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

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.

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