Clinical materials for medicine III

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 70 yrs old male patient admitted with 4th

episode of arthritis.

• PMH - Gout and DM for 11 yrs.

• S.Uric acid- 13.2mgdl (3.4-7). BU-80mgdl,

S. Cr-2.3mgdl, ESR –94mm/h.

• What is your treatment for arthritis in this

patient.

Case No - 1

Hyperuricaemia cause four clinical syndromes.

1. Acute urate synovitis-gout,

2. Chronic polyarticular gout,

3. Chronic tophaceous gout,

4. Urate renal stone formation.

Here you see a patient with Chronic tophaceous gout.

Tophi – Sodium urate forms smooth white deposits

(tophi) in skin and around joints.

Notice the scar of removal of tophi (left hand at the

elbow)

Don’t read description first: Classical radiological feature in Gout - Punched

out erosions away from joint.which is not much obvious in this patient. (At the

distal end of 3rd middle phalanx you can see a erosion which is not a typical one)

Urate renal stone formation or urate

nephropathy

• Try to identify abnormalities and some

common normal variations.

Case No - 2

Don’t read description first: Look at the anterior ends of the ribs. they look like multiple

cystic lesions in the lung. With this sign you can guess whether this CXR is from a male

or female. Males - have peripheral thickening, Females – have middle area thickening.

• A 38 yrs old male patient referred from eye hospital after treating for iritis of right eye. Patient had several clinical problems.

– Chronic pancreatitis with pancreatic pseudocyst

– High ESR – 120mm/1st h

– High ALKP – 1620 u/l (2.8-279)

– Intrahepatic bile duct dilatation.

– Anaemia

– Blood and mucous diarrhoea 4-5 times a day even in the night, associated with abdominal pain.

Case No - 3

• Clinicians thought of two main possibilities.

– Chronic pancreatitis and pseudocyst causing CBD

obstruction and malabsorption.

– Chronic pancreatitis with Inflammatory bowel

disease.

• Gastroenterologist suggested US guided

aspiration of the cyst and observation for

improvement.

• Here you see a series of CT and XR abdomen.

Train your eyes to read these materials.

Don’t read description first: Low density well defined lesion in the region of head

of the pancreas, multiple cystic lesions in the pancreas, intra hepatic duct dilatation

present. Two rounded bodies you see either sides of the aorta are cruses of diaphragm.

Don’t read description first: Low density well defined lesion in the region of head of

the pancreas, multiple cystic lesions in the pancreas, intra hepatic duct dilatation present.

Pancreatitis can cause ileus but no features to suggest ileus in this patient.

Don’t read description first: Here you can see the pancreatic calcifications.

• An 18 yrs old male patient admitted with

polyarthritis for 3 months duration.

• Diagnosis – Seronegative arthritis

• Look at the X-ray hand. Are there any

abnormalities? Comment.

Case No - 4

Don’t read description first: No abnormality, his hand bones show

trabecular pattern clearly. No significant reduction in bone density.

• A 52 yrs old male patient came with fever,

loss of appetite, loss of weight, Cough for

last 3 months.

• Examine the CXR and describe the

abnormalities.

Case No - 5

Don’t read description first: CXR shows left apical cavity, with right

perihilar nodular shadow. Active TB cavity.

Patient’s sputum AFB was positive and sent to a chest hospital for further

management.

• A 58 yrs old male patient admitted with a

history of fever, shortness of breath,

productive cough for 2 wks duration. Also

he had loss of appetite, loss of weight.

• PMH - DM

• Lungs - B/L coarse crackles.

• Examine the CXR and comment.

• What is the differential diagnosis?

Case No - 6

Don’t read description first: Period of signs and symptoms were not

compatible with the lesion, highly suggestive of Pulmonary TB.

• A 20 yrs old male patient admitted with a

history of productive cough, fever, night

sweats, loss of appetite and loss of weight

for about 5 months.

• On examination – left sided apical crackles.

• Examine the CXR and comment.

Case No - 7

Don’t read description first: You can see cavitating lesion of pulmonary TB in

the left apical region. Thick wall cavity with regular inner wall, streaky shadows

involved in left upper lobe consistent with fibrosis.

• These X-rays are from a 54 yrs old male

patient with DM.

• Describe the abnormalities you see.

Case No - 8

Don’t read description first:

You can see a hyperdense

circular lesion at the lower zone

of left lung.

“Single pulmonary nodule” –

Differential diagnosis include

benign lesions like Hamatoma

(calcification seen in 40% of

cases ), Arterio-venous

malformation and

malignant lesions either

primary or secondary,

secondary deposits are mainly

from Breast or Brain. It can

also be patch of consolidation.

• A 23 yrs old unmarried male patient came

with a history of dysuria and urethral

discharge for 8 days.

• About 4 days after onset of symptoms he

developed fever with chills, oligoarthritis

(Right knee joint, ankle joint), features of

tenosynovitis, arthralgia and a rash in

distal limbs.

• Examine the slides.

Case No - 9

Don’t read description first: Pustular lesions with surrounding erythema distributed

mainly over the distal limbs.(most of the time closer to a joint)

Pustular lesions with surrounding erythema distributed mainly over the distal limbs.(most

of the time closer to a joint)

• What else you want to explore in the history ?

• What is the differential diagnosis ?

• How are you going to confirm your diagnosis ?

This is a case of possible Disseminated gonococcal infection (DGI), Sexual history

and symptoms relating to urethritis, proctitis, pharyngitis need to be explored.

If you find only the clinical features – diagnosis is a - possible diagnosis of DGI

If you could isolate the organism from any primary site of infection – diagnosis is a

probable diagnosis of DGI.

If you could isolate the organism from the blood, synovial fluid, or from the pustular

lesions the diagnosis is proven diagnosis of DGI.

• A 66 yrs old male patient who had progressive shortness of breath for 6 months with non productive cough, loss of appetite, loss of weight, no fever, night sweats

• PMH- DM complicated with right above knee amputation.

• On examination - B/L crackles over lungs.

• Train your eyes to describe the HRCT films in the next slides. And find out the abnormalities.

• Give two differential diagnosis for this appearance.

• What is the most probable diagnosis of this patient?

Case No - 10

Radiologist’s opinion on HRCT films of this patient

• Inter alveolar septal thinning noted in sub-pleural distribution in

both lung fields involving all 3 zones but predominantly basal,

• Cystic air spaces seen in subpleural regions of both lung fields

and predominantly basal distribution R>L,

• Ground glass opacities are noted in left lower zone posteriorly

and right perihilar region.

• Traction bronchiectatic changes seen in right upper lobe and left

lower lobe.

• Irregular interfaces between lungs and pleura, venules, airways

also seen.

• Small pneumothorax is seen on right side.

• Impression-Fibrosing alveolitis.

• A 54 yrs old female patient with Rheumatoid arthritis, diabetes mellitus, hypertension and epilepsy, followed up at a medical clinic,

• Treatment regimens include

– Nifidipine SR 20mg bd

– Methotrixate 7.5mg Every WED

– Folic acid .5mg Every SUN

– Prednisolon 5mg tds

– Glibenclamide 2.5mg bd

– Atenolol 50mg mane

– Na Valproate 300mg tds

• Look at the outcome in this patient who has a history of 35yrs of RA.Describe the hand deformities in RA.

Case No - 11

1. Metacarpophalangeal subluxation

2. Ulnar deviation of fingers at the

metacarpophalangeal joints.

3. Swan-neck deformity of the fingers

4. Disuse atrophy of hand muscles

5. Buttonhole or Boutonniere deformity (fixed

flexion)

6. Pathological bone fractures.

Case No - 12

• A 26 yrs old male patient presented with shortness of breath, pleuritic chest pain, cough, loss of appetite and loss of weight for about 3 weeks duration.

• He had a past history of pulmonary TB 2yrs back and taken full course of Anti-TB treatment.

• Examine the CXR and identify the abnormalities.

Don’t read description first: You can see areas of fibrosis and bronchectasis.

Thanks