Arcot J. Chandrasekhar, M.D.
Clinical Pearls To Take To Clinical Years
Our job is to abort the infarct. Decide (with Cardiology consultation) on the method of reperfusion and "Just do it".
Meningitis
Fever + change of mental status = Rule out meningitis.
In the setting of meningitis, what will you note in the CSF?
High protein and Leucocytes. Consider bacterial meningitis with low sugar and polys. Consider Viral mengitis with normal sugar and lymphoctes.
Conditions giving low CSF sugar:
Bacteria, Tuberculosis, Fungi, Malignancy
Conditions giving CSF lymphocytosis:
Virus, Tuberculosis, Fungi, Listeria, Malignancy
Meningitis and AIDS? Think cryptococcus (yeast) infection.
Why do patients with chronic bronchitis cough all morning? Mucociliary escalator system dead with accumulation of secretions overnight.
Physical Examination
What causes hypothermia? Shock. Cold exposure. (Typhoid?)
Common causes for sinus bradycardia: Great athlete, Digitalis, Beta-blockers, Myxoedema, Aortic stenosis, Raised intracranial tension
Contraction of scalene muscles with quiet breathing should be checked to assess use of accessory muscles of breathing.
Postural hyotension: Consider Hypovolemia and autonomic dysfunction. Common causes for hypovolemia: blood loss, vomiting, diarrhea, Diabetic keto acidosis.
Common causes for autonomic dysfunction: Diabetes mellitus, ganglion blocking drugs.
How to distinguish postural hypotension due to hypovolemic from autonomic dysfunction? Pulse rate does not go up with autonomic dysfunction.
If S2 split is louder over pulmonic area than S1, you have pulmonary hypertension.
Causes of edema:Pitting: CHF, DVT, hypoalbuminemia/malnutrition
Non-pitting: Filariasis, Thyroid –pretibial myxoedeama, Lymphatic obstruction
Causes of clubbing of nails in pulmonary diseases: Intra thoracic malignancy (primary and secondary), Suppurative lung disease (abscesses, CF, bronchiectasis, empyema), Interstitial lung disease (alveoli/capillary block).
Central Cyanosis: Tongue and conjunctiva blue. Low PO2. Warm hands.MI, pulmonary interstitial fibrosis, hypoventilation, polycythemia, COPD
Peripheral: Lips, nose and fingers bue. Noramal conjunctiva and tongue. Normal PO2. Heart failure (prolonged circulation time), Cold, Raynauds, , DVT
Drugs that cause interstitial lung disease: amioderone, Au+
Causes of ARDS: Sepsis, trauma/burns, gastric aspiration, acute pancreatitis
Your patient developed food poisoning overnight.. It has to be exotoxin-releasing bug in order to cause such a quick reaction. Think Clostridium, staph aureus, listeria?