Day-to-day medicine for medical students, interns and enthusiastic doctors!

These are some of the common abnormalities in rheumatological conditions involving the hands. 1. This is sclerodactyly in scleroderma. Note the thickening of the skin and telangiectasias. There can be many causes for ulceration in these patients. 2. This is classic rheumatoid arthritis. Note the involvement of wrist, metacarpophalangeal and proximal interphalangeal joints with sparing of distal interphalangeal joints. Deformities include 1. Volar subluxation at the wrist 2. Z thumb 3. Ulnar deviation at MCP joints 4. Boutonnieres 5. Swan neck 3. This is psoriatic arthritis. Note the involvement of distal interphalangeal joints. There are nail changes characteristic of psoriatic arthritis. Not only those, but there's psoriatic rash as well in the web between 3rd and 4th fingers of the left hand!! 4. This is osteoarthritis. PIP and DIP affected with prominent osteophyte formation. They are called Herbeden's and Bouchard'...

Thanks, Subodha Sugandika for your comprehensive answer. I will just add what's missing in red and will strikethrough  what is not that relevant. Microvascular complications of diabetes are diabetic nephropathy, diabetic retinopathy, and diabetic neuropathy.  1) Questions to ask from the patient:  Nephropathy: do u have a history of frothy urine? Have you noticed a change in the volume of urine you pass?  Or have u experienced dysuria or fever recently? Is there Increased fre quency of urination? Retinopathy: have u experienced any visual impairments recently?  Neuropathy:  Do not forget that there are different types of nerves! Sensory do u have numbness in your hands and feet? Are the limbs painful at night?  Do you lose your slippers when you are walking? When you are walking barefoot do  you feel as if you are walking on cotton? Autonomic Do you feel dizzy when you stand up from the bed or chair? Do you sweat profusely aft...

The commonest cause for pleural effusion is pneumonia when it's called a parapneumonic effusion. But if a patient comes with pleural effusion with no evidence of an infection, that effusion is considered malignant unless proven otherwise. The first investigation in any pleural effusion is a chest Xray. It will confirm the diagnosis There will be aetiological clues like Pneumonic patch Malignant lesion Rib erosions Infarctions Nowadays, an ultrasound scan of the chest is done routinely in all patients with effusions. USS can sometimes visualize consolidations, masses and pleural diseases that might not be apparent on the Xrays. When a malignancy is suspected or the cause is not evident in other investigation modalities, CT becomes the most useful investigation. The most important investigation in any pleural effusion is the pleural fluid aspiration. You all have to know the technique of doing it. But, now the blind approach is no longer recommended and it alwa...

Whenever we are examining a patient, we should have several objectives in mind. 1. Making a diagnosis 2. Grade the severity 3. Look for complication 4. Look for etiology 5. Look for associated conditions 6. Look for comorbid conditions 7. Look for drug-related side effects Remember this golden rule of physical examination. UNLESS YOU LOOK FOR A SIGN, YOU WILL NEVER SEE IT! Doing a thorough examination is a daunting task. Do not get depressed after reading this. I’m just trying to stimulate you. For your exam purposes telling 3-4 positives and negatives will be adequate. But, becoming a good clinician is not so easy. As an example let's see what we should look for in the general examination to find the aetiology (Only the aetiology!) of a pleural effusion. Please do not forget to read the part in red ! 1. Acute infection Fever Specific signs of some infections Melioidosis - Arthritis Atypical pneumonia - Skin rashes like erythemi...

A 46 years old clerk presented with central chest pain for 1 hour duration. This is his ECG. How are you going to manage the patient? Sir, the ECG shows an acute inferior ST elevation MI. This is a medical emergency. My task is to relieve the symptoms of the patient, stabilize him and reperfuse the ischemic muscle as quickly as possible. I will make sure that evaluation and management will happen simultaneously with minimal delay. I will immediately get the patient to an HDU and call my support staff to help me with the management. I will get them to attach the patient to a continuous cardiac monitor, check RBS, get blood for basic investigations and cardiac biomarkers and to insert a wide bore cannula while I'm evaluating the patient.  I will assess his airway and then breathing paying specific attention to the presence of bibasal crepitations indicative of cardiac failure and oxygen saturation. If saturation is less than 90% I will start oxygen via face mask . I will a...

Sir, this is a 12 lead ECG of Mr. blah blah. It is correctly calibrated. Heart rate is around 60/min, but there is a slight irregularity. P waves are normal and all p waves are followed by QRS complexes. Therefore, it is in sinus rhythm, and the irregularity is most likely to be due to sinus arrhythmia. The cardiac axis is normal. PR interval is normal. There are small Q waves in inferior and lateral leads. QRS complexes are normal and there is good R wave progression in anterior leads. There are prominent ST elevations in leads II, III and aVF. There are also mild ST elevations in V5 and V6. There is ST segment depression in aVL. T waves are upright and the QT interval appears to be normal. In conclusion, this patient has an ACUTE INFERIOR ST ELEVATION MI with possible lateral extension and reciprocal ECG changes in lead aVL. There is sinus arrhythmia, but no evidence of AV nodal dysfunction. I would like to do V4R and V7-V9 to look for right ventricular and posteri...

Sir, on examination of the respiratory system of this gentleman; His respiratory rate was 18 per minute. Trachea was deviated to the right side. Apex was felt 2 cm medial to the left midclavicular line. All my positive findings were confined to the left lower zone. There was, Reduced chest expansion Reduced vocal fremitus Stony dull percussion note and Absent breath sounds with reduced vocal resonance. I could not hear any added breath sounds. The rest of the lung fields were clinically normal with vesicular breath sounds. These findings are compatible with a clinical diagnosis of a left sided moderate pleural effusion with mediastinal shift to the right side.

Sir, This Xray belongs to *blah blah. It is an erect posteroanterior chest Xray. It is a good quality X-ray taken in deep inspiration, with no rotation and good penetration. The most striking abnormality is seen on the left side of the X-ray, where there is a homogenous opacity. It has silhouetted both cardiac and diaphragmatic borders. The upper margin is well distinct and it is concave upwards. I can not see any significant abnormality in the rest of lung fields such as consolidation or mass lesions. The trachea has slightly deviated to the right side. It is not possible to comment on cardiac size. There are no mediastinal abnormalities. I can not see any rib erosions or bone lesions. Soft tissue shadows appear normal. In conclusion, this shows a left-sided moderate pleural effusion with a mediastinal shift. There are no features to suggest a secondary cause such as consolidations, masses or bone deposits.

A 28 years old driver presented to a GP with a painful skin rash. He has had chicken pox when he was 6 years old. He had no other significant past medical history. GP made the diagnosis of herpes zoster (Shingles) and started him on oral aciclovir 800mg five times a day with oral Panadeine and Gabapentin for pain. He also checked the patient's RBS which was normal. How would you have managed this patient? The diagnosis is correct. It indeed is herpes zoster. However, there is something unusual about the distribution. If you compare with this picture of dermatomes, you will note that the rash is distributed over more than one dermatome. In such cases, it is essential to consider underlying immunodeficiencies. In a young patient, HIV should not be missed. Other common causes include diabetes and hematological malignancies.

A 62 years old lady presented with a history of shortness of breath for 2 years. She denied cough or wheezing. There was no history of ischemic chest pain in the past. Family history was unremarkable. On examination she was tachycardic. Blood pressure was 110/80mmHg. The house officer could not detect a murmur. Lungs were clear. In view of the cardiomegaly on the Xray, the house officer started IV frusemide and aspirin. The next day during the ward round, the consultant asked the HO to re-auscultate the patient. What is the diagnosis?

A 76 years old male patient admitted to the medical casualty ward with low-grade fever for 2 days with rhinitis and cough. He was on losartan for hypertension. His grandchild also has had similar symptoms a couple of days back. On examination the lungs were clear. WBC - 7.6, Hb 11.8, Plt 234, RBS 92, CRP 4.2 How will you manage the patient? Well, the upper respiratory tract infection will settle on its own. You might not have to do anything. If there is an epidemic of influenza you may use oseltamivir. Chest Xray shows some features of hyperinflation. So, take a history of smoking and other exposure. If the patient has exertional SOB you can manage as COPD. But, if you look carefully, chest Xray also shows a rib that's too white! What is it? That's due to sclerotic bone mets, probably from a prostate carcinoma.

A 75 years old lady was brought to the medical casualty ward semiconscious. Her consciousness had deteriorated over the preceding 3 days. There was no history of fever. On examination, she was overweight and had generalized edema. The pulse rate was 46/min and blood pressure was 80/50mmHg. There were bilateral basal crepitations. RBS was 130mg/dl. A bolus of IV normal saline was given, but there was no improvement of blood pressure. She was given several boluses of atropine but the response was transient and blood pressure didn't improve. What are the possibilities? In a bradycardic patient coming with a reduced level of consciousness, apart from the usual differentials such as myocardial infarction, you should always suspect less common causes. Some of them are, 1. Myxedema coma 2. Beta-blocker poisoning 3. Calcium channel blocker poisoning 4. Organophosphate poisoning What features would suggest the diagnosis of myxedema coma? Their appearance itself...

A 21 years old boy presented with a painful perianal lump. He had taken treatment 4 times from a another doctor during the last two years for similar symptoms. He made an incision and drained the abscess under local anaesthesia. Started the patient on oral coamoxyclav and sent him home. If you were the doctor, what would you have done? In any patient presenting with recurrent perianal disease including abscesses and fistulae, you have to suspect Crohn's disease. Is it common? It certainly is, but only if you are vigilant enough to suspect it and diagnose. Why should you bother, if it's a fistula or abscess you can just drain it or do a surgical intervention, isn't it? NO! Perianal involvement in crohn's disease is nasty. It can badly affect the patients quality of life. Imagine having to live the rest of life with discharging wounds in the perineum.  How can you make the diagnosis of crohn's disease? A good history and examination will help you...

A 52 years old man presented with central chest pain for one-hour duration. He admitted that he had on and off chest pain on exertion for the last few months. Picture from internet House-officer noted the ST depressions and gave S/L GTN, Aspirin 300mg, Clopidogrel 300mg, and atorvastatin 40mg stat doses. The ECG was 'vibered' to SHO and on his approval, HO started S/C enoxaparin 60mg bd. The next morning when the ECG was shown to the consultant, his eyebrows rose! 'You should've sent me the ECG.' He said. What would you have done if this patient came to you?? Whenever you see an ECG of a patient coming with chest pain, your priority should be to look for the presence of any evidence of STEMI, STEMI equivalents or other ECG changes that warrant immediate intervention. This is one such ECG. As you can see there are ST-segment depressions in many chest leads. In such instances make it a habit to look at aVR and V1 leads.  According to ESC guideli...

A 64 years old female patient with hypertension and hyperlipidemia was attending her GP very frequently with various complaints. Her major complaints included myalgia, backache, constipation, malaise, epigastric pain, headache and loss of appetite. On examination GP noted an abnormality in her hands. He could not pick up any other obvious abnormalities. Picture from internet What is this abnormality? This is carotenemia. You have to differentiate it from icterus, where the sclera is also yellow. What are the common causes? Primary carotenemia is when a patient develops this due to ingestion of food containing large amounts of carotenoids like carrot! When carotenoid intake is not excessive it's called secondary carotenemia, for which hypothyroidism is probably the commonest cause. Other causes include diabetes mellitus, hyperlipidemia and nephrotic syndrome. What will you do? In the setting of multiple complaints and carotenemia hypothyroidism is the likely ca...

This lady presented with a painful rash over the face for 2 days' duration. (Picture from internet) What is this? This is reactivation of varicella-zoster infection in the ophthalmic division of trigeminal ganglion, also known as herpes zoster or shingles. What are the features? The diagnosis is easy and the presentation is typical. Patients present like this with an extremely painful vesicular eruption confined to a single dermatome. Sometimes pain can be the presenting complaint and the rash can appear later. Who can get this? Anyone! But you see more complications in the elderly and in those who are immune compromised.  Is it contagious? Until the vesicles are crusted, it is contagious. So try to keep the rash covered if possible, and get the patient to wash hands frequently! So the treatment is aciclovir and gabapentin, isn't it? Herpes Zoster Ophthalmicus Well, in some patients that may suffice. But not in this patient. Why? One thing yo...

An 18 years old schoolboy came with epigastric burning pain for 2 days duration. He had similar episodes in the past which responded to over the counter antacids. This ECG was taken. What is it? Brugada syndrome. Well the nomenclature is confusing. But as long as you are not a cardiologist, call it Brugada Syndrome! What is Brugada syndrome? It is an autosomal dominant genetic disorder. Mutation is in a cardiac sodium channel. It leads to an abnormal ECG pattern called 'Brugada pattern' which carries an increased risk of ventricular arrhythmias and sudden cardiac deaths. Is it common? Do I really have to know it? It's not uncommon. Prevalence can be up to 1%, but could be even more as there can be many undetected people. But, if you miss it the consequences can be catastrophic! What are the ECG features? There are two patterns. Type 1 pattern is diagnostic. There will be 'coved' ST elevation of more than 2m...

A 63 years old retired teacher came to a GP to check her blood pressure as she had on and off headache for about 2 months. He denied vomiting, blurring of vision, angina or SOB. There was no significant past history except for a fall in the washroom causing a colles fracture to which had taken ayurvedic treatment. On examination her blood pressure was 180/100 in both arms and there was no other significant positive finding. GP adjusted the antihypertensives and within a several months, her BP was well controlled. However, about a year later she came to GP in a wheelchair! She had again fallen in the bathroom, and this time had fractured her hip. Oops!!! Yeah, that's so unfortunate isn't it. There was a chance to prevent this fracture. So what should have been done? Any patient with a fragility fracture needs to be investigated for osteoporosis and treated. What is osteoporosis? In the simplest terms, there is reduced d...

A 55 years old male patient admitted to medical casualty with a febrile illness for 3 days with myalgia. Examination was unremarkable. He was previously well except for chronic bilateral knee joint osteoarthritis. He consumed liquor quarter to half a bottle on a daily basis. Investigations revealed. WBC - 5.6 Hb - 11.2 Plt - 135 AST - 45 ALT - 42 S.Cr - 54 He was managed as viral fever and became fever free the next day. However the platelet count was persistently low around 130. Further investigations arranged. Blood picture - Thrombocytopenia probably due to liver disease S. Bilirubin, ALP - Normal S. Albumin - 38, S globulin - 37 USS abdomen - Coarse echogenicity of liver. Mild portal hypertension. Mild splenomegaly. Compatible with chronic liver cell disease. This patient has Cirrhosis with portal hypertension. Now the obvious cause for his cirrhosis is alcohol, isn't it? NO! Just because of the history of significant alcohol consumption you ca...