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 44 yrs old male patient presented with fever for two months and chronic cough, LOW, LOA for last one month.

• On examination - mild degree of clubbing, pallor, and left lung lower zone bronchial breathing was found.

• Two days later patient developed hoarseness. ENT examination revealed that he has laryngitis and vocal cord inflammation with nodules and ulceration.

Case No -1

• FBC - leucocytosis with 62% N, 35% L, 1% E, 2% M.

Hb – 10.8

RBC – just below normal lower limit.

• ESR-120mm/1st h

• FBS-114mgdl.

• Plural fluid - AFB negative.

• Here you see the repeated CXRs of this patient over two weeks.Work out the course of the disease. what is the differential diagnosis?

Don’t read description first: Consolidation and cavitating lesion at the lower

zone of the left lung.

Don’t read description first: Cavitating lesion has become a fairly

large cavity with a fluid level.

Don’t read

description first:

Here you can see two

fluid levels, may be

due to two cavitating

lesions overlying or

cavity with a unusual

effusion here need to

do a lateral CXR to

comment further on

fluid levels.

Don’t read description first: Irrespective of the antibiotic treatment patient’s

condition became progressively worsened and new lesions noted in the CXR. Ultimate

diagnosis was Tuberculosis although it is unlikely to have basal lesions. Initially the

probable diagnosis was pyogenic lung Abscess.

• A 58 yrs old fat female patient with

Hypertension and Diabetes mellitus

presented to the medical clinic with painful

swellings of 1st and 2nd finger distal

interphalageal joints.

• Identify.

Case No - 2

Don’t read description first: These are inflamed painful subcutaneous collection

of hyaluronic acid when you see these nodes at the DIP called Heberden’s nodes.

when it is at PIP joints it is called Bouchared’s nodes. Tender Bouchard’s nodes

may cause confusion with the synovitis of RA.

Identify the device, what are the uses ?

Case No - 3

Don’t read description first: Pulseoximeter

• Identify XR abnormalities.

• What is the differential diagnosis?

Case No - 4

Don’t read description first: You can see hypodense multiple rounded lesions in the

skull bones (Multiple lytic lesions) differential diagnosis for multiple lytic lesions

include 1. Metastasis 2. Multiple myeloma.

Usually metastatic lytic lesions you don’t see in the mandible whereas multiple

myeloma you can see lesions in the mandible as well. In this X-ray you cant see

mandible properly. So suggest repeat x-ray skull lateral view to assess the mandible.

Train your eyes to

identify the vessels

and abnormalities.

Case No - 5

X-ray skull, sinus view, identify the

structures, train your eyes (larger

view in the next slide).

Case No - 6

Don’t read description first: This X-rays look normal, identify the structures, some

times you can see fluid levels in the sinuses, soft tissue lesions like polyps, hyperdense

margins (thickenings)

• A 61yrs old male patient admitted with a history of on and off cough and yellowish sputum for two months duration and suddenly developed haemoptysis (one cup full of blood )

• On examination - left upper zone bronchial breathing +, finger clubbing and mild hepatomegaly.

• ESR-110mm/1sth

• Here you see the CXR and contrast CT thorax of this patient.

• What is the differential diagnosis?

Case No - 7

Don’t read description first: In Radiology it is a “solitaory pulmonary nodule” at

the right upper zone of the left lung - commonly seen in primary lung malignancy.

Secondary deposits are usually multiple with varying sizes. Tuberculoma is usually

small can vary from .5cm to 4cm.

Soft tissue window of CT scan with Contrast. In CT scans you can view them in three

main windows, 1. Soft tissue window, 2. Bone window, 3. Lung tissue window. Bone

erosions not to be seen.

The previous CT is the lung tissue window. Where you can

see the broncho-vascular markings properly. Usually vascular

structures are more clear and larger than Broncheoles.

Radiologists opinion

There is a soft tissue density mass in the left upper zone

extending from anterior to middle, there is irregular

enhancement trachea and bronchi are patent, heart and grate

vessels appear normal, no mediastinal lymphadenopathy, no

evidence of deposits in the lung fields, no pneumothorax,

pleural effusion, no definite evidence of rib destruction .

Impression – Neoplastic lesion in the left lung appear to be

most probably a primary lesion suggest biopsy.

In the same patient right supraclavicular lymph node excision

biopsy and TruCut biopsy of left lung lesion were done. Results

are mentioned below.

• Lymph node Biopsy ( 1x1x.5cm)- section from the

lymph node shows preserved architecture with

follicular hyperplasia with germinal centres. The

sinuses show many pigment laiden macrophages.

• Conclusion-Reactive follicular hyperplasia no

evidence of tumour metastasis.

• Lung Biopsy- Section reveals a tumour consist of

atypical glandular structures lined by columnar

epithelium cells and are pleomorphic and mitotic

figures were seen. Extensive necrosis was

identified.

• Conclusion-Moderately differentiated

adenocarcenoma of lung.Glaison grade III & IV.

• A 75 yrs old male pt with past history of bronchial asthma and ischemic heart diseases admitted with sudden onset of vertigo which was lasted for about 5mts. There were no focal neurological signs, BP was 110/70mmHg.

• On the same day patient suddenly developed left sided weakness. Cerebro-vascular accident was suspected and non contrast CT-brain was done. (scan no-1)

• Scan was repeated 48 hrs later. (scan-no 2)

• Compare both CT and interpret the findings. What are the lobes and vessel involved, and probable visual field defect?

Case No - 8

Scan No 1

Don’t read description first: You can see very mild

hypodense area at the right occipital region, and

calcification of the choroid.

Sensitivity of non contrast CT in identifying infarction –

Days after infarction.

1st Day 48%

1st to 2nd Day 59%

7th to 10th Day 66%

Scan taken 48hrs later, shows more prominent hypodensity than the previous one.

Scan No 2

• A 17 yrs old female patient transferred from

local hospital with headache, fits and

confusion developed on 9th day post partum.

• GCS was 12 (E3,V3,M6).

• Identify the lesion by examining non

contrast and contrast CT Brain.

Case No - 9

Infarctions could be either arterial or venous.

In arterial infarcts – there is no arterial territorial crossing

unless it is multiple infarct

In venous infarcts - usually no definite territorial involvement

and it involves multiple sites. Delta sign may present.

Here you see a haemorrhagic infarct at fronto- parietal region.

This is a case of cerebral venous thrombosis.

Remember- you can see Pseudo delta sign in subarachnoid

hemorrhage (SAH) on non contrast film.

Don’t read description first: Here you see a haemorrhagic infarct at fronto- parietal

region. This is a case of cerebral venous thrombosis.

• A 57 yrs old male patient presented with

shortness of breath and fever for two weeks

duration.

• ESR was 65mm/1sth

• Describe the abnormalities you see in the

CXR and what is the differential diagnosis?

Case No - 10

Don’t read description first: There is right apical fibrosis with marked

traction of trachea, probably due to healed TB with fibrosis.

• A 50 yrs old male patient presented with

fever with chills, cough, and shortness of

breath for four days duration.

• Examine the CXR and describe the

abnormalities.

• What is your diagnosis?

Case No - 11

Don’t read description first: There is opacification of lower zone of right lung .most

probably middle lobe lateral segment consolidation. Note the right horizontal fissure in

two planes.

Note: right horizontal fissure in two planes.

• A 44 yrs old male patient presented with left sided chest pain, shortness of breath on exertion and low grade fever for 2 wks duration.

• FBC shows leucocytosis with normal differential counts. Sputum for AFB-six times negative. Mantoux was 15mm.

• Fever slowly responded to antibiotics.

• Treated with iv Cefotaxime for 2wks and sent home on oral Augmentin after radiologist’s opinion on CXR.

• You can see a series of CXRs of this patient. Describe the course of the disease and radiological abnormalities.

Case No - 12

Don’t read description first: Changes are compatible with resolving

Pneumonia.just below the left hemi diaphragm you can see the splenic flexure of

colon. And there is obliteration of left costophrenic angle due to small effusion.

• One week later, again got admitted with

fever, chest pain and shortness of breath on

exertion.

• CXR was repeated.

• Comment on changes.

Don’t read description first: You can see wedge shaped hyperdense area, at the

posterior surface of the left lung probably at the level of apex of the lower lobe. It

looks like a posterior encysted effusion can be confirmed with US guided aspiration.

• After one week of iv Meropenem

consolidation was cleared, leaving a circular

shadow.

• But ESR was persistently over 100mm/1sth

with highly positive mantoux >15mm.

• Comment.

Don’t read description first: Here you can see posteriorly encysted effusion

(Since the left heart border is clearly seen the lesion should most probably be

posterior). For further investigation and management patient was sent to a

specialized unit. Still the clinical diagnosis of Tuberculosis not excluded although

tests are negative for TB.

• A 48 yrs old male patient admitted with

neck pain and restricted movements for

about 1 wk.

• He is having backache and stiffness

gradually developed over the last 15 years.

• Examine the X-rays and describe the

abnormalities. What is your diagnosis?

Case No - 13

Ankylosing spondititis

1. B/L symmetricl sacroilitis (asymetrical in Reiter’s and Psorisis)

2. Early lesions seen in thoracolumbar or lumbosacral areas.

3. Ligament calcification.

4. Appearance of syndesophytes

This process eventually involve cervical spine

Note in the cervical spine X-ray - Ankylosing spondylitis of cervical

spine, cervical spine involvement is usually late in the course of the

disease.

Here you can see the classical fracture at C-6 leading to

pseudoarthrosis.

Thanks