Clinical Materials for

Self 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 – ajith.karawita@gmail.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)

• 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?

Case No - 1

Don’t read description first: There is apparent elevation of the right hemi

diaphragm, causes could be above diaphragm, in the diaphragm and below the

diaphragm.

Same patient, Lateral view

• 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.

Case No - 2

Don’t read description first: Note Tracheal compression and deviation with right

extensive pleural effusion. You can also see the extent of thyroid gland.

Before aspiration After aspiration

USS of effusion - shows numerous pleural tags, two mixed

echogenic pleural basal lesions seen at right costo-phrenic region

? Inflammatory lesion ? Soft tissue lesion

• 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 - 3

• 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.

Case No - 4

Don’t read description first: Compression with narrowing of the intervertebral disk

at T10 and T11, and calcified fibroid.

• 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 - 5

1.00 p.m Sample Evening sample

• 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 - 6

• 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 ?

Case No - 7

1500ml of Blood stained pleural fluid was aspirated

After aspiration of 1500ml of Blood stained pleural fluid

Case No - 8

Comment on this

report of

arterial blood gas

analysis

• Describe the radiological abnormalities you

see in this CXR.

Case No - 9

Don’t read description first: Female patient with straight left heart border on

CXR, and on right side you can see nicely the double shadow.

• Identify abnormalities in this CT-Brain.

Case No - 10

• 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 - 9

• 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 - 10

Don’t read description first: Mycetoma, notice the “air crescent sign”

• Identify the lesion. What is the differential

diagnosis ?

Case No - 11

• 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.

Case No - 12

Before aspiration After aspiration

In next slide, you see the report of pleural fluid

aspiration. Comment on that.

• 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.

Case No - 13

Don’t read description first: Case of Pulmonary TB.

• Identify the abnormality and describe it

Case No - 16

1st patient

Don’t read description first: There is a hypodense area at the border of left fronto-parietal

area of the brain without dilatation of the ventricular systems and midline shift. Diagnosis is

CSF hydroma.

2nd patient

Don’t read description first: There is a hypodense area posteriorly at the left lobe of the

cerebellum. Diagnosis is CSF hydroma.

Case No - 17

53 yrs old male patient

presented with backache

and stiffness for 6

months.

X-ray shows Lumbar

lordosis.

What are the causes of

lumbar lordosis.

• 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.

Case No - 18

Don’t read description first: You can see two apical bullous lesions on either sides of the

lungs. Note that bronchovascular markings are not apparently seen over the lesions.

You can see the typical thin wall in the bullae.

• 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.

Case No - 19

This patient has right side lower motor neuron type of

facial palsy.

When trying to close the eye he gets exaggeration of

eye ball movement to upwards.

Here, you have to direct the clinical examination to

identify the level of the lesion and probable aetiology

Common site of lesion could be at the muscle,

nuromuscular junction, facial nerve at the parotid

gland, facial nerve in side the canal, at facial mortor

nucleus in the pons.,

• 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.

Case No - 20

At the age of 18 At the age of 35

In summary she had primary ovarian failure,

Hypothyroidism and adrenal cortical failure

This all three account for Polyglandular autoimmune

syndrome.

Thanks