Posts

Things not to miss - Chronic SDH

Image
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.

Things not to miss - Acute leukemia

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 patient wi

Tricky cases - Intestinal perforation

Image
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

2 min read - Anaphylaxis

Image
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

Lessons for life - The inhaler technique

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

Lessons for life - Cultures before antibiotics

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,

Things not to miss - Dengue

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