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

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

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,

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

A young female patient admitted with a one week history of headache and low grade fever. She has had on and off headache for 2 weeks prior to the onset of headache. On examination she had neck stiffness and papilloedema. Patient had diplopia towards right side. CSF study was done Appearance - clear Opening Pressure - normal Cell count - 80 (70% lymphocytes, 30% neutrophils) Protein - 120mg/dl Sugar - 34mg/dl (Blood sugar 88mg/dl) AFB - Not seen Culture - No growth She was started on anti TB treatment as the most likely diagnosis was TB meningitis. 6 days into illness her headache was slightly reduced. Fever was still there, but the patient was feeling relatively better. She was spent most of her time on bed as she found it difficult to walk due to diplopia. On day 10 after admission she complained of sudden onset shortness of breath. There was tachycardia. Saturation was 89% on air. Lungs were clear to auscultation. Her left leg was swollen and t

A 16 years old boy presented with 2 days history of perioral numbness and difficulty in speaking. He denied having carpopedal spasms. There were no other complaints. Mother was concerned that the child was moody for the last two days. He was no smiling and appeared very grumpy. When he spoke he hardly opened his mouth and was staring at the doctor during the entire consultation. Chvostek's and Trousseaus signs were negative. Basic investigations including electrolytes and calcium were normal. Like always, the consultant made a spot diagnosis next morning. Bilateral facial nerve palsy! Lesson It is easy to miss bilateral facial palsy as there may not be an obvious asymmetry. Google and see some pictures of bilateral facial palsy. Known causes are Guillain Barre Syndrome Sarcoidosis Diabetes Vasculitic conditions Bilateral bells palsy! Is there a way to differential bilateral lower motor neuron facial palsy from bilateral upper motor neuron facial palsy??

An elderly patient with hypertension was found to have hyperkalemia in a routine check up. His hypertension was well controlled with amlodipine. Initial potassium (K) value was 5.9mmol/l. He was seen by a general practitioner and was asked to avoid fruits and king coconut juice and repeat a serum electrolyte in 3 days. Repeat K value was still 5.7mmol/l. As the ECG did not show any significant hyperkalemic changes he was asked to continue avoiding high K containing food and beverages. A week later he presented again with a K value of 6.1mmol/l. He was so annoyed that he had to avoid fruits as he used to have a fruit platter each morning. The GP decided to admit him for further investigations. He was admitted to medical casualty ward. Investigations revealed WBC - 16.67  N - 60% L - 36% Hb - 16.8 g/dl Plt - 570 S. Cr - 73umol/l Na - 138mmol/l K - 6.1mmol/l ECG  The consultant made a spot diagnosis and an hour later the patient was seen eating a ful

Elderly man presented to medical casualty with severe central chest pain. He was restless and was sweating. Blood pressure was 180/100 and pulse rate was 96/min. There was a murmur. Lungs were clear. Urgent ECG was taken. As there were widepread ST depressions the house officer started the patient on aspirin, clopidogrel, atorvastatin and enoxaparin. For pain he prescribed GTN and morphine which calmed down the patient. Two hours later patient again complained of severe chest pain which did not respond to GTN. The registrar was summoned. Blood pressure was still 180/100 and the heart rate was 120/min. Registrar noted also noted a murmur. The differential diagnosis of aortic dissection was immediately considered. There was a radio femoral delay! After urgent management a CT aortogram was done which showed a massive dissection of aorta extending from aortic root down to aortic bifurcation. The had a cardiac arrest a few hours later. Lesson. ~ Any chest pain could be an ao