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

A 62 years old lady presented with a history of shortness of breath for 2 years. She denied cough or wheezing. There was no history of ischemic chest pain in the past. Family history was unremarkable. On examination she was tachycardic. Blood pressure was 110/80mmHg. The house officer could not detect a murmur. Lungs were clear. In view of the cardiomegaly on the Xray, the house officer started IV frusemide and aspirin. The next day during the ward round, the consultant asked the HO to re-auscultate the patient. What is the diagnosis?

A 76 years old male patient admitted to the medical casualty ward with low-grade fever for 2 days with rhinitis and cough. He was on losartan for hypertension. His grandchild also has had similar symptoms a couple of days back. On examination the lungs were clear. WBC - 7.6, Hb 11.8, Plt 234, RBS 92, CRP 4.2 How will you manage the patient? Well, the upper respiratory tract infection will settle on its own. You might not have to do anything. If there is an epidemic of influenza you may use oseltamivir. Chest Xray shows some features of hyperinflation. So, take a history of smoking and other exposure. If the patient has exertional SOB you can manage as COPD. But, if you look carefully, chest Xray also shows a rib that's too white! What is it? That's due to sclerotic bone mets, probably from a prostate carcinoma.

A 75 years old lady was brought to the medical casualty ward semiconscious. Her consciousness had deteriorated over the preceding 3 days. There was no history of fever. On examination, she was overweight and had generalized edema. The pulse rate was 46/min and blood pressure was 80/50mmHg. There were bilateral basal crepitations. RBS was 130mg/dl. A bolus of IV normal saline was given, but there was no improvement of blood pressure. She was given several boluses of atropine but the response was transient and blood pressure didn't improve. What are the possibilities? In a bradycardic patient coming with a reduced level of consciousness, apart from the usual differentials such as myocardial infarction, you should always suspect less common causes. Some of them are, 1. Myxedema coma 2. Beta-blocker poisoning 3. Calcium channel blocker poisoning 4. Organophosphate poisoning What features would suggest the diagnosis of myxedema coma? Their appearance itself

A 21 years old boy presented with a painful perianal lump. He had taken treatment 4 times from a another doctor during the last two years for similar symptoms. He made an incision and drained the abscess under local anaesthesia. Started the patient on oral coamoxyclav and sent him home. If you were the doctor, what would you have done? In any patient presenting with recurrent perianal disease including abscesses and fistulae, you have to suspect Crohn's disease. Is it common? It certainly is, but only if you are vigilant enough to suspect it and diagnose. Why should you bother, if it's a fistula or abscess you can just drain it or do a surgical intervention, isn't it? NO! Perianal involvement in crohn's disease is nasty. It can badly affect the patients quality of life. Imagine having to live the rest of life with discharging wounds in the perineum.  How can you make the diagnosis of crohn's disease? A good history and examination will help you

A 52 years old man presented with central chest pain for one-hour duration. He admitted that he had on and off chest pain on exertion for the last few months. Picture from internet House-officer noted the ST depressions and gave S/L GTN, Aspirin 300mg, Clopidogrel 300mg, and atorvastatin 40mg stat doses. The ECG was 'vibered' to SHO and on his approval, HO started S/C enoxaparin 60mg bd. The next morning when the ECG was shown to the consultant, his eyebrows rose! 'You should've sent me the ECG.' He said. What would you have done if this patient came to you?? Whenever you see an ECG of a patient coming with chest pain, your priority should be to look for the presence of any evidence of STEMI, STEMI equivalents or other ECG changes that warrant immediate intervention. This is one such ECG. As you can see there are ST-segment depressions in many chest leads. In such instances make it a habit to look at aVR and V1 leads.  According to ESC guideli

A 64 years old female patient with hypertension and hyperlipidemia was attending her GP very frequently with various complaints. Her major complaints included myalgia, backache, constipation, malaise, epigastric pain, headache and loss of appetite. On examination GP noted an abnormality in her hands. He could not pick up any other obvious abnormalities. Picture from internet What is this abnormality? This is carotenemia. You have to differentiate it from icterus, where the sclera is also yellow. What are the common causes? Primary carotenemia is when a patient develops this due to ingestion of food containing large amounts of carotenoids like carrot! When carotenoid intake is not excessive it's called secondary carotenemia, for which hypothyroidism is probably the commonest cause. Other causes include diabetes mellitus, hyperlipidemia and nephrotic syndrome. What will you do? In the setting of multiple complaints and carotenemia hypothyroidism is the likely ca

This lady presented with a painful rash over the face for 2 days' duration. (Picture from internet) What is this? This is reactivation of varicella-zoster infection in the ophthalmic division of trigeminal ganglion, also known as herpes zoster or shingles. What are the features? The diagnosis is easy and the presentation is typical. Patients present like this with an extremely painful vesicular eruption confined to a single dermatome. Sometimes pain can be the presenting complaint and the rash can appear later. Who can get this? Anyone! But you see more complications in the elderly and in those who are immune compromised.  Is it contagious? Until the vesicles are crusted, it is contagious. So try to keep the rash covered if possible, and get the patient to wash hands frequently! So the treatment is aciclovir and gabapentin, isn't it? Herpes Zoster Ophthalmicus Well, in some patients that may suffice. But not in this patient. Why? One thing you