A 48-year-old woman presented with sudden-onset altered sensorium 2 days after a snake bite (unidentified species) and was found to have a large right frontal intracerebral haemorrhage (ICH) with transtentorial herniation (TTH) causing brain stem compression. A day later, neurological examination revealed internuclear ophthalmoplegia (INO) fitting the clinical description of wall eyed bilateral INO syndrome. INO is a rare ocular motor sign, the most common causes being brain stem infarction, haemorrhage or demyelinating disease. It rarely acts as a false localising sign, such as in this case, and in an even rarer cause for ICH, that is, haemotoxic snake bite without initial evidence of coagulopathy. An emphasis needs to be laid on detailed physical examination, often considered a lost art nowadays, to help detect subtle clinical signs which could herald ominous complications of conditions like TTH and help in early diagnosis and treatment of the same.

Takotsubo cardiomyopathy may present like acute coronary syndrome and is characterized by reversible left ventricular (LV) apical ballooning in the absence of any significant underlying coronary artery disease. A 65-year-old lady presented to the ED with history of sudden onset left-sided weakness of body. Head CT scan was suggestive of right gangliocapsular intracerebral bleed with intraventricular extension. 2D Echo showed characteristic LV apical ballooning with hypokinesia and LV ejection fraction of 25%-30%. Diagnosing Takotsubo cardiomyopathy includes resolution in electrocardiogram (ECG) changes and reversible LV dysfunction on two-dimensional echocardiogram, and a normal coronary angiography.

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MGMJMS MGMJMS Table 1: Blood investigations Parameters Day 1 Day 3 Hemoglobin (gm/dl) 11.6 gm/dl 10.5 gm/dl WBC/mm 3 12,800/mm 3 11,500/mm 3 Platelets/mm 3 2.0 lakhs 2.2 lakhs Bleeding time 2 mins 15 secs 2 mins 10 secs Clotting time 3 mins 45 secs 3 mins 30 secs Prothrombin time 14 secs 12 secs Serum creatinine (mg%) 1.6 mg% 0.88 mg% Sodium (mmol/l) 132 mmol/l 140 mmol/l Potassium (mmol/l) 2.7 mmol/l 3.2 mmol/l

Protein C deciency (PCD) is a rare genetic disorder that occurs due to mutation in PROC gene and results in increased predisposition to thrombosis, PCD can be 'autosomal dominant 'which is relatively more common occurs in adults and usually presents as recurrent DVT, ischemic colitis or may remain asymptomatic. 'Autosomal recessive PCD' is relatively rare, more severe and presents in neonates as 'neonatal purpura fulminans'. I report a case of 41-yearold male who came with history DVT (recurrent) and diagnosed as 'Protein C deciency: Type 1'