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 48 yrs old housewife admitted with generalized skin lesions, fever, and burning abdominal pain for about 3 days duration.• Recently she has taken treatment from a general practitioner for painful heels.• Identify these skin lesions.
Dermatologist says that it looks like Erythema multiforme, butnot in typical distribution.Typical target lesions (or iris lesion) seen on the hands and feet,consist of raised erythematous periphary with central palloror purple area which may blister.Blistering lesion is called Bullous erythema multiforme.Erythema multiforme is an immune mediated disease.More sever cases may also have fever, arthralgia/arthritis,involvement of eye, oral and or genital mucosae with ulcerationand crusting such cases are known as Stevens-Johnsonsyndrome.
• Initially those lesions (previous slides) were thought as target lesions of erythema multiforme.• But with time new lesions appeared which were in favour of vasculitic rash.• Look at next slide and identify these lesions.
Case No - 2• What are the funduscopic changes you see in systemic lupus erythematosis (SLE) and rheumatoid arthritis (RA).• See the next slide and Identify the abnormality.
Don’t read description first: Cytoid Body, you see in SLE and Overlapping syndrome.This is from a patient with overlapping syndrome SLE + RA
Case No - 3• A 64 yrs old patient came with a multiple papular skin lesions on the posterior aspect of neck and upper chest.• What is your differential diagnosis ?
Don’t read description first: This patient has a multiple solid papular lesions withoutcentral umbilication, crossing the midline, symmetrical and distributed mainly on the backof neck and back of upper chest as you can see. Rash is not a vesicular rash.Dermatologist suggested that this is a case of Cow pox infection.
Case No - 4• A 74 yrs old male patient was investigated for PUO. Clinical features directed the investigation towards exclusion of possible malignancy and causes of bladder outflow obstruction.• Blood & urine cultures, sputum AFB, USS-Abd, and myeloma screening were negative.• He also had difficulty in walking and unsteadiness.• In next slides, you see serum electrophoresis and nerve conduction studies of above patient. Comment on results.
Total protein6.1gdl Report- Total protein is low, MildAlbumin 2.4gdl increase of GammaGlobulin 3.7gdl globulin, suggest liver profileA/G Ratio 0.7
Sensory findings Stim. site Rec. site Latency ms Amplitude uV Velocity m/sR Sural Calf Ankle OedemaL Sural Calf Ankle OedemaR Ulnar Digit V Wrist 2.7 3.6Motor findings Stim. site Rec. site Distal Lat ms Amp 1mV Amp 2mV Velocity m/sR C Peroneal Fib Neck EDB not recordableR median W-Elbw APB 4.4 6.3 6.1 51.4L C Peroneal Fib Neck EDB 5.9 0.4 0.3 31.4Don’t read description first: The test shows nerve conduction abnormality in thelower limbs. This could be due to a sensori-mortor axonal peripheral neuropathy. Thesignificance of the abnormalities is low since the test may have been interfered withoedema.
Case No - 5• A 40 yrs old thin female patient admitted with shortness of breath, ankle swelling, fever and cough for last 15 days.• She is a patient who underwent mitral valve replacement in 2002.• She is having persistently high ESR.• Examination findings were compatible with mitral re-stenosis.• Presently she is being treated for Infective endocarditis.• Describe all the abnormalities you see in the CXRs.
Don’t read description first:1. Cardiomegaly2. Straightening of left heart border3. Splaying of carina4. Double shadow5. Milliary shadowing6. Spleenic enlargement7. Thoracotomy wiring
Case No - 6• A 30 yrs old male patient referred from private sector with CT scan films of brain.• patient presented with headache, drowsiness for last 2 yrs. symptoms were mild daily activities were not much affected.• During the last 5 days he developed blurring of vision and one episode of vomiting.• There was a past history of accident 2 yrs back (his vehicle rolled 3-4 times off the road, he escaped major injuries because of seat belts)• On examination - no focal neurological signs.• What is your diagnosis.• How are you going to age the lesion ?• What is your immediate management if you are in a medical ward.
Case No - 7• A 25 yrs old patient transferred from local hospital due to the presence of chronic blood stained pleural fluid.• He has presented to local hospital with fever, cough and shortness of breath for 3 wks duration.• PMH- Mentally retarded and known epileptic patient for 7yrs.• On examination left side VF & VR was low and breath sounds were diminished.• Go through the CXRs and explain radiological changes you observe.
Case No - 9• A 52 yrs old male patient presented with fever with chills for 1 month followed by non productive cough for 3 days.• Patient had night sweating, evening pyrexia and loss of appetite.• On examination bronchial breathing heard over mid zone of the right lung.• ESR-56mm/h, Sputum for AFB – negative, Mantoux- 10mm.• Examine the CXRs and explain the radiological changes. What is the differential diagnosis.
Case No - 10• A 53 yrs old male patient presented with on and off fever, haemoptysis for 2 months followed by one month history of shortness of breath and chest pain.• He is a smoker 5-8 cig/d for 30 years.• Resp. system - right lung -VF, VR and breath sounds diminished, dull on purcussion.
Case No - 11• A 35 yrs old, female patient presented with fever, shortness of breath and cough for 3/52 duration.• She has pectus carinatum, and under developed left forearm and hand.• Pt has B/L rhonchi with inspiratory and expiratory whistling sounds on right side.• Here you see the CXR of this patient. Comment on that.
Case No - 12• A 43 yrs old known patient with alcoholic liver disease presented with shortness of breath, ankle swelling and abdominal distension for about 2wks duration.• On examination - cardiomegaly, hepatomegaly ascites and pitting ankle oedema were found.• What is your differential diagnosis• What are the clinical features you look for in differentiating your diagnosis.• What is the most probable diagnosis ?
Case No - 13• A 46 yrs old male patient admitted with sudden onset of left sided body weakness.• PMH – diabetes mellitus for 20 yrs complicated with nephropathy and hypertension.• CT Brain shows right side intracranial haemorrhage which was drained on the following day after admission.• About 7 days later, CT-brain repeated. comment on the radiological findings.
Case No - 14• A 74 yrs old patient presented with right sided pleuritic chest pain for 5 days.• ESR – 100mm/1st h, mantoux – 30mm, sputum for AFB – Negative.• Describe the CXR.• How are you going to investigate this patient for the cause?
Don’t read description first:Encysted effusion in the obliqueand horizontal fissure called “vanishing tumors”.There is a small effusion anteriorly.