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 – firstname.lastname@example.org
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 44 yrs old male patient presented with fever for two months and chronic cough, LOW, LOA for last one month.• On examination - mild degree of clubbing, pallor, and left lung lower zone bronchial breathing was found.• Two days later patient developed hoarseness. ENT examination revealed that he has laryngitis and vocal cord inflammation with nodules and ulceration.
• FBC - leucocytosis with 62% N, 35% L, 1% E, 2% M. Hb – 10.8 RBC – just below normal lower limit.• ESR-120mm/1st h• FBS-114mgdl.• Plural fluid - AFB negative.• Here you see the repeated CXRs of this patient over two weeks.Work out the course of the disease. what is the differential diagnosis?
Don’t read description first: Consolidation and cavitating lesion at the lowerzone of the left lung.
Don’t read description first: Cavitating lesion has become a fairlylarge cavity with a fluid level.
Don’t readdescription first:Here you can see twofluid levels, may bedue to two cavitatinglesions overlying orcavity with a unusualeffusion here need todo a lateral CXR tocomment further onfluid levels.
Don’t read description first: Irrespective of the antibiotic treatment patient’scondition became progressively worsened and new lesions noted in the CXR. Ultimatediagnosis was Tuberculosis although it is unlikely to have basal lesions. Initially theprobable diagnosis was pyogenic lung Abscess.
Case No - 2• A 58 yrs old fat female patient with Hypertension and Diabetes mellitus presented to the medical clinic with painful swellings of 1st and 2nd finger distal interphalageal joints.• Identify.
Don’t read description first: These are inflamed painful subcutaneous collectionof hyaluronic acid when you see these nodes at the DIP called Heberden’s nodes.when it is at PIP joints it is called Bouchared’s nodes. Tender Bouchard’s nodesmay cause confusion with the synovitis of RA.
Case No - 3 Identify the device, what are the uses ? Don’t read description first: Pulseoximeter
Case No - 4• Identify XR abnormalities.• What is the differential diagnosis?
Don’t read description first: You can see hypodense multiple rounded lesions in theskull bones (Multiple lytic lesions) differential diagnosis for multiple lytic lesionsinclude 1. Metastasis 2. Multiple myeloma.Usually metastatic lytic lesions you don’t see in the mandible whereas multiplemyeloma you can see lesions in the mandible as well. In this X-ray you cant seemandible properly. So suggest repeat x-ray skull lateral view to assess the mandible.
Case No - 5Train your eyes toidentify the vesselsand abnormalities.
Case No - 6 X-ray skull, sinus view, identify the structures, train your eyes (larger view in the next slide).Don’t read description first: This X-rays look normal, identify the structures, sometimes you can see fluid levels in the sinuses, soft tissue lesions like polyps, hyperdensemargins (thickenings)
Case No - 7• A 61yrs old male patient admitted with a history of on and off cough and yellowish sputum for two months duration and suddenly developed haemoptysis (one cup full of blood )• On examination - left upper zone bronchial breathing +, finger clubbing and mild hepatomegaly.• ESR-110mm/1sth• Here you see the CXR and contrast CT thorax of this patient.• What is the differential diagnosis?
Don’t read description first: In Radiology it is a “solitaory pulmonary nodule” atthe right upper zone of the left lung - commonly seen in primary lung malignancy.Secondary deposits are usually multiple with varying sizes. Tuberculoma is usuallysmall can vary from .5cm to 4cm.
Soft tissue window of CT scan with Contrast. In CT scans you can view them in threemain windows, 1. Soft tissue window, 2. Bone window, 3. Lung tissue window. Boneerosions not to be seen.
The previous CT is the lung tissue window. Where you cansee the broncho-vascular markings properly. Usually vascularstructures are more clear and larger than Broncheoles.Radiologists opinionThere is a soft tissue density mass in the left upper zoneextending from anterior to middle, there is irregularenhancement trachea and bronchi are patent, heart and gratevessels appear normal, no mediastinal lymphadenopathy, noevidence of deposits in the lung fields, no pneumothorax,pleural effusion, no definite evidence of rib destruction .Impression – Neoplastic lesion in the left lung appear to bemost probably a primary lesion suggest biopsy.
In the same patient right supraclavicular lymph node excisionbiopsy and TruCut biopsy of left lung lesion were done. Results are mentioned below.• Lymph node Biopsy ( 1x1x.5cm)- section from the lymph node shows preserved architecture with follicular hyperplasia with germinal centres. The sinuses show many pigment laiden macrophages.• Conclusion-Reactive follicular hyperplasia no evidence of tumour metastasis.
• Lung Biopsy- Section reveals a tumour consist of atypical glandular structures lined by columnar epithelium cells and are pleomorphic and mitotic figures were seen. Extensive necrosis was identified.• Conclusion-Moderately differentiated adenocarcenoma of lung.Glaison grade III & IV.
Case No - 8• A 75 yrs old male pt with past history of bronchial asthma and ischemic heart diseases admitted with sudden onset of vertigo which was lasted for about 5mts. There were no focal neurological signs, BP was 110/70mmHg.• On the same day patient suddenly developed left sided weakness. Cerebro-vascular accident was suspected and non contrast CT-brain was done. (scan no-1)• Scan was repeated 48 hrs later. (scan-no 2)• Compare both CT and interpret the findings. What are the lobes and vessel involved, and probable visual field defect?
Don’t read description first: You can see very mildhypodense area at the right occipital region, andcalcification of the choroid.Sensitivity of non contrast CT in identifying infarction –Days after infarction. 1st Day 48% 1st to 2nd Day 59% 7th to 10th Day 66%
Scan No 2Scan taken 48hrs later, shows more prominent hypodensity than the previous one.
Case No - 9• A 17 yrs old female patient transferred from local hospital with headache, fits and confusion developed on 9th day post partum.• GCS was 12 (E3,V3,M6).• Identify the lesion by examining non contrast and contrast CT Brain.
Infarctions could be either arterial or venous.In arterial infarcts – there is no arterial territorial crossingunless it is multiple infarctIn venous infarcts - usually no definite territorial involvementand it involves multiple sites. Delta sign may present.Here you see a haemorrhagic infarct at fronto- parietal region.This is a case of cerebral venous thrombosis.Remember- you can see Pseudo delta sign in subarachnoidhemorrhage (SAH) on non contrast film.
Don’t read description first: Here you see a haemorrhagic infarct at fronto- parietalregion. This is a case of cerebral venous thrombosis.
Case No - 10• A 57 yrs old male patient presented with shortness of breath and fever for two weeks duration.• ESR was 65mm/1sth• Describe the abnormalities you see in the CXR and what is the differential diagnosis?
Don’t read description first: There is right apical fibrosis with markedtraction of trachea, probably due to healed TB with fibrosis.
Case No - 11• A 50 yrs old male patient presented with fever with chills, cough, and shortness of breath for four days duration.• Examine the CXR and describe the abnormalities.• What is your diagnosis?
Don’t read description first: There is opacification of lower zone of right lung .mostprobably middle lobe lateral segment consolidation. Note the right horizontal fissure intwo planes.
Case No - 12• A 44 yrs old male patient presented with left sided chest pain, shortness of breath on exertion and low grade fever for 2 wks duration.• FBC shows leucocytosis with normal differential counts. Sputum for AFB-six times negative. Mantoux was 15mm.• Fever slowly responded to antibiotics.• Treated with iv Cefotaxime for 2wks and sent home on oral Augmentin after radiologist’s opinion on CXR.• You can see a series of CXRs of this patient. Describe the course of the disease and radiological abnormalities.
Don’t read description first: Changes are compatible with resolvingPneumonia.just below the left hemi diaphragm you can see the splenic flexure ofcolon. And there is obliteration of left costophrenic angle due to small effusion.
• One week later, again got admitted with fever, chest pain and shortness of breath on exertion.• CXR was repeated.• Comment on changes.
Don’t read description first: You can see wedge shaped hyperdense area, at theposterior surface of the left lung probably at the level of apex of the lower lobe. Itlooks like a posterior encysted effusion can be confirmed with US guided aspiration.
• After one week of iv Meropenem consolidation was cleared, leaving a circular shadow.• But ESR was persistently over 100mm/1sth with highly positive mantoux >15mm.• Comment.
Don’t read description first: Here you can see posteriorly encysted effusion(Since the left heart border is clearly seen the lesion should most probably beposterior). For further investigation and management patient was sent to aspecialized unit. Still the clinical diagnosis of Tuberculosis not excluded althoughtests are negative for TB.
Case No - 13• A 48 yrs old male patient admitted with neck pain and restricted movements for about 1 wk.• He is having backache and stiffness gradually developed over the last 15 years.• Examine the X-rays and describe the abnormalities. What is your diagnosis?
Ankylosing spondititis1. B/L symmetricl sacroilitis (asymetrical in Reiter’s and Psorisis)2. Early lesions seen in thoracolumbar or lumbosacral areas.3. Ligament calcification.4. Appearance of syndesophytesThis process eventually involve cervical spineNote in the cervical spine X-ray - Ankylosing spondylitis of cervicalspine, cervical spine involvement is usually late in the course of thedisease.Here you can see the classical fracture at C-6 leading topseudoarthrosis.