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

A 21 years old boy presented with a painful perianal lump. He had taken treatment 4 times from a another doctor during the last two years for similar symptoms. He made an incision and drained the abscess under local anaesthesia. Started the patient on oral coamoxyclav and sent him home. If you were the doctor, what would you have done? In any patient presenting with recurrent perianal disease including abscesses and fistulae, you have to suspect Crohn's disease. Is it common? It certainly is, but only if you are vigilant enough to suspect it and diagnose. Why should you bother, if it's a fistula or abscess you can just drain it or do a surgical intervention, isn't it? NO! Perianal involvement in crohn's disease is nasty. It can badly affect the patients quality of life. Imagine having to live the rest of life with discharging wounds in the perineum.  How can you make the diagnosis of crohn's disease? A good history and examination will help you...

A 52 years old man presented with central chest pain for one-hour duration. He admitted that he had on and off chest pain on exertion for the last few months. Picture from internet House-officer noted the ST depressions and gave S/L GTN, Aspirin 300mg, Clopidogrel 300mg, and atorvastatin 40mg stat doses. The ECG was 'vibered' to SHO and on his approval, HO started S/C enoxaparin 60mg bd. The next morning when the ECG was shown to the consultant, his eyebrows rose! 'You should've sent me the ECG.' He said. What would you have done if this patient came to you?? Whenever you see an ECG of a patient coming with chest pain, your priority should be to look for the presence of any evidence of STEMI, STEMI equivalents or other ECG changes that warrant immediate intervention. This is one such ECG. As you can see there are ST-segment depressions in many chest leads. In such instances make it a habit to look at aVR and V1 leads.  According to ESC guideli...

A 64 years old female patient with hypertension and hyperlipidemia was attending her GP very frequently with various complaints. Her major complaints included myalgia, backache, constipation, malaise, epigastric pain, headache and loss of appetite. On examination GP noted an abnormality in her hands. He could not pick up any other obvious abnormalities. Picture from internet What is this abnormality? This is carotenemia. You have to differentiate it from icterus, where the sclera is also yellow. What are the common causes? Primary carotenemia is when a patient develops this due to ingestion of food containing large amounts of carotenoids like carrot! When carotenoid intake is not excessive it's called secondary carotenemia, for which hypothyroidism is probably the commonest cause. Other causes include diabetes mellitus, hyperlipidemia and nephrotic syndrome. What will you do? In the setting of multiple complaints and carotenemia hypothyroidism is the likely ca...

This lady presented with a painful rash over the face for 2 days' duration. (Picture from internet) What is this? This is reactivation of varicella-zoster infection in the ophthalmic division of trigeminal ganglion, also known as herpes zoster or shingles. What are the features? The diagnosis is easy and the presentation is typical. Patients present like this with an extremely painful vesicular eruption confined to a single dermatome. Sometimes pain can be the presenting complaint and the rash can appear later. Who can get this? Anyone! But you see more complications in the elderly and in those who are immune compromised.  Is it contagious? Until the vesicles are crusted, it is contagious. So try to keep the rash covered if possible, and get the patient to wash hands frequently! So the treatment is aciclovir and gabapentin, isn't it? Herpes Zoster Ophthalmicus Well, in some patients that may suffice. But not in this patient. Why? One thing yo...

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...