel Ekbom (1907–1977) provided a detailed and comprehensive report of this condition in his doctoral thesis, Restless legs: clinical study of hitherto overlooked disease. Ekbom coined the term “restless legs” and continued work on this disorder throughout his career. He described the essential diagnostic symptoms, differential diagnosis from other conditions, prevalence, relation to anemia, and common occurrence during pregnancy. Epidemiology Except perhaps in Asian populations, RLS is a common disorder, occurring in about 10% of the population. The age-adjusted prevalence of RLS determined by telephone interviews in a random population of 1803 adults in Kentucky was 10%. A Canadian survey of 2019 adults estimated the prevalence of RLS symptoms at 17% for women and 13% for men. A population-based survey in West Pomerania, Germany, of 4107 subjects found an overall 10.6% prevalence. Using standardized questions in face-to-face interviews, Rothdach et al. reported an overall prevalence of 9.8% in 369 participants ages 65-83 years in Augsburg, Germany. In a study from Japan, 4612 participants living in urban residential areas were assessed for a single symptom of RLS by a self-administered questionnaire of the following two items: (1) Have you ever been told you jerk your legs or kick sometimes and (2) have you ever experienced sleep disturbance due to a creeping sensation or hot feeling in your legs? The prevalence of RLS ranged from 3% in women ages 20-29 years to 7% in women ages 50-59 years and correlated with age. In contrast to the first three studies, RLS had a higher prevalence in men than women, with the difference reaching significance in those 40-49 years old; in men there was no positive correlation with age. Face-to-face interviews of 157 consecutive individuals ages 55 years and older participating in a health screening program and 1000 consecutive individuals ages 21 years and older from a primary health care center in Singapore yielded much lower prevalence data. Using IRLSSG criteria, the prevalence of RLS in this predominantly Asian population was 0.6% in the older (1 male) and 0.1% (1 female) in the younger cohorts. In the Kentucky and Singapore studies, there was no gender difference; however, in the two German studies, the prevalence was higher in women and in the Japanese study it was higher in men. The Canadian study reported a significantly higher occurrence of bedtime leg restlessness in women. Types Restless legs syndrome (RLS) can be either primary or secondary, and the causes vary. Primary RLS is a neurological disorder. Although the majority of people with RLS begin to experience symptoms in their middle years, some may have signs of the problem in childhood. Their symptoms may slowly progress for years before becoming a regular occurrence. Secondary RLS tends to be more severe than the primary type and stems from another underlying condition, including the following: Anemia or low blood-iron levels Folate deficiency Nerve damage due to diabetes or other conditions Kidney disease or dialysis Attention deficit disorder (ADD) Attention deficit/hyperactivity disorder (ADHD) Pregnancy Rheumatoid arthritis Parkinson’s disease Risk factors RLS/WED can develop at any age, even during childhood. The disorder is more common with increasing age and more common in women than in men. Restless legs syndrome usually isn’t related to a serious underlying medical problem. However, RLS/WED sometimes accompanies other conditions, such as: Peripheral neuropathy: This damage to the nerves in your hands and feet is sometimes due to chronic diseases such as diabetes and alcoholism. Iron deficiency: Even without anemia, iron deficiency can cause or worsen RLS/WED. If you have a history of bleeding from your stomach or bowels, experience heavy menstrual periods or repeatedly donate blood, you may have iron deficiency. Kidney failure: If you have kidney failure, you may also have iron deficiency, often with anemia. When kidneys don’t function properly, iron stores in your blood can decrease. This, with other changes in body chemistry, may cause or worsen RLS/WED. Causes The cause of restless leg syndrome is unknown in most people. However, restless leg syndrome has been associated with Pregnancy, Obesity, Smoking, Iron deficiency and anemia, Nerve disease, Polyneuropathy (which can be associated with hypothyroidism, heavy metal toxicity, toxins, and many other conditions), Other hormone diseases such as diabetes, and Kidney failure (which can be associated with vitamin and mineral deficiency). Some drugs and medications have been associated with restless leg syndrome including: Caffeine, Alcohol, H2-histamine blockers (such as ranitidine [Zantac] and cimetidine [Tagamet]), and certain antidepressants (such as amitriptyline [Elavil, Endep]). Occasionally, restless leg syndrome run in families. Recent studies have shown that restless leg syndrome appears to become more common as a person ages. Also, poor venous circulation of the legs (such as with varicose veins) can cause restless leg syndrome. Symptoms The International Restless Legs Syndrome Study Group described the following symptoms of restless legs syndrome (RLS): Strange itching, tingling, or “crawling” sensations occurring deep within the legs; these sensations may also occur in the arms. A compelling urge to move the limbs to relieve these sensations Restlessness — floor pacing, tossing and turning in bed, rubbing the legs Symptoms may occur only with lying down or sitting. Sometimes, persistent symptoms worsen while lying down or sitting and improve with activity. In very severe cases, the symptoms may not improve with activity. Other symptoms of RLS include the following: Sleep disturbances and daytime sleepiness Involuntary, repetitive, periodic, jerking limb movements that occur either in sleep or while awake and at rest; these movements are called periodic leg movements of sleep or periodic limb movement disorder. Up to 90% of people with RLS also have this condition. In some people with RLS, the symptoms do not occur every night but come and go. These people may go weeks or months without symptoms (remission) before the symptoms return again. Complications Restless legs syndrome rarely results in any serious consequences. However, in some cases severe and persistent symptoms can cause considerable mental distress, chronic insomnia, and daytime sleepiness. In addition, since restless legs syndrome (RLS) is worse when resting, people with severe RLS may avoid daily activities that involve long periods of sitting, such as going to movies or traveling long distances. Diagnosis and test There’s no single test for diagnosing restless legs syndrome. A diagnosis will be based on your symptoms, your medical and family history, a physical examination, and your test results. Your GP should be able to diagnose restless legs syndrome, but they may refer you to a neurologist if there’s any uncertainty. There are four main criteria your GP or specialist will look for to confirm a diagnosis. These are: an overwhelming urge to move your legs, usually with an uncomfortable sensation such as itching or tingling your symptoms occur or get worse when you’re resting or inactive your symptoms are relieved by moving your legs or rubbing them your symptoms are worse during the evening or at night Blood tests Your GP may refer you for blood tests to confirm or rule out possible underlying causes of restless legs syndrome. For example, you may have blood tests to rule out conditions such as anaemia, diabetes and kidney function problems. It’s particularly important to find out the levels of iron in your blood because low iron levels can sometimes cause secondary restless legs syndrome. Low iron levels can be treated with iron tablets. Sleep tests If you have restless legs syndrome and your sleep is being severely disrupted, sleep tests such as a suggested immobilisation test may be recommended. The test involves lying on a bed for a set period of time without moving your legs while any involuntary leg movements are monitored. Occasionally, polysomnography may be recommended. This is a test that measures your breathing rate, brain waves and heartbeat throughout the course of a night. The results will confirm whether you have periodic limb movements in sleep (PLMS). Treatment and medications Treatment for RLS is targeted at easing symptoms. In people with mild to moderate restless legs syndrome, lifestyle changes, such as beginning a regular exercise program, establishing regular sleep patterns, and eliminating or decreasing the use of caffeine, alcohol, and tobacco, may be helpful. Treatment of an RLS-associated condition also may provide relief of symptoms. Other non-drug RLS treatments may include: Leg massages Hot baths or heating pads or ice packs applied to the legs Good sleep habits A vibrating pad called Relaxis Medications may be helpful as RLS treatments, but the same drugs are not helpful for everyone. In fact, a drug that relieves symptoms in one person may worsen them in another. In other cases, a drug that works for a while may lose its effectiveness over time. Drugs used to treat RLS include: Dopaminergic drugs, which act on the neurotransmitter dopamine in the brain. Mirapex, Neupro, and Requip are FDA-approved for treatment of moderate to severe RLS. Others, such as levodopa, may also be prescribed. Benzodiazepines, a class of sedative medications, may be used to help with sleep, but they can cause daytime drowsiness. Narcotic pain relievers may be used for severe pain. Anticonvulsants, or antiseizure drugs, such as Tegretol, Lyrica, Neurontin, and Horizant. Although there is no cure for restless legs syndrome, current treatments can help control the condition, decrease symptoms, and improve sleep. Lifestyle and home remedies Making simple lifestyle changes can help alleviate symptoms of RLS/WED. Try baths and massages: Soaking in a warm bath and massaging your legs can relax your muscles. Apply warm or cool packs: Use of heat or cold, or alternating use of the two, may lessen your limb sensations. Try relaxation techniques: such as meditation or yoga. Stress can aggravate RLS/WED. Learn to relax, especially before bedtime. Establish good sleep hygiene: Fatigue tends to worsen symptoms of RLS/WED, so it’s important that you practice good sleep hygiene. Ideally, have a cool, quiet, comfortable sleeping environment; go to bed and rise at the same time daily; and get adequate sleep. Some people with RLS/WED find that going to bed later and rising later in the day helps in getting enough sleep. Exercise: Getting moderate, regular exercise may relieve symptoms of RLS/WED, but overdoing it or working out too late in the day may intensify symptoms. Avoid caffeine: Sometimes cutting back on caffeine may help restless legs. Try to avoid caffeine-containing products, including chocolate and caffeinated beverages, such as coffee, tea and soft drinks, for a few weeks to see if this helps.

A obese 65 yr old male patient presented to opd with complaint of lesion on tongue similar to this photo I have posted sorry this is not pt photo, he was known diabetic and hypertensive and was already on medication under some physician, already taking metformin 500 mg , he had stopped medication for BP management, his BP was 164/110 mmhg with swelling in leg , fasting sugar 95 and post prandial 115 , with burning and tingling sensation in soles , bloating in abdomen and constipation complaint, I prescribed medications for tongue lesion , ganatone 50 mg bd for bloating for 15 days , metformin to be continued, amlodipine 10 mg hypertension, advised lipid profile , RFT, Sgot, Sgpt, ....... Please suggest other test which are missing here , drug combination to control BP on long term, and treatment for peripheral neuropathy in long term

60 yrs female known diabetic uncontrolled with painless non healing ulcer left big toe 3months,elevated ESR 50mm at the end of 1hr, Xray chest shows rt upperzone infilterates.kindly give ur opinion about management.Pt has developed slow speech, bradycardia and severe constipation.

*Hypothyroidism* *☝ all about☝* – also called underactive thyroid – is the most common thyroid disorder. It happens when your thyroid gland doesn’t produce enough thyroid hormone, which is essential because thyroid hormone helps regulate important body processes, such as your metabolism. But with low thyroid function, these body processes slow down. Pathophysiology The hormones produced by the thyroid gland are T3 and T4. These hormones have an action on almost all parts of the body. The secretion of these hormones is regulated by TSH or thyroid stimulating hormone that is secreted by the pituitary gland. The secretion of thyroid hormone occurs only from this particular gland. The presence of iodine and amino acid tyrosine are a must for the production of thyroid hormones. Hypothyroidism and low levels of the thyroid hormones can occur if there is a deficiency of iodine for thyroid or thyroid stimulating hormone (TSH). The hypothalamus of the brain secretes TRH thyroid releasing hormone which acts on the pituitary gland and initiates the release of TSH or thyroid stimulating hormone. TSH then acts directly on the thyroid gland to release thyroid hormones T3 and T4. The normal functioning of the thyroid (healthy thyroid) is regulated by negative feedback mechanism where the levels of thyroid hormones increase or decrease under the influence of TSH. Causes Hashimoto’s thyroiditis: This autoimmune disease is the most common cause of hypothyroidism. Medications: Certain medications, such as lithium, can cause hypothyroidism. Pregnancy: Hypothyroidism can develop during or after pregnancy. Treatment for hyperthyroidism: People who have hyperthyroidism (overactive thyroid) are treated with radioactive iodine therapy, which impairs thyroid function and can cause hypothyroidism. Thyroid surgery: If your thyroid gland is removed, you can’t make thyroid hormone, so you’ll need to take thyroid hormone replacement. Radiation therapy: Radiation used for the treatment of cancer in the head or neck, lymphoma, or leukemia, may slow or halt the production of thyroid hormone. This will almost always lead to hypothyroidism. Risk factors There are two main factors to consider – age and sex. The chances of being hypothyroid increase with age, and they are greater if an individual is a woman. You have a family history of thyroid disease or any autoimmune disease You have type 1 diabetes or rheumatoid arthritis, or other autoimmune disorders As mentioned in the causes section medications and thyroid surgery also a major risk factors Signs and Symptoms in adults Women who are over age 60, as well as men who are aging, should look out for these potential symptoms of hypothyroidism: Weight gain Fatigue Sensitivity to cold temperatures Depression Dry skin Thinning hair Heavy menstrual periods (in women) Trouble sleeping Difficulty concentrating Pain or swelling of the joints Constipation High cholesterol levels Muscle weakness Signs and symptoms in Children and teen Symptoms of hypothyroidism in children and teens are similar to symptoms in adults and can include: Poor growth or short stature Delayed puberty Slow reaction time Weight gain Coarse, dry hair or skin Muscle cramps Delayed mental development Increased menstrual flow for girls Signs and Symptoms in Infants Symptoms of hypothyroidism in infants may include: Jaundice (yellowing of the skin and whites of the eyes) Frequent choking Puffy face Constipation Complications Heart disease and stroke Hypothyroidism can lead to insulin resistance The myxedema coma Goiter Mental health issues Peripheral neuropathy Low levels of thyroid hormone can interfere with ovulation, which impairs fertility Birth defects Diagnosis and test Medical evaluation Your doctor will complete a thorough physical exam and medical history. They’ll check for physical signs of hypothyroidism, including: Dry skin Slowed reflexes Swelling A slower heart rate In addition, your doctor will ask you to report any symptoms you’ve been experiencing, such as fatigue, depression, constipation, or feeling constantly cold. Blood test There are several types of blood tests – the most definitive one is called the TSH test (thyroid-stimulating hormone). However, in some cases, physicians may refer to the free thyroxine or T4, free T4 index, or total T4 to aid in the diagnosis. TSH Test A thyroid-stimulating hormone or TSH is a blood test that measures the amount of T4 (thyroxine) that the thyroid is being signaled to make. If you have an abnormally high level of TSH, it could mean you have hypothyroidism. 0.4 mU/L to 4.0 mU/L is considered the reference range (there may be a slight variation depending on the laboratory), TSH >4.0/mU/L with a low T4 level indicates hypothyroidism. T4 (thyroxine) Test The thyroid gland produces T4 (thyroxine). The free T4 and the free T4 index are blood tests that, in combination with a TSH test, can let your physician know how your thyroid is functioning. Anti-thyroid Microsomal Antibodies Testing A third hypothyroid test is for anti-thyroid microsomal antibodies—anti-thyroid peroxidase (anti-TPO). These antibodies, which are produced by the immune system, may attack thyroid cells. If a blood test determines their presence, it shows that there has been thyroid damage which could potentially lead to hypothyroidism. Differentiation of Hypothyroidism Primary hypothyroidism Primary hypothyroidism is due to disease in the thyroid; thyroid-stimulating hormone (TSH) is increased. The most common cause is autoimmune. It usually results from Hashimoto thyroiditis and is often associated with a firm goiter or, later in the disease process, with a shrunken fibrotic thyroid with little or no function. The 2nd most common cause is post-therapeutic hypothyroidism, especially after radioactive iodine therapy or surgery for hyperthyroidism or goiter. Secondary hypothyroidism Secondary hypothyroidism occurs when the hypothalamus produces an insufficient thyrotropin-releasing hormone (TRH) or the pituitary produces insufficient TSH. Sometimes, deficient TSH secretion due to deficient TRH secretion is termed tertiary hypothyroidism. Subclinical hypothyroidism Subclinical hypothyroidism is elevated serum TSH in patients with absent or minimal symptoms of hypothyroidism and normal serum levels of free T4. Subclinical thyroid dysfunction is relatively common; it occurs in more than 15% of elderly women and 10% of elderly men, particularly in those with underlying Hashimoto thyroiditis. Treatment and medication Medications Hypothyroidism is a lifelong condition. For many people, medication reduces or alleviates symptoms. Hypothyroidism is best treated by using levothyroxine (Levothroid, Levoxyl). This synthetic version of the T4 hormone copies the action of the thyroid hormone your body would normally produce. The medication is designed to return adequate levels of thyroid hormone to your blood. Once hormone levels are restored, symptoms of the condition are likely to disappear or at least become much more manageable. Animal extracts that contain thyroid hormone are available. These extracts come from the thyroid glands of pigs. They contain both T4 and triiodothyronine (T3). If you take levothyroxine, you’re only receiving T4. But that’s all you need because your body is capable of producing T3 from the synthetic T4. These alternative animal extracts are often unreliable in dosing and haven’t been shown in studies to be better than levothyroxine. For these reasons, they aren’t routinely recommended. Thyroid Hormone Replacement Therapy The main goal is to compensate for the lack of hormone secreted by the thyroid gland. In most cases, an affected individual will take a daily dose of T4 (or T3 and T4) in a pill taken orally. But it’s important to understand that every patient’s therapy may be different. There is no cookie-cutter dosage or treatment plan when it comes to thyroid hormone replacement therapy. How the body absorbs the hormones, along with the number of hormones needed to help the body function properly is very varied. Prevention Taking iodine supplements can prevent hypothyroidism. Exercises and alternative therapies may prove more than effective in minimizing symptoms of thyroid imbalance than traditional treatments. Get a screening test every five years if you are 50 years old or older. Get regular screenings if you: Have Type 1 diabetes Have infertility (females) Take certain medications Natural remedies Do not use non-stick cookware Eliminate Soy: Soy restrains functions of the thyroid, imbalances hormones & it has been appeared to cause goiters Balance Estrogen Levels: Excessive consumption of estrogen slows down the thyroid organ. This implies disposing of anti-conception medication, expanding the fiber in the eating routine & keeping away from all non- organic meats. Adhere to an Alkaline Diet: This is greatly useful when curing any severe issue. Exercise: Find a physical movement activity that is fun & does it regularly. Iodine: The thyroid requires iodine to work appropriately & loads of individuals now experience the ill effects of iodine lacks. To test yourself, put some iodine on your stomach. In case it vanishes in 12 hours, at that point you are lacking iodine. Continue including iodine in increased amounts, until it doesn’t vanish in a 12-14 hours’ time. This works because of the way that the body trans-dermally absorbs iodine at the rate at which it is required. Avoid all types of fluoride Move for natural diet: To enable the body to recuperate itself, take away the loads on its immune system. This implies every single processed food, synthetic flavors, hues, additives, white sugar, white flour, table salt, hydrogenated oils, aluminum and etc. ought to be removed from the diet chart. Organic food is perfect. Chlorophyll: Including chlorophyll gives fundamental copper, oxygenates the body, adds healthy RBC’s, and in general helps with skin health. Chlorophyll is a safe strategy for the oral supplement of copper. Pears and Apples: Pears help most when combined with or mixed with apple juice. Try this pear juice formula, and drink it routinely. Zinc and Selenium: Studies demonstrate that serious zinc or selenium insufficiencies would cause diminished thyroid levels. Never take zinc first thing in the stomach. Brazil nuts are high in both zinc and selenium. Coconut Oil: Buy natural, fresh squeezed, coconut oil from a health store. Take around 1 teaspoon every day. You can likewise use it in cooking, yet be cautioned that it smokes at low cooking temperatures, so it should just be utilized for low-warm cooking. Coconut oil speeds up the digestion improve thyroid hormone generation and cut down candida yeast. Avoid Canola Oil: Canola oil meddles with the generation of thyroid hormones, among its numerous risks. Treat canola oil like the evil, genetically engineered hereditarily designed poison.