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

A 26 years old patient presented with a history of fever for approximately 5 days duration. He complained of nausea, headache, backache and myalgia. His brother has had a febrile illness about a week ago. On examination he was ill looking. There was no rash or lymphadenopathy. Pulse rate was 110/min. Blood pressure was 90/60mmHg. There was mild tender hepatomegaly. This is a very common clinical presentation you will encounter every now and then. 1. What are the main differential diagnoses? 2. What clinical features will you specifically look for? 3. How will you initially manage the patient? As the patient was ill looking the house officer summoned the registrar. Registrar elicited following points from the history and examination. The patient had worked in a paddy field during the last few weeks. (leptospirosis exposure) He had conjunctival suffusion. (A feature of leptospirosis) There was no icterus. There was no pleural effusions, ascites. (To exclude dengue hae...

Treatment of thyrotoxicosis has several aspects 1. Symptomatic relief Beta-blockers are the first line. Beta-blockers can be started even before the diagnosis is confirmed. When you suspect thyrotoxicosis start beta-blockers before reviewing the patient with TSH and Free T4 reports. The usual dose is Propranolol 20-40mg three to four times a day. Make sure the patient does not have bronchial asthma! 2. Reduce thyroid hormone synthesis Thionamides are safe and have a quick onset of action Carbimazole is the commonly used drug The usual dose is 10mg three times a day, but according to the initial Free T4 level, the dose can be adjusted. The maintenance dose should be continued for a year or two before considering stopping the treatment. Many patients will relapse requiring other definitive treatments MCQ tip Agranulocytosis is a 'favorite' complication of thionamides The patient should be advised to stop taking carbimazole and immediately come to the hos...

Scenario An elderly lady presented with a history of feverish feeling for one week duration on a busy casualty night. She had taken treatment once from a GP without an improvement. She complained of aches, pains and fatigue. She complained of a mild on and off cough. There was no chest pain, urinary symptoms, vomiting or diarrhoea. On examination she was a thin built lady, who appeared anxious. Her pulse rate was 110/min. Blood pressure was 140/100mmHg. Lungs were clear and abdominal examination was normal. House officer made the diagnosis of a possible respiratory tract infection and started her on paracetamol, piriton, nebulization SOS with salbutamol and oral coamoxyclav. During the morning ward round the house officer noticed the patients pulse was 170/min. He immediately attached the patient to the monitor and called the SHO. The monitor showed atrial fibrillation. Diagnosis? Thyrotoxicosis with AF precipitated by salbutamol nebulization. Lesson - Thyrotoxicosis ...

A 78 years old patient was brought to the hospital by his son. The son had noted his father was behaving oddly yesterday. He was increasingly forgetful. For half an hour he was muttering to himself. But by evening he had completely recovered. However, today morning he had urinated inside the house. The patient denied any history of fever, headache, limb weakness or numbness. The patient was a known hypertensive patient on losartan. But he was otherwise well. On examination the patient was well alert and oriented. The house officer failed to elicit any positive physical signs. As the father had fully recovered the son wanted to take him home against advice without further testing. What would you do?? What are the possibilities? House officer was reluctant to send the patient back without being seen by a senior doctor. He called the senior house officer, who came and ordered a non contrast CT brain. CT scan showed a large SDH! It needed urgent neurosurgical intervention....

A young girl admitted with a history of low-grade fever for 3 days duration during a dengue epidemic. She was otherwise well. There were no other physical features on examination. She was managed as a dengue fever with oral fluids. Her initial FBC showed WBC 4.3 and PLT 88. On day 6 her WBC was 4.6 with PLT 95. As she was afebrile for 2 days she was discharged with a plan to review in 3 days.  She returned 3 days later with another FBC. WBC was 4.4 and PLT was 112. As the platelets were rising the plan was to review her SOS. Two weeks later she admitted with fever to the same ward. By that time her FBC was drastically different. WBC - 1.2 Hb - 9.5 PLT - 6 Further investigations revealed that she had got acute lymphocytic leukemia. Lesson Especially in young patients, consider all abnormal investigations to be a serious disease unless proven otherwise. Whenever you detect an abnormal report at the time of discharge make sure to review the patien...

An elderly man with a past history of knee joint osteoarthritis on long term analgesics from a GP presented with worsening abdominal pain for 1-day duration to the medical casualty ward. There was no fever or vomiting. He had not passed stools on the day of admission. There was no history of hematemesis or malena. On examination, the patient was ill-looking. Epigastrium was tender. He was tachycardic, but the blood pressure was normal. The house officer ordered IV omeprazole and IV fluids. He kept the patient nil by mouth. He ordered basic investigations including supine and erect Xrays of the abdomen and serum amylase. About an hour later the Xrays were taken and as they were normal same management was continued. The senior registrar came for the ward round in the evening and he immediately called the colleague surgical senior registrar. "Hey, I think we've got a patient for laparatomy. Please come and see!" Tentative Diagnosis?? Perforated peptic ulcer ...

A young man presented with a skin rash which he developed soon after eating a pizza. He had a generalized urticarial rash. He was not dyspnoeic. He came walking to the ward. House officer was noted that the blood pressure was 85/65mmHg. As the patient was asymptomatic he ordered one pint of IV normal saline over 30min. He also prescribed IV chlorpheniramine 10mg and IV hydrocortisone 100mg. 30 minutes later he was reviewed by the house officer. The patient was conscious and not dyspnoeic. But the blood pressure was 60/40mmHg. He immediately called the SHO. Diagnosis - Anaphylactic shock Lesson Anaphylaxis is a killer Your patient will die in front of you unless you act fast Once the anaphylaxis is established, it’s a nightmare to treat There’s no other drug for anaphylaxis better and safer than ADRENALINE. Never hesitate to give adrenaline if you suspect anaphylaxis. Never hesitate to give adrenaline if you suspect anaphylaxis. Never hes...

An elderly lady presented with 2 days history of cough and wheezing. She has had recurrent wheezing and was followed up at a local hospital. She was on regular salbutamol 2mg tablets three times a day and oral theophylline 125mg twice a day. On examination, she was dyspnoeic and had bilateral wheezing. She was managed with oral antibiotics, regular nebulizations and a short course of oral prednisolone. The consultant asked the house officer to start her on an MDI inhaler and spacer at the time of discharge. 2 days later she again admitted to a local hospital with wheezing. She got better with nebulization and discharged on the following day. A day later she again readmitted with wheezing and transferred back to the tertiary hospital. Her response to nebulization was good. She was nearly asymptomatic the next day morning. The consultant asked the house officer to check the inhaler technique as she got recurrent admissions. She took the spacer out, fixed it. Took the inhaler out...

A middle-aged lady with diabetes mellitus admitted to the medical casualty ward with a high fever. She also complained of dysuria and left-sided loin pain. She had dysuria for the past one week and had taken treatment from a private practitioner. She was given oral cefuroxime for 7 days. But she had stopped taking treatment after 3 days as her dysuria got better. two days later she developed a high-grade fever with chills and rigors with loin pain and vomiting. On examination, she was ill and dehydrated. The pulse rate was 120/min. Her blood pressure was 90/60mmHg. There was marked left side renal angle tenderness. Diagnosis - Left-sided pyelonephritis with shock in a patient with diabetes mellitus After initial resuscitation and antibiotics, she made a good recovery. Blood culture yielded E. coli which was only sensitive to meropenem. Lessons Never ever prescribe an antibiotic without taking proper cultures! Always prescribe the correct antibiotic, in the correct dose,...

A young girl presented with fever for 4 days duration in the evening to the casualty medical ward. She complained about few episodes of diarrhea and 2 episodes of vomiting. There was mild epigastric pain. Her younger brother also had a diarrheal illness about a five days back. She denied outside food consumption. She was ill looking but the blood pressure was 110/80mmHg. Pulse rate was 104/min. House officer decided to give a pint of normal saline over 1 hour as she was not taking orally. He also ordered bifilac, oral rehydration solution and intravenous metoclopromide. He didn't start an antibiotic, but made a mental note to ask the registrar during the night ward round. Three hours later he went to review the patient. She was still ill looking but the blood pressure was 80/60 mmHg. There had been one another episode of loose stools but the amount was little. He asked to give a pint of saline fast and called the registrar. On examination the registrar detected bilateral pleu...

A young female patient admitted with a one week history of headache and low grade fever. She has had on and off headache for 2 weeks prior to the onset of headache. On examination she had neck stiffness and papilloedema. Patient had diplopia towards right side. CSF study was done Appearance - clear Opening Pressure - normal Cell count - 80 (70% lymphocytes, 30% neutrophils) Protein - 120mg/dl Sugar - 34mg/dl (Blood sugar 88mg/dl) AFB - Not seen Culture - No growth She was started on anti TB treatment as the most likely diagnosis was TB meningitis. 6 days into illness her headache was slightly reduced. Fever was still there, but the patient was feeling relatively better. She was spent most of her time on bed as she found it difficult to walk due to diplopia. On day 10 after admission she complained of sudden onset shortness of breath. There was tachycardia. Saturation was 89% on air. Lungs were clear to auscultation. Her left leg was swollen and t...

A 16 years old boy presented with 2 days history of perioral numbness and difficulty in speaking. He denied having carpopedal spasms. There were no other complaints. Mother was concerned that the child was moody for the last two days. He was no smiling and appeared very grumpy. When he spoke he hardly opened his mouth and was staring at the doctor during the entire consultation. Chvostek's and Trousseaus signs were negative. Basic investigations including electrolytes and calcium were normal. Like always, the consultant made a spot diagnosis next morning. Bilateral facial nerve palsy! Lesson It is easy to miss bilateral facial palsy as there may not be an obvious asymmetry. Google and see some pictures of bilateral facial palsy. Known causes are Guillain Barre Syndrome Sarcoidosis Diabetes Vasculitic conditions Bilateral bells palsy! Is there a way to differential bilateral lower motor neuron facial palsy from bilateral upper motor neuron facial palsy??

An elderly patient with hypertension was found to have hyperkalemia in a routine check up. His hypertension was well controlled with amlodipine. Initial potassium (K) value was 5.9mmol/l. He was seen by a general practitioner and was asked to avoid fruits and king coconut juice and repeat a serum electrolyte in 3 days. Repeat K value was still 5.7mmol/l. As the ECG did not show any significant hyperkalemic changes he was asked to continue avoiding high K containing food and beverages. A week later he presented again with a K value of 6.1mmol/l. He was so annoyed that he had to avoid fruits as he used to have a fruit platter each morning. The GP decided to admit him for further investigations. He was admitted to medical casualty ward. Investigations revealed WBC - 16.67  N - 60% L - 36% Hb - 16.8 g/dl Plt - 570 S. Cr - 73umol/l Na - 138mmol/l K - 6.1mmol/l ECG  The consultant made a spot diagnosis and an hour later the patient was seen eat...

Elderly man presented to medical casualty with severe central chest pain. He was restless and was sweating. Blood pressure was 180/100 and pulse rate was 96/min. There was a murmur. Lungs were clear. Urgent ECG was taken. As there were widepread ST depressions the house officer started the patient on aspirin, clopidogrel, atorvastatin and enoxaparin. For pain he prescribed GTN and morphine which calmed down the patient. Two hours later patient again complained of severe chest pain which did not respond to GTN. The registrar was summoned. Blood pressure was still 180/100 and the heart rate was 120/min. Registrar noted also noted a murmur. The differential diagnosis of aortic dissection was immediately considered. There was a radio femoral delay! After urgent management a CT aortogram was done which showed a massive dissection of aorta extending from aortic root down to aortic bifurcation. The had a cardiac arrest a few hours later. Lesson. ~ Any chest pain could be an ao...