Prepared by Dr Ajtih Karawita MBBS, PGDV, MD

1. Clinical Materials for
Self Learning - Medicine.
Prepared by
Dr. Ajith Karawita MBBS, MD

2. 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

3. 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)

4. Case No -1
• 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.

5. • 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?

6. Don’t read description first: Consolidation and cavitating lesion at the lower
zone of the left lung.

7. Don’t read description first: Cavitating lesion has become a fairly
large cavity with a fluid level.

8. 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.

9. 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.

10. Case No - 2
• 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.

11. 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.

12. Case No - 3
Identify the device, what are the uses ?
Don’t read description first: Pulseoximeter

13. Case No - 4
• Identify XR abnormalities.
• What is the differential diagnosis?

14. 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.

15. Case No - 5
Train your eyes to
identify the vessels
and abnormalities.

16. Case No - 6 X-ray skull, sinus view, identify the
structures, train your eyes (larger
view in the next slide).
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)

18. Case No - 7
• 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?

19. 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.

20. 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.

22. 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.

23. 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.

24. • 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.

25. Case No - 8
• 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?

26. Scan No 1

27. 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%

28. Scan No 2
Scan taken 48hrs later, shows more prominent hypodensity than the previous one.

29. Case No - 9
• 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.

33. 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.

34. Don’t read description first: Here you see a haemorrhagic infarct at fronto- parietal
region. This is a case of cerebral venous thrombosis.

35. Case No - 10
• 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?

37. Don’t read description first: There is right apical fibrosis with marked
traction of trachea, probably due to healed TB with fibrosis.

38. Case No - 11
• 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?

39. 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.

40. Note: right horizontal fissure in two planes.

41. Case No - 12
• 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.

45. 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.

46. • One week later, again got admitted with
fever, chest pain and shortness of breath on
exertion.
• CXR was repeated.
• Comment on changes.

48. 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.

49. • 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.

50. 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.

51. Case No - 13
• 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?

54. 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.

55. Thanks