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 68 yrs old female patient presented with dyspnoea on exertion, loss of appetite and loss of weight for about 1 ½ months.• She is a known patient with hypertension and diabetes mellitus for about 9 years.• On examination- there were crackles on right base of the lung.• ESR was 85mm/1st h.• Scan the CXR, what are the abnormalities? How do you diagnose and treat this patient?
Don’t read description first: There is apparent elevation of the right hemidiaphragm, causes could be above diaphragm, in the diaphragm and below thediaphragm.
Case No - 2• A 60 yrs old female patient admitted with shortness of breath, on and off fever for last 2 months and increased enlargement of goitre which has been there for last 35 yrs.• Clinically she was euthyriod and the goiter was multinodular without signs and symptoms of infiltration.• Go through the x-rays and identify abnormalities.
Don’t read description first: Note Tracheal compression and deviation with rightextensive pleural effusion. You can also see the extent of thyroid gland.
Before aspiration After aspirationUSS of effusion - shows numerous pleural tags, two mixedechogenic pleural basal lesions seen at right costo-phrenic region ? Inflammatory lesion ? Soft tissue lesion
Case No - 3 • Report of Pleural fluid analysis of that patient is mentioned below, comment on the report. – Protein 5.4 gdl – Cl 121 mmol/l – LDH 100 – WBC 4100 /mm3 ( N-45%, L-55% ) – RBC Field full • Gram stain – Organisms not seen • Culture / ABST – negative
Case No - 4• A 52 yrs old unmarried female patient presented with backache for 6 months duration.• Menapause - at the age of 47yrs.• Examine the x-rays and describe the abnormalities.
Don’t read description first: Compression with narrowing of the intervertebral diskat T10 and T11, and calcified fibroid.
Case No - 5• One young patient has taken his daily oral drugs at at 8.00 a.m.• He noticed a gradual darkening of urine colour.• By 1.00 p.m colour was maximum.• But evening urine sample was quite normal.• What could be the most probable drug that could have caused the colour change?
Case No - 6• A 32 yrs old female patient admitted with high ferritin level. She is a known patient with Thalassaemia diagnosed about 5yrs back.• Hb was 7.1mgdl, about 25 pints of blood had been transfused after the diagnosis.• At 4.00 p.m Desferrioxamine iv infusion was started and stopped at 9.30 p.m.• She urinated at 9.30 p.m and 6.00 a.m, see the urine colour compared with normal sample of urine.• Try to memorize the drugs that cause colour change of urine.
Case No - 7• A 68 yrs old male patient admitted with fever, shortness of breath, loss of appetite and loss of weight for about 5 wks.• On examination of respiratory system- Trachea deviated to the right. Left side of chest- movements, VF , VR, and breath sounds are reduced and stony dull on percussion.• See the CXR and describe the abnormalities. How are you going to manage this patient ?
1500ml of Blood stained pleural fluid was aspirated
After aspiration of 1500ml of Blood stained pleural fluid
Case No - 8Comment on thisreport ofarterial blood gasanalysis
Case No - 9• Describe the radiological abnormalities you see in this CXR.
Don’t read description first: Female patient with straight left heart border onCXR, and on right side you can see nicely the double shadow.
Case No - 10• Identify abnormalities in this CT-Brain.
Case No - 9• A 57 yrs old male patient admitted with sudden onset of left sided weakness.• He is a heavy smoker and a known patient with hypertension for 1 ½ yrs.• Renal and Liver functions were normal, lipid profile and clotting profile were also normal.• Identify the lesion in non contrast CT- brain and describe it.
Case No - 10• A 60 yrs old male patient admitted with right sided focal epilepsy.• He has a history of treated pulmonary TB 12 yrs back.• Sputum AFB- negative, ESR-10mm/1st h• Examine the CXR and identify radiological abnormalities. What is your most probable diagnosis ?
Case No - 11• Identify the lesion. What is the differential diagnosis ?
Case No - 12• A 60 yrs old male patient presented with fever, shortness of breath, cough for 3 months duration.• He is a known patient with multiple valvular lesions. Most prominent lesions are ASD and pulmonary HT.• In echocardiogram - RA and LA dilated, MVP +, Trivial MR+, TR+, large osteum secondum (size 2.2cm), poor left to right shunt.• Describe the features in the CXR.
Before aspiration After aspirationIn next slide, you see the report of pleural fluidaspiration. Comment on that.
Case No - 13• A 42 yrs old male patient presented with low grade fever, shortness of breath for 3 wks and haemoptysis for one day.• See the CXR, describe the abnormalities.
Don’t read description first: Case of Pulmonary TB.
Case No - 16• Identify the abnormality and describe it
1st patientDon’t read description first: There is a hypodense area at the border of left fronto-parietalarea of the brain without dilatation of the ventricular systems and midline shift. Diagnosis isCSF hydroma.
2nd patientDon’t read description first: There is a hypodense area posteriorly at the left lobe of thecerebellum. Diagnosis is CSF hydroma.
Case No - 1753 yrs old male patientpresented with backacheand stiffness for 6months.X-ray shows Lumbarlordosis.What are the causes oflumbar lordosis.
Case No - 18• 50 yrs old male patient presented with fever with chills for about 1 wk duration.• Patient didn’t complaint of chronic cough but he had exertional dyspnoea.• ESR – 90mm/h and AFB was positive.• What are the radiological features you see in this CXR.
Don’t read description first: You can see two apical bullous lesions on either sides of thelungs. Note that bronchovascular markings are not apparently seen over the lesions.You can see the typical thin wall in the bullae.
Case No - 19• 14 yrs old male patient presented with inability to close right eye and mouth deviation to left side.• What is your spot diagnosis.• List the causes of this abnormality.• How are you going to assess the level and extent of the lesion by history and examination.
This patient has right side lower motor neuron type offacial palsy.When trying to close the eye he gets exaggeration ofeye ball movement to upwards.Here, you have to direct the clinical examination toidentify the level of the lesion and probable aetiologyCommon site of lesion could be at the muscle,nuromuscular junction, facial nerve at the parotidgland, facial nerve in side the canal, at facial mortornucleus in the pons.,
Case No - 20• 35 yrs old mother of three children presented with amenorrhoea from the age of 25yrs, dark discoloration of skin started at elbow and knees then to the body later to the gums and buccal mucosa, LOA,apathy.• Observe the features of this patient in next two slides. And identify them.• How are you going to identify the endocrine abnormalities from the history and examination of this patient.• Mention how you investigate this patient.