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

A 26 years old patient presented with a history of fever for approximately 5 days duration. He complained of nausea, headache, backache and myalgia. His brother has had a febrile illness about a week ago. On examination he was ill looking. There was no rash or lymphadenopathy. Pulse rate was 110/min. Blood pressure was 90/60mmHg. There was mild tender hepatomegaly. This is a very common clinical presentation you will encounter every now and then. 1. What are the main differential diagnoses? 2. What clinical features will you specifically look for? 3. How will you initially manage the patient? As the patient was ill looking the house officer summoned the registrar. Registrar elicited following points from the history and examination. The patient had worked in a paddy field during the last few weeks. (leptospirosis exposure) He had conjunctival suffusion. (A feature of leptospirosis) There was no icterus. There was no pleural effusions, ascites. (To exclude dengue hae...

Treatment of thyrotoxicosis has several aspects 1. Symptomatic relief Beta-blockers are the first line. Beta-blockers can be started even before the diagnosis is confirmed. When you suspect thyrotoxicosis start beta-blockers before reviewing the patient with TSH and Free T4 reports. The usual dose is Propranolol 20-40mg three to four times a day. Make sure the patient does not have bronchial asthma! 2. Reduce thyroid hormone synthesis Thionamides are safe and have a quick onset of action Carbimazole is the commonly used drug The usual dose is 10mg three times a day, but according to the initial Free T4 level, the dose can be adjusted. The maintenance dose should be continued for a year or two before considering stopping the treatment. Many patients will relapse requiring other definitive treatments MCQ tip Agranulocytosis is a 'favorite' complication of thionamides The patient should be advised to stop taking carbimazole and immediately come to the hos...

Scenario An elderly lady presented with a history of feverish feeling for one week duration on a busy casualty night. She had taken treatment once from a GP without an improvement. She complained of aches, pains and fatigue. She complained of a mild on and off cough. There was no chest pain, urinary symptoms, vomiting or diarrhoea. On examination she was a thin built lady, who appeared anxious. Her pulse rate was 110/min. Blood pressure was 140/100mmHg. Lungs were clear and abdominal examination was normal. House officer made the diagnosis of a possible respiratory tract infection and started her on paracetamol, piriton, nebulization SOS with salbutamol and oral coamoxyclav. During the morning ward round the house officer noticed the patients pulse was 170/min. He immediately attached the patient to the monitor and called the SHO. The monitor showed atrial fibrillation. Diagnosis? Thyrotoxicosis with AF precipitated by salbutamol nebulization. Lesson - Thyrotoxicosis ...

A 78 years old patient was brought to the hospital by his son. The son had noted his father was behaving oddly yesterday. He was increasingly forgetful. For half an hour he was muttering to himself. But by evening he had completely recovered. However, today morning he had urinated inside the house. The patient denied any history of fever, headache, limb weakness or numbness. The patient was a known hypertensive patient on losartan. But he was otherwise well. On examination the patient was well alert and oriented. The house officer failed to elicit any positive physical signs. As the father had fully recovered the son wanted to take him home against advice without further testing. What would you do?? What are the possibilities? House officer was reluctant to send the patient back without being seen by a senior doctor. He called the senior house officer, who came and ordered a non contrast CT brain. CT scan showed a large SDH! It needed urgent neurosurgical intervention....

A young girl admitted with a history of low-grade fever for 3 days duration during a dengue epidemic. She was otherwise well. There were no other physical features on examination. She was managed as a dengue fever with oral fluids. Her initial FBC showed WBC 4.3 and PLT 88. On day 6 her WBC was 4.6 with PLT 95. As she was afebrile for 2 days she was discharged with a plan to review in 3 days.  She returned 3 days later with another FBC. WBC was 4.4 and PLT was 112. As the platelets were rising the plan was to review her SOS. Two weeks later she admitted with fever to the same ward. By that time her FBC was drastically different. WBC - 1.2 Hb - 9.5 PLT - 6 Further investigations revealed that she had got acute lymphocytic leukemia. Lesson Especially in young patients, consider all abnormal investigations to be a serious disease unless proven otherwise. Whenever you detect an abnormal report at the time of discharge make sure to review the patien...

An elderly man with a past history of knee joint osteoarthritis on long term analgesics from a GP presented with worsening abdominal pain for 1-day duration to the medical casualty ward. There was no fever or vomiting. He had not passed stools on the day of admission. There was no history of hematemesis or malena. On examination, the patient was ill-looking. Epigastrium was tender. He was tachycardic, but the blood pressure was normal. The house officer ordered IV omeprazole and IV fluids. He kept the patient nil by mouth. He ordered basic investigations including supine and erect Xrays of the abdomen and serum amylase. About an hour later the Xrays were taken and as they were normal same management was continued. The senior registrar came for the ward round in the evening and he immediately called the colleague surgical senior registrar. "Hey, I think we've got a patient for laparatomy. Please come and see!" Tentative Diagnosis?? Perforated peptic ulcer ...

A young man presented with a skin rash which he developed soon after eating a pizza. He had a generalized urticarial rash. He was not dyspnoeic. He came walking to the ward. House officer was noted that the blood pressure was 85/65mmHg. As the patient was asymptomatic he ordered one pint of IV normal saline over 30min. He also prescribed IV chlorpheniramine 10mg and IV hydrocortisone 100mg. 30 minutes later he was reviewed by the house officer. The patient was conscious and not dyspnoeic. But the blood pressure was 60/40mmHg. He immediately called the SHO. Diagnosis - Anaphylactic shock Lesson Anaphylaxis is a killer Your patient will die in front of you unless you act fast Once the anaphylaxis is established, it’s a nightmare to treat There’s no other drug for anaphylaxis better and safer than ADRENALINE. Never hesitate to give adrenaline if you suspect anaphylaxis. Never hesitate to give adrenaline if you suspect anaphylaxis. Never hes...