Prepared by Dr Ajith Karawita, MBBS, PGDV, MD

1. Clinical Materials for
Self 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 – ajith.karawita@gmail.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 54 yrs old male patient presented with a history
of shortness of breathing,
• on examination- B/L ankle oedema,
Cardiomegaly, and MR and MS were found,
• Does cardiomegaly look appropriate to the lesion?
Can there be an underlying cardiomyopathy or is it
appropriate to the lesion. Comment .

5. Don’t read description first: Here you can see cardiomegaly, and how the trachea is
divided at the carina, In pure Mitral Stenosis, you can see features of enlarged left
atrium which include 1. splaying of carina, 2. Elevation of left main bronchus 3. double
right heart border with increased density.

6. Case No -2
• 24 years old young boy suddenly developed
headache and found to have SAH and anterior
communicating artery aneurysm which was
clipped 3 months ago.
• However he resumed unconsciousness and was
in ICU for 3 months and developed acute on
chronic renal failure and heamodialysis done.
• Here you see the CT scan of brain. Identify the
radiological abnormalities.

7. Don’t read description first: Lateral ventricles dilated, 3rd ventricle is prominent,
foreign body at anterior communicating artery area (according to the history probably
the clip). There are hypodense areas near the anterior horns of ventricle.

8. Case No -3
• A female patient admitted with right sided
chest pain, shortness of breathing, fever,
cough and weight loss, for about 3 wks.
• She produced a fairly large amount of
yellowish sputum.
• Look at the X-ray and comment.

9. Don’t read description first: Differential diagnosis could be 1. Pyogenic
abscess, 2. Infected haematoma, 3. Cavitaing malignancy, 4. infected
bronchogenic cyst, 5. infected bullae – unlikely in this patient because the walls
are thicker than a bullae. In this kind of a lesion you have to examine features in
the wall, surrounding the wall, within the cvity and distribution of the lesion. In
malignancy – walls are thicker and irregular than what you see here. Note the
fluid level.

10. Case No -4
• A female patient presented with a history of
fever, cough, right sided chest pain, and
weight loss.
• Examine the CXRs and describe the
radiological abnormalities you see.

11. Don’t read description first: Here you can see a effusion with collapse
consolidation of middle lobe of right lung.

12. Case No -5
• A 36 yr old young patient presented with
refractory hypertension and was
investigated.
• Two abnormalities found, one is
parenchymal renal disease and the other one
in renal angiogram.
• Identify the lesion.

14. Don’t read description first: Here you can see renal artery stenosis, usually in
young it is due to fibromuscular narrowing, in old it is due to atheroma, In injecting
Heroin users you can see a condition called Heroin arteritis presenting as renal artery
stenosis.

15. Renal Arteriogram report.
• Through right femoral puncture, mid stream
arteriogram was done, left renal artery
osteal stenosis identified, selective left renal
catheterization done, However balloon
catheter didn’t enter the right stenosis (
baloon angioplasty could not be done )
suggest stenting or surgery.

16. Case No -6
• A 66 years old fat lady admitted with a history of
tendency to fall to right side for about 2wks and
oro-facial dyskinesia (jaw tremour) of about 1wk
duration.
• Cognitive functions were not affected, cog-wheel
rigidity present. plantar was up going. She has a
past history of Hypertension for 10 yrs.
• most features are of Parkinsonism but atypical, so
CT brain done.
• Describe the abnormalities.

18. Don’t read description first: Grossly dilated lateral ventricle, prominent 3rd
ventricle, choroid calcification compatible with age. There is peri ventricular
oedema. Probably a normal pressure hydrocephalus. Features of normal pressure
hydrocephalus include 1. gyri not widende, 2. Ventricles dilated etc..

19. Case No -7
• A 68 yrs old widow presented with sudden
onset of LOC.
• She is a known patient with hypertension,
and diabetes mellitus on regular treatment.
Including antiplatelet drugs.
• Describe the lesion.
• What will be the further management with
regard to Antiplatelet therapy and clot
evacuation.

21. Don’t read description first: you can see ICH at basal ganglia. Blood is seen in 3rd
, 4th and lateral ventricles.

22. Case No -8
• A 55 yr old male patient who has been
treated twice for pneumonia in private
sector, admitted again with fever, chills and
right sided chest pain for 2 days duration.
• Klebsiella and Strep. pneumoniae were
isolated from sputum. Treated as right sided
pneumonia, with iv Clarithromycin,
Cefotaxime, metranidazole for two weeks.
X-rays shows how it resolved.
• Describe the radiological features in the
process of healing.

23. Don’t read description first: here you can see a series of CXR’s, which shows, how
pneumonia resolved in this patient. In third CXR you can see a encysted effusion
which was later resolved with continuation of antibiotics.

24. Case No -9
• A 68 yrs old male admitted with fever, chest
pain, shortness of breath.
• He also has right below knee amputation,
and left foot eczema complicated with
cellulitis.
• Describe the chest x-ray.

25. Don’t read description first : there is a haizyness at the lower zone of the right lung,
but radiological assessment is difficult need to repeat the CXR (train you eyes for x-
ray reading)

26. Case No -10
• This CXR is from a patient with
decompensated alcoholic liver disease who
presented with fever for 1wk.
• Look at the X-ray. Is there any unusual
appearance ?
• How do you proceed.

27. Don’t read description first: this is called “Apperently elevated diaphragm” in
Radiology, causes could be above diaphragm, in the diaphragm and below
diaphragm. Causes 1. Phrenic nerve palsy 2. Sub pulmonic effusion 3. Eventration
of diaphragm 4. Liver pathology.

28. Case No -11
• A 54 yrs old male patient admitted with a history
of dysuria, frequency, and backache for about
1wk.
• He has a past history of DM, BA, IHD, and also
had signs and symptoms of bladder outflow
obstruction.
• On examination prostate was enlarged with
irregular surface and margins, no mucosal
tethering.
• Examine the x-ray spine and pelvis and describe
the abnormalities.

29. Don’t read description first: You can see osteosclerotic lesions (hyperdense
multiple shadows of varying sizes) main causes could be secondary deposits of
Prostate or Breast, and rarely Osteopoikilosis (benign condition).

30. Case No -12
• A 54 yrs old male patient with COPD,
presented with shortness of breath and
swelling of upper chest.
• PMH- 3 months back he presented with B/L
pneumothorax, IC tubes were inserted to
either sides and was improved.
• What is your diagnosis, how are you going
to manage this patient.

32. Don’t read description first: you can see pneumothorax with lung collapse on
right side(note the absence of broncho vascular markings)

35. Don’t read description first: after treating the patient with IC tube insertion pt
developed surgical emphysema.

36. Case No -13
• A 38 yrs old male farmer transferred from
local hospital.
• He presented with progressive exertional
dyspnoea and offensive sputum for about 5
months duration. No chest pain, cough,
fever, heamoptysis, or weight loss.
• Look at the x-ray and comment .

37. Don’t read description first: you can see hyperdense right lung shadow with more
density at the periphary. Diagnosis – mesothelioma

38. Don’t read description first (same X-ray): typiclly measothelioma shows features of
pleural thickening with normal lung volume which may associate with pleural effusion.
there are instances where mesothelioma lookes like a massive effusion, clinically and
radiologiclly) left side has a horizontal line like hyperdense shadow which may be a line
of atelectasis.
Differential diagnosis of radiological appearance
Benign pleural masses like fibroma.
Pleural fibrosis due to infection.( eg. Tuberculosis, Actinomycosis)
Metastasis.

39. Don’t read description first: CT-thorax (lung tissue window) – Shows right sided
pleural malignency- Mesothelioma

41. Case No -14
• A 56 yrs old male patient admitted with dyspnoea
and body swelling for about 1wk duration.
• He was a heavy alcoholic who was diagnosed to
have ALD.
• On examination - JVP was elevated, and fine late
inspiratory crackles heard at lung bases.
• Look at the CXR of this patient and comment.

42. Don’t read description first: Differential diagnosis for a enlarged heart 1.
Cardiomyopathy,2. Pericardial effusion, 3. Multiple valvular disease. Most probable
diagnosis of this patient is Alcoholic cardiomyopathy.

43. Case No -15
• A 56 yrs old female admitted with dyspnoea
and swelling of right side of the chest
including the breast.
• She had past history of treated pulmonary
TB about 24 yrs back and also IHD and BA.
• Describe the abnormalities in the following
CXRs taken on the day of admission and
after insertion of IC tube.

44. Don’t read description first: Right side surgical emphysema

45. Don’t read description first: Pneumomediastinum with right side surgical
emphysema which was developed after insertion of a IC tube, and also you see the
classical feature of pneumomediastinum called “Continuous Diaphragm sign ”.

46. Don’t read description first:“Continuous Diaphragm sign ”

47. Case No -16
• In the next slide you see results of urine
protein electrophoresis compared with
normal diluted (1/50) serum protein
electrophoresis.
• What is your interpretation?

48. urine protein electrophoresis compared with normal
diluted (1/50) serum protein electrophoresis.
Pt’s Urine
Normal diluted
serum (1/50)
Gamma
Beta Alb
Alpha-1
Alpha-2
Don’t read description first: Urine protein electrophoresis shows tubular proteinurea,
No evidence of Benz Johns proteins.

49. Case No -17
• In the next slide you see serum protein
electrophoresis of a patient and absolute
amounts in grams per liter.
• Interpret results.

50. Control Total pro 65.6gL (65-85 )
Albumin 29.9gL (35-55 )
Alpha-1 3.8gL (3-5)
Alpha-2 8.4gL (5-7)
Beta 6.5gL (6-12)
Gamma 17.0gL (9-15)
Alb/Glob 0.8
Sample
Don’t read description first: Serum protein electrophoresis show low albumin and
mild poyclonal gammopathy finding would be consistent with chronic liver disease.

51. Case No -18
This is the result of serum electrophoresis of a
patient who was investigated for lower backache
and high ESR. Comment.
Don’t read description first: There is increase of alpha-2 globulin with a slight
polyclonal increase of Gamma-globulin. Diagnosis is probably a infection

52. Case No - 19
• A 29 yrs old mother of one child who has
been diagnosed as having SLE, 2 yrs back
presented this time with lesions as you see
in the next slide.
• ESR – 60mm/1st h
• Other systems are clinically and
biochemically normal.
• Identify these lesions.
• How are you going to manage this patient?

54. Thanks