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

A 56 years old male patient presented to a GP with a history of hematuria for two days duration. There was no associated dysuria or features of bladder outflow obstruction. The hematuria was persistent and the urine was uniformly red in colour. He was a smoker. Physical examination was unremarkable. The GP reviewed the patient with followed investigations. WBC - 8 Hb - 10.1 MCV - 80 Plt - 145 S. Cr - 1.4mg/dL UFR RBC - Field full Pus cells - 5-10 Protein - 1+ As the reports were almost normal he suspected a carcinoma of the bladder and sent the patient to a urologist with a referral letter. Urologist arranged an ultrasound KUB which was normal. He planned a cystoscopy which was performed in a weeks time. It did not show any evidence of a malignancy. Investigations were repeated. WBC - 10.5 Hb - 9.4 MCV - 80 Plt - 130 S. Cr - 4.5mg/dL UFR RBC - field full Pus cells - 10-20 Protein 1+ The management team was alarmed, and the patient was immediately ref

A 64 years old male patient admitted with worsening shortness of breath for 2 days duration. He had cough and wheezing. He had a history of cigarette smoking for more than 30 years. On examination he was thin built and was dyspneic. He was mildly pale. Lungs were hyperinflated with widespread ronchi. Cardiac and liver dullness were impaired. Clinical Diagnosis? Exacerbation of COPD Management? Stop smoking Nebulized/ Inhaled bronchodilators +/- steroids Antibiotics Investigation reports were as follows. WBC - 13.5  ( N - 70%   L - 30%) Hb - 10.5 Plt - 350 MCV - 76 AST - 35 ALT - 40 S. Cr - 78 CXR What are the abnormalities in this Xray? The patient improved with treatment and was discharged 2 days later. About three weeks later patient readmitted with similar symptoms. Examination findings were again compatible with an exacerbation of COPD. His inhaler technique was good and he was compliant with the medications. He had also qu

An elderly man with long standing diabetes mellitus was followed up at a medical clinic. His blood sugar values and blood pressure recordings were as follows. March 2019 FBS - 180mg/dL PPBS - 210mg/dL BP - 170/110mmHg April 2019 FBS - 155mg/dL PPBS - 190mg/dL BP - 160/100mmHg May 2019 FBS - 150mg/dL PPBS - 176mg/dL BP - 150/90mmHg Happy?? Certainly yes! Blood sugar values were slowly but improving. Blood pressure was also getting better. In June 2019 patient admitted with fever, right leg swelling and pain. Patient was confused, there was tachycardia and low blood pressure. Clinical diagnosis? Cellulitis causing sepsis with shock. How are you going to resuscitate? Recall the sepsis BUNDLE! In summary Hydrate Inotropes - Preferably Noradrenaline Take cultures Start appropriate IV antibiotics Control blood sugar with insulin (140-180mg/dL) Treat empirically for DVT, if excluded give prophylaxis. Get help from surgical team

A 32 years old previously healthy male patient admitted with a history of palpitations for 1 hour duration. He had experienced a similar episode a few months back which lasted only for few minutes. What are your concerns? First priority is to make sure that the patient is stable. Who is unstable? Hypotensive patient (Systolic BP < 90mmHg) Coronary ischemia (Ischemic chest pain) Cardiac failure (Patient has SOB) Patient with brain hypoperfusion (reduced conscious level) IF ANY OF ABOVE ARE PRESENT IRRESPECTIVE OF THE TYPE OF ARRHYTHMIA YOU WILL HAVE TO PERFORM DC CARDIOVERSION (SHOCK) ECG Analysing tachyarrhythmias is a long topic, which might bore you. Let's learn a few short cuts to diagnose common arrhythmias. Look at the QRS Is it narrow or broad? Narrow complex tachycardias we usually encounter are SVT (Read and understand the proper nomenclature. SVT is a wrong term!) Atrial fibrillation/ flutter In most patients both are managed the s

A 45 years old female patient presents to you saying, 'Dr. I think I have blood pressure'. You measures her blood pressure and it's 160/100mmHg. What are you going to do? Your first task is to establish the diagnosis of hypertension. How can you diagnose a patient to have hypertension? Blood pressure should be properly measured! it's not easy. Things that we often miss are Quite/calm room Bladder not full Correct patient position Rest the arm on the table Correct cuff size NO talking during procedure Avoid caffeine, exercise, smoking for minimum 30 min Measure BP in both arms, select the arm with the higher value for future measurements Take two values 1-2min apart and calculate the average. Confirm the high blood pressure on a second occasion/ confirm that it's not transient Sometimes a second measurement is not necessary if there's evidence to say patient had chronic hypertension Retinal changes ECG - LV hypertrophy Hypertens

A 21 years old boy presented with recurrent headache. Headache is severe that he can't do his studies during the episodes. It lasts for about a day, and is associated with nausea and vomiting. He gets pain two to three times a week. What are the possibilities? In young patients, commonest causes for headache are Sinusitis Tension headache Migraine After browsing internet about the symptoms, he himself made the diagnosis of migraine. He took panadiene regularly but the response was poor. Finally he decided to see a doctor to get treatment for his migraine. He was started on flunnerizine by the GP for migraine. Initially the response was good. But about a month later he was brought to hospital by his friends after collapsing while playing a cricket match. He was getting tonic clonic convulsions. Seizure was managed with IV diazepam. Urgent CT brain revealed a large space occupying lesion. Lesson Migraine is common. It's an easy diagnoses to make. But,

A 75 years old female patient with diabetes mellitus, hypertension and ischemic heart disease presented with fever and cough for 3 days duration. She produced yellow color sputum, but there was no hemoptysis. There was right-sided chest pain on breathing. She had nausea and the appetite was poor. What are the possibilities? Fever, cough, sputum and pleuritic chest pain equals pneumonia unless proven otherwise! Many conditions can mimic pneumonia. Read and find out! On examination the patient was ill-looking. She was tachycardic and tachypnoeic. Blood pressure was 100/70mmHg.  Respiratory examination revealed signs localized to the right lower zone. Reduced chest expansion Increased vocal fremitus Dull percussion note Bronchial breathing Increased vocal resonance Whispering pectoriloquy! What do these physical signs mean?  Read about physical signs and how to interpret them. A consolidation in the right lower zone. With these findings, the clinical diagno