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

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.