Clinical Materials forSelf Learning - Medicine. Prepared by Dr. Ajith Karawita MBBS, MD
Objective• To provide collection of clinical materials for your learning in Clinical Medicine. ( These materials are open for further discussion in addition to descriptions provided ) Instructions• Do not rush, carefully examine and analyse each point.• Mail your suggestions – email@example.com
Acknowledgement• I would like to express my sincere thanks to All patients.They have given their consent and fullest support for this exercise.• I am grateful to my teacher , Dr Christie De Silva. MD, FRCP, Consultant physician & Nephrologist, NHSL, Colombo.• My sincere thanks goes to Dr Wijelal Meegoda (MBBS, MD Radiology), Dr Ashanka Beligaswatta (MBBS, MD, MRCP) and Dr Darshani Wijewickrama (MBBS, MD) for reviewing this And to my colleagues who helped me immensely.• Dr T. Thulasi (MBBS, MD)• Dr Mathu Selvarajah (MBBS, MD)• Dr Ajantha Rajapaksha (MBBS, MD)• Dr Chamila Dabare (MBBS, MD)
Case No -1• A 54 yrs old male patient presented with a history of shortness of breathing,• on examination- B/L ankle oedema, Cardiomegaly, and MR and MS were found,• Does cardiomegaly look appropriate to the lesion? Can there be an underlying cardiomyopathy or is it appropriate to the lesion. Comment .
Don’t read description first: Here you can see cardiomegaly, and how the trachea isdivided at the carina, In pure Mitral Stenosis, you can see features of enlarged leftatrium which include 1. splaying of carina, 2. Elevation of left main bronchus 3. doubleright heart border with increased density.
Case No -2• 24 years old young boy suddenly developed headache and found to have SAH and anterior communicating artery aneurysm which was clipped 3 months ago.• However he resumed unconsciousness and was in ICU for 3 months and developed acute on chronic renal failure and heamodialysis done.• Here you see the CT scan of brain. Identify the radiological abnormalities.
Don’t read description first: Lateral ventricles dilated, 3rd ventricle is prominent,foreign body at anterior communicating artery area (according to the history probablythe clip). There are hypodense areas near the anterior horns of ventricle.
Case No -3• A female patient admitted with right sided chest pain, shortness of breathing, fever, cough and weight loss, for about 3 wks.• She produced a fairly large amount of yellowish sputum.• Look at the X-ray and comment.
Don’t read description first: Differential diagnosis could be 1. Pyogenicabscess, 2. Infected haematoma, 3. Cavitaing malignancy, 4. infectedbronchogenic cyst, 5. infected bullae – unlikely in this patient because the wallsare thicker than a bullae. In this kind of a lesion you have to examine features inthe wall, surrounding the wall, within the cvity and distribution of the lesion. Inmalignancy – walls are thicker and irregular than what you see here. Note thefluid level.
Case No -4• A female patient presented with a history of fever, cough, right sided chest pain, and weight loss.• Examine the CXRs and describe the radiological abnormalities you see.
Don’t read description first: Here you can see a effusion with collapseconsolidation of middle lobe of right lung.
Case No -5• A 36 yr old young patient presented with refractory hypertension and was investigated.• Two abnormalities found, one is parenchymal renal disease and the other one in renal angiogram.• Identify the lesion.
Don’t read description first: Here you can see renal artery stenosis, usually inyoung it is due to fibromuscular narrowing, in old it is due to atheroma, In injectingHeroin users you can see a condition called Heroin arteritis presenting as renal arterystenosis.
Renal Arteriogram report.• Through right femoral puncture, mid stream arteriogram was done, left renal artery osteal stenosis identified, selective left renal catheterization done, However balloon catheter didn’t enter the right stenosis ( baloon angioplasty could not be done ) suggest stenting or surgery.
Case No -6• A 66 years old fat lady admitted with a history of tendency to fall to right side for about 2wks and oro-facial dyskinesia (jaw tremour) of about 1wk duration.• Cognitive functions were not affected, cog-wheel rigidity present. plantar was up going. She has a past history of Hypertension for 10 yrs.• most features are of Parkinsonism but atypical, so CT brain done.• Describe the abnormalities.
Don’t read description first: Grossly dilated lateral ventricle, prominent 3rdventricle, choroid calcification compatible with age. There is peri ventricularoedema. Probably a normal pressure hydrocephalus. Features of normal pressurehydrocephalus include 1. gyri not widende, 2. Ventricles dilated etc..
Case No -7• A 68 yrs old widow presented with sudden onset of LOC.• She is a known patient with hypertension, and diabetes mellitus on regular treatment. Including antiplatelet drugs.• Describe the lesion.• What will be the further management with regard to Antiplatelet therapy and clot evacuation.
Don’t read description first: you can see ICH at basal ganglia. Blood is seen in 3rd, 4th and lateral ventricles.
Case No -8• A 55 yr old male patient who has been treated twice for pneumonia in private sector, admitted again with fever, chills and right sided chest pain for 2 days duration.• Klebsiella and Strep. pneumoniae were isolated from sputum. Treated as right sided pneumonia, with iv Clarithromycin, Cefotaxime, metranidazole for two weeks. X-rays shows how it resolved.• Describe the radiological features in the process of healing.
Don’t read description first: here you can see a series of CXR’s, which shows, howpneumonia resolved in this patient. In third CXR you can see a encysted effusionwhich was later resolved with continuation of antibiotics.
Case No -9• A 68 yrs old male admitted with fever, chest pain, shortness of breath.• He also has right below knee amputation, and left foot eczema complicated with cellulitis.• Describe the chest x-ray.
Don’t read description first : there is a haizyness at the lower zone of the right lung,but radiological assessment is difficult need to repeat the CXR (train you eyes for x-ray reading)
Case No -10• This CXR is from a patient with decompensated alcoholic liver disease who presented with fever for 1wk.• Look at the X-ray. Is there any unusual appearance ?• How do you proceed.
Don’t read description first: this is called “Apperently elevated diaphragm” inRadiology, causes could be above diaphragm, in the diaphragm and belowdiaphragm. Causes 1. Phrenic nerve palsy 2. Sub pulmonic effusion 3. Eventrationof diaphragm 4. Liver pathology.
Case No -11• A 54 yrs old male patient admitted with a history of dysuria, frequency, and backache for about 1wk.• He has a past history of DM, BA, IHD, and also had signs and symptoms of bladder outflow obstruction.• On examination prostate was enlarged with irregular surface and margins, no mucosal tethering.• Examine the x-ray spine and pelvis and describe the abnormalities.
Don’t read description first: You can see osteosclerotic lesions (hyperdensemultiple shadows of varying sizes) main causes could be secondary deposits ofProstate or Breast, and rarely Osteopoikilosis (benign condition).
Case No -12• A 54 yrs old male patient with COPD, presented with shortness of breath and swelling of upper chest.• PMH- 3 months back he presented with B/L pneumothorax, IC tubes were inserted to either sides and was improved.• What is your diagnosis, how are you going to manage this patient.
Don’t read description first: you can see pneumothorax with lung collapse onright side(note the absence of broncho vascular markings)
Don’t read description first: after treating the patient with IC tube insertion ptdeveloped surgical emphysema.
Case No -13• A 38 yrs old male farmer transferred from local hospital.• He presented with progressive exertional dyspnoea and offensive sputum for about 5 months duration. No chest pain, cough, fever, heamoptysis, or weight loss.• Look at the x-ray and comment .
Don’t read description first: you can see hyperdense right lung shadow with moredensity at the periphary. Diagnosis – mesothelioma
Don’t read description first (same X-ray): typiclly measothelioma shows features ofpleural thickening with normal lung volume which may associate with pleural effusion.there are instances where mesothelioma lookes like a massive effusion, clinically andradiologiclly) left side has a horizontal line like hyperdense shadow which may be a lineof atelectasis.Differential diagnosis of radiological appearanceBenign pleural masses like fibroma.Pleural fibrosis due to infection.( eg. Tuberculosis, Actinomycosis)Metastasis.
Case No -14• A 56 yrs old male patient admitted with dyspnoea and body swelling for about 1wk duration.• He was a heavy alcoholic who was diagnosed to have ALD.• On examination - JVP was elevated, and fine late inspiratory crackles heard at lung bases.• Look at the CXR of this patient and comment.
Don’t read description first: Differential diagnosis for a enlarged heart 1.Cardiomyopathy,2. Pericardial effusion, 3. Multiple valvular disease. Most probablediagnosis of this patient is Alcoholic cardiomyopathy.
Case No -15• A 56 yrs old female admitted with dyspnoea and swelling of right side of the chest including the breast.• She had past history of treated pulmonary TB about 24 yrs back and also IHD and BA.• Describe the abnormalities in the following CXRs taken on the day of admission and after insertion of IC tube.
Don’t read description first: Right side surgical emphysema
Don’t read description first: Pneumomediastinum with right side surgicalemphysema which was developed after insertion of a IC tube, and also you see theclassical feature of pneumomediastinum called “Continuous Diaphragm sign ”.
Case No -16• In the next slide you see results of urine protein electrophoresis compared with normal diluted (1/50) serum protein electrophoresis.• What is your interpretation?
urine protein electrophoresis compared with normal diluted (1/50) serum protein electrophoresis. Pt’s Urine Normal diluted serum (1/50) Gamma Beta Alb Alpha-1 Alpha-2Don’t read description first: Urine protein electrophoresis shows tubular proteinurea,No evidence of Benz Johns proteins.
Case No -17• In the next slide you see serum protein electrophoresis of a patient and absolute amounts in grams per liter.• Interpret results.
Control Total pro 65.6gL (65-85 ) Albumin 29.9gL (35-55 ) Alpha-1 3.8gL (3-5) Alpha-2 8.4gL (5-7) Beta 6.5gL (6-12) Gamma 17.0gL (9-15) Alb/Glob 0.8SampleDon’t read description first: Serum protein electrophoresis show low albumin andmild poyclonal gammopathy finding would be consistent with chronic liver disease.
Case No -18 This is the result of serum electrophoresis of a patient who was investigated for lower backache and high ESR. Comment.Don’t read description first: There is increase of alpha-2 globulin with a slightpolyclonal increase of Gamma-globulin. Diagnosis is probably a infection
Case No - 19• A 29 yrs old mother of one child who has been diagnosed as having SLE, 2 yrs back presented this time with lesions as you see in the next slide.• ESR – 60mm/1st h• Other systems are clinically and biochemically normal.• Identify these lesions.• How are you going to manage this patient?