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

A 75 years old female patient known to have hypertension for 10 years admitted with a progressively deteriorating level of consciousness for one day. There was no history of fever, headache, vomiting, diarrhea or trauma. Her medication included aspirin, losartan, HCT and atorvastatin. Examination revealed a GCS of 9 with no focal neurological deficits. She was mildly dehydrated. Her blood pressure was 140/90 mmHg. Respiratory and abdominal examinations were unremarkable. What are the possibilities? Intracranial vascular events (Stroke/ hemorrhage)  less likely in the absence of focal neurological deficits Infections - Meningitis/ encephalitis Absence of fever and meningism is against, but elderly patients can present without those symptoms Seizures Nonconvulsive status epilepticus Prolonged postictal drowsiness Metabolic derangements Hypoglycemia Particularly hyponatremia List down a few more possibilities. RBS was 127mg/dl. Urgent non-contrast CT of the

A 55 years old man from Hatharaliyadda (A small town which forms the margin between districts of Kurunegala, Kandy, and Kegalle) presented with a history of fever for 4 days duration. He had a headache, myalgia, arthralgia, and a faint generalized erythematous rash. There was no contact history of fever. He was a farmer who consumed alcohol regularly. On examination he looked ill, pulse rate was 100/min, blood pressure 90/60mmHg, lungs were clear and there was mild epigastric tenderness. What are the possibilities? The first differential diagnosis for this presentation is invariably dengue. An in-ward ultrasound scan was done to look for evidence of leaking. Leaking or not?? Urgent PCV was done - it was 42%. As there was no evidence of leaking, the patient was managed as dehydration. One pint of normal saline was given for resuscitation and 100cc/hr drip was continued for maintenance as the patient was reluctant to take fluids orally. A blue chart was maintaine

A 52 years old teacher was brought to hospital by her relatives with a history of abnormal behaviour. She was apparently well until 3 weeks back, when she became increasingly forgetful. Over the next week she became over talkative and aggressive. She was seen by a psychiatrist in the private sector and was started on treatment for bipolar affective disorder. A CT scan of the brain, TSH and basic investigations were normal. Despite initial treatment her symptoms got worse. At the time of admission she was restless and agitated. Her hemodynamic parameters and neurological examination was normal. What non-psychiatric condition should be considered in a patient presenting with psychiatric manifestations? Electrolyte abnormalities/ hyper/hypoglycemia Endocrine diseases Cushing syndrome Thyroid disorders Central nervous system causes Infections Tumors Autoimmune encephalitis Vasculitis Drugs and toxins Alcohol! Upon the suspicion of encephalitis LP and EEG wer

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