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 70 yrs old male patient admitted with 4th episode of arthritis.• PMH - Gout and DM for 11 yrs.• S.Uric acid- 13.2mgdl (3.4-7). BU-80mgdl, S. Cr-2.3mgdl, ESR –94mm/h.• What is your treatment for arthritis in this patient.
Hyperuricaemia cause four clinical syndromes.1. Acute urate synovitis-gout,2. Chronic polyarticular gout,3. Chronic tophaceous gout,4. Urate renal stone formation. Here you see a patient with Chronic tophaceous gout. Tophi – Sodium urate forms smooth white deposits (tophi) in skin and around joints. Notice the scar of removal of tophi (left hand at the elbow)
Don’t read description first: Classical radiological feature in Gout - Punchedout erosions away from joint.which is not much obvious in this patient. (At thedistal end of 3rd middle phalanx you can see a erosion which is not a typical one)
Urate renal stone formation or uratenephropathy
Case No - 2• Try to identify abnormalities and some common normal variations.
Don’t read description first: Look at the anterior ends of the ribs. they look like multiplecystic lesions in the lung. With this sign you can guess whether this CXR is from a maleor female. Males - have peripheral thickening, Females – have middle area thickening.
Case No - 3• A 38 yrs old male patient referred from eye hospital after treating for iritis of right eye. Patient had several clinical problems. – Chronic pancreatitis with pancreatic pseudocyst – High ESR – 120mm/1st h – High ALKP – 1620 u/l (2.8-279) – Intrahepatic bile duct dilatation. – Anaemia – Blood and mucous diarrhoea 4-5 times a day even in the night, associated with abdominal pain.
• Clinicians thought of two main possibilities. – Chronic pancreatitis and pseudocyst causing CBD obstruction and malabsorption. – Chronic pancreatitis with Inflammatory bowel disease.• Gastroenterologist suggested US guided aspiration of the cyst and observation for improvement.• Here you see a series of CT and XR abdomen. Train your eyes to read these materials.
Don’t read description first: Low density well defined lesion in the region of headof the pancreas, multiple cystic lesions in the pancreas, intra hepatic duct dilatationpresent. Two rounded bodies you see either sides of the aorta are cruses of diaphragm.
Don’t read description first: Low density well defined lesion in the region of head ofthe pancreas, multiple cystic lesions in the pancreas, intra hepatic duct dilatation present.Pancreatitis can cause ileus but no features to suggest ileus in this patient.
Don’t read description first: Here you can see the pancreatic calcifications.
Case No - 4• An 18 yrs old male patient admitted with polyarthritis for 3 months duration.• Diagnosis – Seronegative arthritis• Look at the X-ray hand. Are there any abnormalities? Comment.
Don’t read description first: No abnormality, his hand bones showtrabecular pattern clearly. No significant reduction in bone density.
Case No - 5• A 52 yrs old male patient came with fever, loss of appetite, loss of weight, Cough for last 3 months.• Examine the CXR and describe the abnormalities.
Don’t read description first: CXR shows left apical cavity, with rightperihilar nodular shadow. Active TB cavity.Patient’s sputum AFB was positive and sent to a chest hospital for furthermanagement.
Case No - 6• A 58 yrs old male patient admitted with a history of fever, shortness of breath, productive cough for 2 wks duration. Also he had loss of appetite, loss of weight.• PMH - DM• Lungs - B/L coarse crackles.• Examine the CXR and comment.• What is the differential diagnosis?
Don’t read description first: Period of signs and symptoms were notcompatible with the lesion, highly suggestive of Pulmonary TB.
Case No - 7• A 20 yrs old male patient admitted with a history of productive cough, fever, night sweats, loss of appetite and loss of weight for about 5 months.• On examination – left sided apical crackles.• Examine the CXR and comment.
Don’t read description first: You can see cavitating lesion of pulmonary TB inthe left apical region. Thick wall cavity with regular inner wall, streaky shadowsinvolved in left upper lobe consistent with fibrosis.
Case No - 8• These X-rays are from a 54 yrs old male patient with DM.• Describe the abnormalities you see.
Don’t read description first:You can see a hyperdensecircular lesion at the lower zoneof left lung.“Single pulmonary nodule” –Differential diagnosis includebenign lesions like Hamatoma(calcification seen in 40% ofcases ), Arterio-venousmalformation andmalignant lesions eitherprimary or secondary,secondary deposits are mainlyfrom Breast or Brain. It canalso be patch of consolidation.
Case No - 9• A 23 yrs old unmarried male patient came with a history of dysuria and urethral discharge for 8 days.• About 4 days after onset of symptoms he developed fever with chills, oligoarthritis (Right knee joint, ankle joint), features of tenosynovitis, arthralgia and a rash in distal limbs.• Examine the slides.
Don’t read description first: Pustular lesions with surrounding erythema distributedmainly over the distal limbs.(most of the time closer to a joint)
Pustular lesions with surrounding erythema distributed mainly over the distal limbs.(mostof the time closer to a joint)
• What else you want to explore in the history ?• What is the differential diagnosis ?• How are you going to confirm your diagnosis ?This is a case of possible Disseminated gonococcal infection (DGI), Sexual historyand symptoms relating to urethritis, proctitis, pharyngitis need to be explored.If you find only the clinical features – diagnosis is a - possible diagnosis of DGIIf you could isolate the organism from any primary site of infection – diagnosis is aprobable diagnosis of DGI.If you could isolate the organism from the blood, synovial fluid, or from the pustularlesions the diagnosis is proven diagnosis of DGI.
Case No - 10• A 66 yrs old male patient who had progressive shortness of breath for 6 months with non productive cough, loss of appetite, loss of weight, no fever, night sweats• PMH- DM complicated with right above knee amputation.• On examination - B/L crackles over lungs.• Train your eyes to describe the HRCT films in the next slides. And find out the abnormalities.• Give two differential diagnosis for this appearance.• What is the most probable diagnosis of this patient?
Radiologist’s opinion on HRCT films of this patient• Inter alveolar septal thinning noted in sub-pleural distribution in both lung fields involving all 3 zones but predominantly basal,• Cystic air spaces seen in subpleural regions of both lung fields and predominantly basal distribution R>L,• Ground glass opacities are noted in left lower zone posteriorly and right perihilar region.• Traction bronchiectatic changes seen in right upper lobe and left lower lobe.• Irregular interfaces between lungs and pleura, venules, airways also seen.• Small pneumothorax is seen on right side.• Impression-Fibrosing alveolitis.
Case No - 11• A 54 yrs old female patient with Rheumatoid arthritis, diabetes mellitus, hypertension and epilepsy, followed up at a medical clinic,• Treatment regimens include – Nifidipine SR 20mg bd – Methotrixate 7.5mg Every WED – Folic acid .5mg Every SUN – Prednisolon 5mg tds – Glibenclamide 2.5mg bd – Atenolol 50mg mane – Na Valproate 300mg tds• Look at the outcome in this patient who has a history of 35yrs of RA.Describe the hand deformities in RA.
1. Metacarpophalangeal subluxation2. Ulnar deviation of fingers at the metacarpophalangeal joints.3. Swan-neck deformity of the fingers4. Disuse atrophy of hand muscles5. Buttonhole or Boutonniere deformity (fixed flexion)6. Pathological bone fractures.
Case No - 12• A 26 yrs old male patient presented with shortness of breath, pleuritic chest pain, cough, loss of appetite and loss of weight for about 3 weeks duration.• He had a past history of pulmonary TB 2yrs back and taken full course of Anti-TB treatment.• Examine the CXR and identify the abnormalities.
Don’t read description first: You can see areas of fibrosis and bronchectasis.