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

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

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