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

An 18 years old schoolboy came with epigastric burning pain for 2 days duration. He had similar episodes in the past which responded to over the counter antacids. This ECG was taken. What is it? Brugada syndrome. Well the nomenclature is confusing. But as long as you are not a cardiologist, call it Brugada Syndrome! What is Brugada syndrome? It is an autosomal dominant genetic disorder. Mutation is in a cardiac sodium channel. It leads to an abnormal ECG pattern called 'Brugada pattern' which carries an increased risk of ventricular arrhythmias and sudden cardiac deaths. Is it common? Do I really have to know it? It's not uncommon. Prevalence can be up to 1%, but could be even more as there can be many undetected people. But, if you miss it the consequences can be catastrophic! What are the ECG features? There are two patterns. Type 1 pattern is diagnostic. There will be 'coved' ST elevation of more than 2m...

A 63 years old retired teacher came to a GP to check her blood pressure as she had on and off headache for about 2 months. He denied vomiting, blurring of vision, angina or SOB. There was no significant past history except for a fall in the washroom causing a colles fracture to which had taken ayurvedic treatment. On examination her blood pressure was 180/100 in both arms and there was no other significant positive finding. GP adjusted the antihypertensives and within a several months, her BP was well controlled. However, about a year later she came to GP in a wheelchair! She had again fallen in the bathroom, and this time had fractured her hip. Oops!!! Yeah, that's so unfortunate isn't it. There was a chance to prevent this fracture. So what should have been done? Any patient with a fragility fracture needs to be investigated for osteoporosis and treated. What is osteoporosis? In the simplest terms, there is reduced d...

A 55 years old male patient admitted to medical casualty with a febrile illness for 3 days with myalgia. Examination was unremarkable. He was previously well except for chronic bilateral knee joint osteoarthritis. He consumed liquor quarter to half a bottle on a daily basis. Investigations revealed. WBC - 5.6 Hb - 11.2 Plt - 135 AST - 45 ALT - 42 S.Cr - 54 He was managed as viral fever and became fever free the next day. However the platelet count was persistently low around 130. Further investigations arranged. Blood picture - Thrombocytopenia probably due to liver disease S. Bilirubin, ALP - Normal S. Albumin - 38, S globulin - 37 USS abdomen - Coarse echogenicity of liver. Mild portal hypertension. Mild splenomegaly. Compatible with chronic liver cell disease. This patient has Cirrhosis with portal hypertension. Now the obvious cause for his cirrhosis is alcohol, isn't it? NO! Just because of the history of significant alcohol consumption you ca...

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...