This document provides clinical materials for self-learning in clinical medicine. It was prepared by Dr. Ajith Karawita and contains acknowledgements, instructions for use, and 12 case studies with associated radiological images and reports. The case studies cover a range of topics in clinical medicine and are intended to allow the reader to examine each case, analyze the findings, and suggest a diagnosis and treatment plan.

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 68 yrs old female patient presented with
dyspnoea on exertion, loss of appetite and loss of
weight for about 1 ½ months.
• She is a known patient with hypertension and
diabetes mellitus for about 9 years.
• On examination- there were crackles on right base
of the lung.
• ESR was 85mm/1st h.
• Scan the CXR, what are the abnormalities? How
do you diagnose and treat this patient?

5. Don’t read description first: There is apparent elevation of the right hemi
diaphragm, causes could be above diaphragm, in the diaphragm and below the
diaphragm.

6. Same patient, Lateral view

7. Case No - 2
• A 60 yrs old female patient admitted with
shortness of breath, on and off fever for last
2 months and increased enlargement of
goitre which has been there for last 35 yrs.
• Clinically she was euthyriod and the goiter
was multinodular without signs and
symptoms of infiltration.
• Go through the x-rays and identify
abnormalities.

8. Don’t read description first: Note Tracheal compression and deviation with right
extensive pleural effusion. You can also see the extent of thyroid gland.

10. Before aspiration After aspiration
USS of effusion - shows numerous pleural tags, two mixed
echogenic pleural basal lesions seen at right costo-phrenic region
? Inflammatory lesion ? Soft tissue lesion

11. Case No - 3
• Report of Pleural fluid analysis of that patient is
mentioned below, comment on the report.
– Protein 5.4 gdl
– Cl 121 mmol/l
– LDH 100
– WBC 4100 /mm3 ( N-45%, L-55% )
– RBC Field full
• Gram stain – Organisms not seen
• Culture / ABST – negative

12. Case No - 4
• A 52 yrs old unmarried female patient
presented with backache for 6 months
duration.
• Menapause - at the age of 47yrs.
• Examine the x-rays and describe the
abnormalities.

13. Don’t read description first: Compression with narrowing of the intervertebral disk
at T10 and T11, and calcified fibroid.

14. Case No - 5
• One young patient has taken his daily oral
drugs at at 8.00 a.m.
• He noticed a gradual darkening of urine
colour.
• By 1.00 p.m colour was maximum.
• But evening urine sample was quite normal.
• What could be the most probable drug that
could have caused the colour change?

15. 1.00 p.m Sample Evening sample

16. Case No - 6
• A 32 yrs old female patient admitted with high
ferritin level. She is a known patient with
Thalassaemia diagnosed about 5yrs back.
• Hb was 7.1mgdl, about 25 pints of blood had been
transfused after the diagnosis.
• At 4.00 p.m Desferrioxamine iv infusion was
started and stopped at 9.30 p.m.
• She urinated at 9.30 p.m and 6.00 a.m, see the
urine colour compared with normal sample of
urine.
• Try to memorize the drugs that cause colour
change of urine.

18. Case No - 7
• A 68 yrs old male patient admitted with fever,
shortness of breath, loss of appetite and loss of
weight for about 5 wks.
• On examination of respiratory system-
Trachea deviated to the right.
Left side of chest- movements, VF , VR, and
breath sounds are reduced and stony dull on
percussion.
• See the CXR and describe the abnormalities. How
are you going to manage this patient ?

20. 1500ml of Blood stained pleural fluid was aspirated

21. After aspiration of 1500ml of Blood stained pleural fluid

22. Case No - 8
Comment on this
report of
arterial blood gas
analysis

23. Case No - 9
• Describe the radiological abnormalities you
see in this CXR.

25. Don’t read description first: Female patient with straight left heart border on
CXR, and on right side you can see nicely the double shadow.

26. Case No - 10
• Identify abnormalities in this CT-Brain.

29. Case No - 9
• A 57 yrs old male patient admitted with
sudden onset of left sided weakness.
• He is a heavy smoker and a known patient
with hypertension for 1 ½ yrs.
• Renal and Liver functions were normal,
lipid profile and clotting profile were also
normal.
• Identify the lesion in non contrast CT- brain
and describe it.

31. Case No - 10
• A 60 yrs old male patient admitted with
right sided focal epilepsy.
• He has a history of treated pulmonary TB
12 yrs back.
• Sputum AFB- negative, ESR-10mm/1st h
• Examine the CXR and identify radiological
abnormalities. What is your most probable
diagnosis ?

33. Don’t read description first: Mycetoma, notice the “air crescent sign”

34. Case No - 11
• Identify the lesion. What is the differential
diagnosis ?

36. Case No - 12
• A 60 yrs old male patient presented with fever,
shortness of breath, cough for 3 months duration.
• He is a known patient with multiple valvular
lesions. Most prominent lesions are ASD and
pulmonary HT.
• In echocardiogram - RA and LA dilated, MVP +,
Trivial MR+, TR+, large osteum secondum (size
2.2cm), poor left to right shunt.
• Describe the features in the CXR.

37. Before aspiration After aspiration
In next slide, you see the report of pleural fluid
aspiration. Comment on that.

39. Case No - 13
• A 42 yrs old male patient presented with
low grade fever, shortness of breath for 3
wks and haemoptysis for one day.
• See the CXR, describe the abnormalities.

40. Don’t read description first: Case of Pulmonary TB.

41. Case No - 16
• Identify the abnormality and describe it

42. 1st patient
Don’t read description first: There is a hypodense area at the border of left fronto-parietal
area of the brain without dilatation of the ventricular systems and midline shift. Diagnosis is
CSF hydroma.

43. 2nd patient
Don’t read description first: There is a hypodense area posteriorly at the left lobe of the
cerebellum. Diagnosis is CSF hydroma.

44. Case No - 17
53 yrs old male patient
presented with backache
and stiffness for 6
months.
X-ray shows Lumbar
lordosis.
What are the causes of
lumbar lordosis.

45. Case No - 18
• 50 yrs old male patient presented with fever
with chills for about 1 wk duration.
• Patient didn’t complaint of chronic cough
but he had exertional dyspnoea.
• ESR – 90mm/h and AFB was positive.
• What are the radiological features you see
in this CXR.

46. Don’t read description first: You can see two apical bullous lesions on either sides of the
lungs. Note that bronchovascular markings are not apparently seen over the lesions.
You can see the typical thin wall in the bullae.

47. Case No - 19
• 14 yrs old male patient presented with
inability to close right eye and mouth
deviation to left side.
• What is your spot diagnosis.
• List the causes of this abnormality.
• How are you going to assess the level and
extent of the lesion by history and
examination.

49. This patient has right side lower motor neuron type of
facial palsy.
When trying to close the eye he gets exaggeration of
eye ball movement to upwards.
Here, you have to direct the clinical examination to
identify the level of the lesion and probable aetiology
Common site of lesion could be at the muscle,
nuromuscular junction, facial nerve at the parotid
gland, facial nerve in side the canal, at facial mortor
nucleus in the pons.,

50. Case No - 20
• 35 yrs old mother of three children presented with
amenorrhoea from the age of 25yrs, dark
discoloration of skin started at elbow and knees
then to the body later to the gums and buccal
mucosa, LOA,apathy.
• Observe the features of this patient in next two
slides. And identify them.
• How are you going to identify the endocrine
abnormalities from the history and examination of
this patient.
• Mention how you investigate this patient.

51. At the age of 18 At the age of 35

53. In summary she had primary ovarian failure,
Hypothyroidism and adrenal cortical failure
This all three account for Polyglandular autoimmune
syndrome.

54. Thanks