This document provides clinical materials for self-learning in clinical medicine. It contains 14 case studies with imaging and test results. Each case asks the reader to identify findings, make diagnoses, and suggest management. The materials were prepared by Dr. Ajith Karawita for discussion and are available to further learning in clinical medicine. Feedback can be provided by email.

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 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.

6. Dermatologist says that it looks like Erythema multiforme, but
not in typical distribution.
Typical target lesions (or iris lesion) seen on the hands and feet,
consist of raised erythematous periphary with central pallor
or 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 ulceration
and crusting such cases are known as Stevens-Johnson
syndrome.

7. • 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.

9. 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.

10. Don’t read description first: Cytoid Body, you see in SLE and Overlapping syndrome.
This is from a patient with overlapping syndrome SLE + RA

11. 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 ?

12. Don’t read description first: This patient has a multiple solid papular lesions without
central umbilication, crossing the midline, symmetrical and distributed mainly on the back
of 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.

13. 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.

14. Total protein6.1gdl Report-
Total protein is low, Mild
Albumin 2.4gdl increase of Gamma
Globulin 3.7gdl globulin, suggest liver
profile
A/G Ratio 0.7

15. Sensory findings
Stim. site Rec. site Latency ms Amplitude uV Velocity m/s
R Sural Calf Ankle Oedema
L Sural Calf Ankle Oedema
R Ulnar Digit V Wrist 2.7 3.6
Motor findings
Stim. site Rec. site Distal Lat ms Amp 1mV Amp 2mV Velocity m/s
R C Peroneal Fib Neck EDB not recordable
R median W-Elbw APB 4.4 6.3 6.1 51.4
L C Peroneal Fib Neck EDB 5.9 0.4 0.3 31.4
Don’t read description first: The test shows nerve conduction abnormality in the
lower limbs. This could be due to a sensori-mortor axonal peripheral neuropathy. The
significance of the abnormalities is low since the test may have been interfered with
oedema.

16. 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.

18. Don’t read description first:
1. Cardiomegaly
2. Straightening of left heart border
3. Splaying of carina
4. Double shadow
5. Milliary shadowing
6. Spleenic enlargement
7. Thoracotomy wiring

19. 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.

23. Don’t read description first: Subdural haemorrhage,of recent onset with midline shift

24. 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.

28. Case No - 8
• Identify the abnormality.

31. 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.

34. 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.

40. CXR taken
before this
presentation.

41. 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.

44. 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 ?

45. Don’t read description first:
Differential diagnosis
1. Multiple valvular disease,
2. Cardiomyopathy,
3. Pericardial effusion.
Probable diagnosis could be
Alcoholic cardiomyopthy.

46. 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.

50. Don’t read description first: Haemorrhagic infarction.

51. 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?

54. Don’t read description first:
Encysted effusion in the oblique
and horizontal fissure called “
vanishing tumors”.
There is a small effusion anteriorly.

55. Thanks