This document provides clinical materials for self-learning in clinical medicine. It includes 12 clinical cases with descriptions, examination findings, imaging results, and summaries. The objective is to examine each case carefully and analyze the findings to aid in learning. Suggestions and feedback can be provided to the author via email. The author acknowledges and thanks the patients, teachers, and colleagues who contributed to developing this resource.

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 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.

7. 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)

8. 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)

9. Urate renal stone formation or urate
nephropathy

10. Case No - 2
• Try to identify abnormalities and some
common normal variations.

11. 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.

12. Case No - 3
• 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.

13. • 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.

14. 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.

18. 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.

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

22. Case No - 4
• 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.

24. Don’t read description first: No abnormality, his hand bones show
trabecular pattern clearly. No significant reduction in bone density.

25. Case No - 5
• 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.

26. 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.

27. Case No - 6
• 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?

28. Don’t read description first: Period of signs and symptoms were not
compatible with the lesion, highly suggestive of Pulmonary TB.

29. Case No - 7
• 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.

30. 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.

31. Case No - 8
• These X-rays are from a 54 yrs old male
patient with DM.
• Describe the abnormalities you see.

33. 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.

34. Case No - 9
• 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.

35. Don’t read description first: Pustular lesions with surrounding erythema distributed
mainly over the distal limbs.(most of the time closer to a joint)

36. Pustular lesions with surrounding erythema distributed mainly over the distal limbs.(most
of the time closer to a joint)

38. • 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.

39. Case No - 10
• 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?

48. 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.

49. Case No - 11
• 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.

51. 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.

52. 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.

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

54. Thanks