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

A 48 years old female patient came to a GP for a routine check up. She was asymptomatic. BMI - 25.8kg/m2 Blood pressure - 135/85 FBS - 145 HbA1C - 7.6% She was started on metformin 500mg three times a day. A month later she was reviewed with following investigations. Lipid Profile Total C - 255 LDL C - 168 HDL C - 38 TG C - 215 FBS - 96mg/dl ALT - 56 u/l AST - 38 u/l How are you going to approach this patient? (Please note the following discussion is fairly superficial as it is intended to be read by medical students. They hardly ever read though!) What are the problems this patient has got? She has diabetes mellitus which is under reasonable control. She has obesity. She has hypercholesterolemia. She has abnormal liver functions. Her blood pressure is just around the margin for hypertension. What are you going to do about her diabetes? With metformin alone her blood sugar is controlled. Therefore, I shall continue it. However I would review ...

A 54 years old male patient with a history of diabetes mellitus for 12 years came to see his family doctor with a complain of fever and phlegm. Headache was mainly over the right side. He had rhinitis with yellowish discharge and nasal block. He was poorly compliant with the treatment for diabetes and his FBS usually fluctuated around 200mg/dl. Doctor started him on oral coamoxyclav, paracetamol and fexofenadine as for sinusitis. Three days later he presented again complaining of persistent phlegm. He also complained of some numbness and fullness over the right side of the face. There was tenderness over the maxillary sinus. A Xray of the sinus view was ordered. The doctor was convinced that the diagnosis was sinusitis in view of the haziness in the right maxillary sinus. However, as the response was poor he asked the patient to get admitted to hospital to be seen by an ENT surgeon. Patient refused admission saying that his daughter was about to leave the country for her ...

A 52 years old patient with well controlled diabetes mellitus came to see his family doctor on a Sunday morning. He has developed a mild chest pain last night which lasted only for a few minutes. Pain was central, without any radiation or autonomic features. However, he had experienced a similar pain about a month back when he was running to catch a train. At the time of consultation there was no pain whatsoever. An ECG was taken. In view of the mild T inversions, the GP asked to check a troponin level, which was normal. He started the patient on Aspirin and increased his usual atorvastatin dose to 40mg. He also prescribed sublingual GTN to be used SOS. If you were the GP, what would you have done? This is Wellens syndrome! What is it? It is a characteristic ECG pattern which indicates critical stenosis of the proximal Left Anterior Descending artery. What would happen if you miss it? Unless proper intervention is done, it will progress into a anterior ST ele...

A 32 years old patient came with vomiting for one day after outside food consumption. He had vomited about 20 times during the last couple of hours. He complained of upper abdominal pain due to repeated vomiting. He had several episodes of cough and developed shortness of breath. Xray was taken to exclude aspiration. What would you do? This Xray on the first glance looks quite normal. But when you closely have a look you might see some abnormality in the right upper zone. However, if you look even more closely you will pick that there are some streaky air shadows along both sides of the trachea.  This is pneumomediatinum. In the context of vomiting you will have to consider the possibility of esophageal rupture. Which has the fancy name 'Boerhaave Syndrome'. What are the other features? A classical sign would be surgical emphysema. That is not a sign you should ever miss. Do you really have to know this? It should be rare isn't it? Rare indeed. But in Sri...

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...

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...