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 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 .

Case No -1

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.

• 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.

Case No -2

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.

• 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.

Case No -3

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.

• 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.

Case No -4

Don’t read description first: Here you can see a effusion with collapse

consolidation of middle lobe of right lung.

• 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.

Case No -5

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.

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.

• 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.

Case No -6

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..

• 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.

Case No -7

Don’t read description first: you can see ICH at basal ganglia. Blood is seen in 3rd

, 4th and lateral ventricles.

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.

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.

• 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.

Case No -9

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)

• 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.

Case No -10

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.

• 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.

Case No -11

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).

• 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.

Case No -12

Don’t read description first: you can see pneumothorax with lung collapse on

right side(note the absence of broncho vascular markings)

Don’t read description first: after treating the patient with IC tube insertion pt

developed surgical emphysema.

• 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 .

Case No -13

Don’t read description first: you can see hyperdense right lung shadow with more

density at the periphary. Diagnosis – mesothelioma

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.

Don’t read description first: CT-thorax (lung tissue window) – Shows right sided

pleural malignency- Mesothelioma

• 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.

Case No -14

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.

• 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.

Case No -15

Don’t read description first: Right side surgical emphysema

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 ”.

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

• In the next slide you see results of urine

protein electrophoresis compared with

normal diluted (1/50) serum protein

electrophoresis.

• What is your interpretation?

Case No -16

Pt’s Urine

Normal diluted

serum (1/50)

Alb

Alpha-1

Alpha-2

Beta

Gamma

urine protein electrophoresis compared with normal

diluted (1/50) serum protein electrophoresis.

Don’t read description first: Urine protein electrophoresis shows tubular proteinurea,

No evidence of Benz Johns proteins.

• In the next slide you see serum protein

electrophoresis of a patient and absolute

amounts in grams per liter.

• Interpret results.

Case No -17

Sample

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

Don’t read description first: Serum protein electrophoresis show low albumin and

mild poyclonal gammopathy finding would be consistent with chronic liver disease.

This is the result of serum electrophoresis of a

patient who was investigated for lower backache

and high ESR. Comment.

Case No -18

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

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?

Thanks