1. Clinical Materials forSelf Learning - Medicine. Prepared by Dr. Ajith Karawita MBBS, MD
2. 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
3. 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)
4. Case No - 1• A 65 yrs old female patient presented with left sided chest pain, cough and backache for about 2 months.• PMH-Iron deficiency anaemia.• Examine the CXR and describe radiological features. What is your diagnosis?
5. Don’t read description first:Hypodense almost circularlesion close to posteriorsurface of the left lung withrib erosion.
6. Case No - 2• A 74 yrs old male patient presented with productive cough, shortness of breath.• Describe the features in the CXR.
7. Don’t readdescription first:This patient hasundergone leftlobectomy about 40yrs back due toBronchiectasis.thistime the featurs aresuggestive ofpulmonary TB withbronchiectasis.
8. Don’t read description first: Note wiring of ribs – left lower two ribs.
9. Case No - 3• A 33 yrs old male patient investigated for PUO.• He had persistently high ESR over 100mm/1st h.• Renal and liver functions were normal.• Describe the abnormalities you see in the CT-Brain.
10. Non-contrast CT-Brain
11. IV Contrast CT-Brain
12. A hypodense area seen in the region of posterior limbof the left internal capsule.Small hypodensity also seen in the region of rightinternal capsule as evident in non contrast film.No other enhancing lesions, no midline shift.ventricular systems, basal cisterns are within normallimits, no haemorrhages are seen.CT appearance – left and right internal capsuleinfarction.
13. Case No - 4• A 37 yrs old male presented with fever with chills and rigors for 2 wks.• There was firm splenomegaly.• PMH – Typhoid 1yr back.• Describe the CXR abnormalities.• What is the differential diagnosis?
14. Don’t read description first: Cavitating lesion of active TB
15. Case No - 5• A 50 yrs old male patient admitted with signs and symptoms of urinary tract infections (UTI) for 5 days.• PMH – patient with chronic renal failure due to bilateral obstructive uropathy identified about 13 yrs back. 7 months back he underwent left urethrolithotomy and right nephrostomy due to acute on chronic CRF.• Describe the abnormalities.
16. Case No - 6• A 44 yrs old male patient presented with increased frequency of fits and left hemiparesis for 1day.• PMH – known patient with epilepsy not on regular treatment. he has history of frequent falls and injury to right side of the head.
17. Don’t read description first: Frontal infarction and a depressed fracture
18. Case No - 7• A 38 yrs old male patient presented with severe occipital headache, neck pain and blurring of vision for about 1 wk duration.• Clinically he had hepatosplenomegaly and retinal infarcts.• Comment on the FBC report.
19. Don’t read description first: This is from a patient with polycythemia complicatedwith superior sagital sinus thrombosis. He is on anticagulation therapy.
20. Case No - 8• This patient was investigated for apperently elevated diaphragm in the CXR.• She had persistently elevated ESR and CRP with marginal elevation of transaminases.• Then CT-abdomen done.• Examine and describe the abnormalities.
21. Case No - 9• A 54 yrs old male patient admitted with shortness of breath, cough, and fever for 2 wks.• PMH – non insulin dependent diabetes mellitus for about 8 yrs, hepatitis B, left side bronchial carcenoma which was declared cleared 2 years back.• Describe the CXR. What are the findings, how are you going to manage this patient?
22. Don’t read description first: Nodular shadows at right hilum, with effusion andconsolidation.
23. Case No - 10• A 26 yrs old patient admitted with fever and myalgia for 3 days.• His platelet count has dropped to 19,000 cumm, PCV was at upper limit of normal, transaminases increased about three times.• Look at the puncture site in the next slide a peculiar lesion. it recurred once it has been broken by patient.
24. Don’t read description first: Peculiar lesion at puncture site It is not just a bulb ofblood, macroscopically it has a membrane
25. Case No - 11• A 74 yrs old male patient presented with productive cough and shortness of breath for 1 month duration.• He also had backache and high ESR for about 1 month.• Mantoux was 22mm,• Describe the abnormalities in the lumbosacral spine of this patient and comment on the serum electrophoresis report.• How are you going to investigate this patient.
26. Don’t read description first: There is slight increase of alpha-2 globulin, nomonoclonal band ?infection
27. Case No - 12• A 75 yrs old male patient admitted with bilateral chest pain which is like lightening pain for about 1wk.• PMH – TB was completely treated 10 yrs back.• Describe the abnormalities in the CXR, what is your differential diagnosis and how are you going to investigate this patient ?
28. Don’t read description first:Multiple hyperdense circualarshadows at the apex of bothlungs.
29. Case No - 13• A 22 yrs old patient admitted with diarrhoea for 2 wks and fever for 1day.• Look at the CXR identify abnormalities. (history is not related to findings in the CXR).
30. Don’t read descriptionfirst:Note that anterior ends of the3rd and 4th ribs of right sideare more wider.
31. Case No - 14• A 66 yrs old male patient came with polyuria, polydipsia for 1 yrs duration.• On investigation – patient had diabetes mellitus and urinary tract infections.• Describe the abnormalities in the X-ray KUB (kidney, bladder, ureter).• How are you going to manage this patient?
32. Don’t read description first:You can see bilateral Staghorncalculi.
33. Case No - 15• What is your spot diagnosis?
34. Don’t read description first: Scar of herpes zoster. In fact he had this activelesion about 1yrs ago, which was not a complicated one, rash only lasted about 5days.
35. Case No - 16 How do you collect sputum for AFB?
36. Case No - 17• A 60 yrs old female fat lady presented with chest pain for 1 day.• PMH – hypertension for 5 yrs, ischemic heart disease for 1 ½ yrs.• Patient didn’t tolerate exercise ECG.• Next slide you will see a coronary calcium score of this patient.• Interpret the results.• What is the significance of coronary calcium score.• How you perform coronary calcium score?
37. Coronary Calcium ScoreLeft Main Artery (LMA) 0Left Anterior Descending (LAD) 0Left Circumflex (LCX) 0Right Coronary Artery (RCA) 102Posterior Descending Artery 0(PDA)TOTAL 102The diagram demonstrate the general location ofcoronary artery calcification only. Does not necessarilyindicate the presence or location of a stenotic lesion.
38. Coronary calcium score is performed as same as CT scanning is performed,but only chest is scanned and score is calculated by a different software.Information is based on analysis of the coronary arteries. Calcium depositsdo not correspond directly to the percentage of narrowing of arteries only.They do correlate directly to the amount of coronary plaque and to the risk offuture coronary disease. These calcium deposits usually begin to form yearsbefore any symptoms develop. Early detection and modification of riskfactors such as smoking , high cholesterol can slow the progress of coronaryartery disease.A low score suggest a low likelihood of coronary artery disease but does notexclude the possibility of significant coronary artery narrowing. The resultsshould be discussed with your physician taking into account other risk factorssuch as age, gender, family history, diabetes, smoking or high cholesterollevels.
39. Case No - 18Note any abnormality
40. Case No - 19• A 26 yrs old male patient admitted with right hypochondrial pain for 1 wk.• Describe the CXR.• How would you investigate this patient.
41. Don’t read description first: There is a small pleural effusion in right side of thelung, Can you assess the amount of fluid?
42. Case No - 20• A 78 yrs old male patient presented with polyuria, polydipsia and body weakness.• PMH –diabetes mellitus for 5 yrs. and pulmonary TB completely treated about 50 yrs back.• Describe the CXR abnormalities.
43. Case No - 21• Identify the lesion
44. Case No - 22• Describe the following two FBCs.• How are you going to identify the patient’s condition.• What further investigation do you need to confirm your diagnosis.
45. Case No - 23• Comment on the following serum electrophoresis report.