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

A 64 years old male patient admitted with worsening shortness of breath for 2 days duration. He had cough and wheezing. He had a history of cigarette smoking for more than 30 years. On examination he was thin built and was dyspneic. He was mildly pale. Lungs were hyperinflated with widespread ronchi. Cardiac and liver dullness were impaired. Clinical Diagnosis? Exacerbation of COPD Management? Stop smoking Nebulized/ Inhaled bronchodilators +/- steroids Antibiotics Investigation reports were as follows. WBC - 13.5  ( N - 70%   L - 30%) Hb - 10.5 Plt - 350 MCV - 76 AST - 35 ALT - 40 S. Cr - 78 CXR What are the abnormalities in this Xray? The patient improved with treatment and was discharged 2 days later. About three weeks later patient readmitted with similar symptoms. Examination findings were again compatible with an exacerbation of COPD. His inhaler technique was good and he was compliant with the medications. He ha...

An elderly man with long standing diabetes mellitus was followed up at a medical clinic. His blood sugar values and blood pressure recordings were as follows. March 2019 FBS - 180mg/dL PPBS - 210mg/dL BP - 170/110mmHg April 2019 FBS - 155mg/dL PPBS - 190mg/dL BP - 160/100mmHg May 2019 FBS - 150mg/dL PPBS - 176mg/dL BP - 150/90mmHg Happy?? Certainly yes! Blood sugar values were slowly but improving. Blood pressure was also getting better. In June 2019 patient admitted with fever, right leg swelling and pain. Patient was confused, there was tachycardia and low blood pressure. Clinical diagnosis? Cellulitis causing sepsis with shock. How are you going to resuscitate? Recall the sepsis BUNDLE! In summary Hydrate Inotropes - Preferably Noradrenaline Take cultures Start appropriate IV antibiotics Control blood sugar with insulin (140-180mg/dL) Treat empirically for DVT, if excluded give prophylaxis. Get help from surgical team...

A 32 years old previously healthy male patient admitted with a history of palpitations for 1 hour duration. He had experienced a similar episode a few months back which lasted only for few minutes. What are your concerns? First priority is to make sure that the patient is stable. Who is unstable? Hypotensive patient (Systolic BP < 90mmHg) Coronary ischemia (Ischemic chest pain) Cardiac failure (Patient has SOB) Patient with brain hypoperfusion (reduced conscious level) IF ANY OF ABOVE ARE PRESENT IRRESPECTIVE OF THE TYPE OF ARRHYTHMIA YOU WILL HAVE TO PERFORM DC CARDIOVERSION (SHOCK) ECG Analysing tachyarrhythmias is a long topic, which might bore you. Let's learn a few short cuts to diagnose common arrhythmias. Look at the QRS Is it narrow or broad? Narrow complex tachycardias we usually encounter are SVT (Read and understand the proper nomenclature. SVT is a wrong term!) Atrial fibrillation/ flutter In most patients both are managed the s...

A 45 years old female patient presents to you saying, 'Dr. I think I have blood pressure'. You measures her blood pressure and it's 160/100mmHg. What are you going to do? Your first task is to establish the diagnosis of hypertension. How can you diagnose a patient to have hypertension? Blood pressure should be properly measured! it's not easy. Things that we often miss are Quite/calm room Bladder not full Correct patient position Rest the arm on the table Correct cuff size NO talking during procedure Avoid caffeine, exercise, smoking for minimum 30 min Measure BP in both arms, select the arm with the higher value for future measurements Take two values 1-2min apart and calculate the average. Confirm the high blood pressure on a second occasion/ confirm that it's not transient Sometimes a second measurement is not necessary if there's evidence to say patient had chronic hypertension Retinal changes ECG - LV hypertrophy Hypertens...

A 21 years old boy presented with recurrent headache. Headache is severe that he can't do his studies during the episodes. It lasts for about a day, and is associated with nausea and vomiting. He gets pain two to three times a week. What are the possibilities? In young patients, commonest causes for headache are Sinusitis Tension headache Migraine After browsing internet about the symptoms, he himself made the diagnosis of migraine. He took panadiene regularly but the response was poor. Finally he decided to see a doctor to get treatment for his migraine. He was started on flunnerizine by the GP for migraine. Initially the response was good. But about a month later he was brought to hospital by his friends after collapsing while playing a cricket match. He was getting tonic clonic convulsions. Seizure was managed with IV diazepam. Urgent CT brain revealed a large space occupying lesion. Lesson Migraine is common. It's an easy diagnoses to make. But,...

A 75 years old female patient with diabetes mellitus, hypertension and ischemic heart disease presented with fever and cough for 3 days duration. She produced yellow color sputum, but there was no hemoptysis. There was right-sided chest pain on breathing. She had nausea and the appetite was poor. What are the possibilities? Fever, cough, sputum and pleuritic chest pain equals pneumonia unless proven otherwise! Many conditions can mimic pneumonia. Read and find out! On examination the patient was ill-looking. She was tachycardic and tachypnoeic. Blood pressure was 100/70mmHg.  Respiratory examination revealed signs localized to the right lower zone. Reduced chest expansion Increased vocal fremitus Dull percussion note Bronchial breathing Increased vocal resonance Whispering pectoriloquy! What do these physical signs mean?  Read about physical signs and how to interpret them. A consolidation in the right lower zone. With these findings, the clinic...

A 54 years old previously well patient admitted with progressively worsening shortness of breath for 2 days duration. He had low grade fever for the same duration. There was no history of cough, wheezing or chest pain. He had facial and leg swelling. 4 days back he had taken medications from the local hospital for a back pain he developed after lifting a cupboard. What are the differential diagnoses? Like in any patient with acute SOB, respiratory and cardiac causes should be considered first. On examination he was ill, tachypnoeic and had generalized edema. There was a erythematous rash all over the body. Blood pressure was 180/100mmHg. There was no cardiomegaly or murmurs. Lungs had few basal crepirations and occasional wheezing. Abdomen was soft. In patients who are tachypnoeic, few lung signs can always be present. Correlate the degree of SOB with the lung signs. If the SOB is disproportionately severe compared to the signs, consider following differentials. Pulm...

A 54 years old male patient, known to have GORD for many years presented with burning chest pain. The pain was persistent. There was no radiation to the arm. He had sweating and nausea. There was no shortness of breath. He is a smoker. He has never tested his blood sugar or lipid profile. On examination, the patient is ill and sweaty. The pulse rate is 92/min. Blood pressure is 150/100mmHg. There are no murmurs. Lungs are clear. What are you going to do? This is a very common clinical scenario. Nearly half of the patients you encounter will admit that they have ’Gastritis’. The majority who present with chest pain believe that the pain is due to gastritis. So the clinical problem is differentiating ischemic chest pain from gastritis. What features will suggest that the pain is ischemic? You know what the features are. I’ll highlight only a few points. In most MIs the pain is tightening. But we have seen patients with burning pain coming with MI. So...

An elderly lady was brought to casualty medical unit of a tertiary care hospital with the complaint of faintishness for several hours. There was no history of chest pain, palpitations, fever, vomiting or diarrhoea. She was a known patient with hypertension for which she was on several medications. On examination she was pale looking and sweaty. Her pulse rate was 36/min. Blood pressure was 80/60mmHg. 1. What is the probable diagnosis? Brady-arrhythmia causing hemodynamic instability. 2. What are you going to do? Be HAPPY that you are in a tertiary care centre! Initial priority is to improve patients hemodynamic parameters Easiest way is to correct the BRADYCARDIA! But until you find what it is and correct it, you may try the following Raise the foot end IV fluid boluses IV atropine Give as boluses 0.6mg every 3-5 minutes You may give up to 5 vials If there's no response you can try other inotropic drugs. Adrenaline Dobutamine In many patients the on...

It is a very common infection seen in all parts of Sri Lanka. USUAL PRESENTATION is with abrupt onset fever with marked myalgia and headache. Main differential diagnoses to be considered are, Dengue fever Typhus fever Hanta virus infection In many patients conjunctival suffusion and occasionally conjunctival haemorrhages can be seen. Major life threatening complications include Weil's disease (Jaundice with acute renal failure) Pulmonary haemorrhages. Acute respiratory distress syndrome Myocarditis DIC MCQ points Hypokalemia is a well known feature ALT > AST (This is in contrast to dengue) Thrombocytopenia is common Some can develop aseptic meningitis DIAGNOSIS of leptospirosis is mostly done serologically. Antibody tests have to be done after 5 days of illness. Microscopic agglutination test (MAT) is the reference investigation. (Available in Medical research institute - MRI Colombo) Pulmonary haemorrhages ELISA is available in m...