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 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?

Case No - 1

Don’t read description first:

Hypodense almost circular

lesion close to posterior

surface of the left lung with

rib erosion.

• A 74 yrs old male patient presented with

productive cough, shortness of breath.

• Describe the features in the CXR.

Case No - 2

Don’t read

description first:

This patient has

undergone left

lobectomy about 40

yrs back due to

Bronchiectasis.this

time the featurs are

suggestive of

pulmonary TB with

bronchiectasis.

Don’t read description first: Note wiring of ribs – left lower two ribs.

• 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.

Case No - 3

Non-contrast CT-Brain

IV Contrast CT-Brain

A hypodense area seen in the region of posterior limb

of the left internal capsule.

Small hypodensity also seen in the region of right

internal capsule as evident in non contrast film.

No other enhancing lesions, no midline shift.

ventricular systems, basal cisterns are within normal

limits, no haemorrhages are seen.

CT appearance – left and right internal capsule

infarction.

• 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?

Case No - 4

Don’t read description first: Cavitating lesion of active TB

• 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.

Case No - 5

• 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.

Case No - 6

Don’t read description first: Frontal infarction and a depressed fracture

• 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.

Case No - 7

Don’t read description first: This is from a patient with polycythemia complicated

with superior sagital sinus thrombosis. He is on anticagulation therapy.

• 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.

Case No - 8

• 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?

Case No - 9

Don’t read description first: Nodular shadows at right hilum, with effusion and

consolidation.

• 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.

Case No - 10

Don’t read description first: Peculiar lesion at puncture site It is not just a bulb of

blood, macroscopically it has a membrane

• 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.

Case No - 11

Don’t read description first: There is slight increase of alpha-2 globulin, no

monoclonal band ?infection

• 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 ?

Case No - 12

Don’t read description first:

Multiple hyperdense circualar

shadows at the apex of both

lungs.

• 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).

Case No - 13

Don’t read description

first:

Note that anterior ends of the

3rd and 4th ribs of right side

are more wider.

• 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?

Case No - 14

Don’t read description first:

You can see bilateral Staghorn

calculi.

• What is your spot diagnosis?

Case No - 15

Don’t read description first: Scar of herpes zoster. In fact he had this active

lesion about 1yrs ago, which was not a complicated one, rash only lasted about 5

days.

Case No - 16

How do you collect

sputum for AFB?

• 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?

Case No - 17

Coronary Calcium Score

Left Main Artery (LMA) 0

Left Anterior Descending (LAD) 0

Left Circumflex (LCX) 0

Right Coronary Artery (RCA) 102

Posterior Descending Artery

(PDA)

0

TOTAL 102

The diagram demonstrate the general location of

coronary artery calcification only. Does not necessarily

indicate the presence or location of a stenotic lesion.

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 deposits

do 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 of

future coronary disease. These calcium deposits usually begin to form years

before any symptoms develop. Early detection and modification of risk

factors such as smoking , high cholesterol can slow the progress of coronary

artery disease.

A low score suggest a low likelihood of coronary artery disease but does not

exclude the possibility of significant coronary artery narrowing. The results

should be discussed with your physician taking into account other risk factors

such as age, gender, family history, diabetes, smoking or high cholesterol

levels.

Case No - 18

Note any abnormality

• A 26 yrs old male patient admitted with

right hypochondrial pain for 1 wk.

• Describe the CXR.

• How would you investigate this patient.

Case No - 19

Don’t read description first: There is a small pleural effusion in right side of the

lung, Can you assess the amount of fluid?

• 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.

Case No - 20

• Identify the lesion

Case No - 21

• 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.

Case No - 22

• Comment on the following serum

electrophoresis report.

Case No - 23

Don’t read description first: Slight polyclonal increase of Gamma globulin, No

monoclonal bands ?infection

• Identify the clinical sign

• What could be the causes for the appearance

• How would you grade that.

Case No - 24

Finger clubbing could be due to

A. Congenital – no disease

B. Lung disease – bronchial carcenoma, chronic

suppurative lung disease (bronchiectasis, lung abscess,

empyma), pulmonary fibrosis, pleural and mediastinal

tumours (mesothelioma), cryptogentic organizing

pneumonia

C. Heart disease – cyanaotic heart disease, subacute

infective endocarditis, atrial myxome,

D. Liver disease – Cirrhosis

E. Bowel disease – inflammatory bowel disease

Thanks