Prepared by Dr Ajith 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 65 yrs old female patient presented with
left sided chest pain, cough and backache for
about 2 months.
• PMH-Iron deficiency anaemia.
• Examine the CXR and describe radiological
features. What is your diagnosis?

5. Don’t read description first:
Hypodense almost circular
lesion close to posterior
surface of the left lung with
rib erosion.

6. Case No - 2
• A 74 yrs old male patient presented with
productive cough, shortness of breath.
• Describe the features in the CXR.

7. Don’t read
description first:
This patient has
undergone left
lobectomy about 40
yrs back due to
Bronchiectasis.this
time the featurs are
suggestive of
pulmonary TB with
bronchiectasis.

8. Don’t read description first: Note wiring of ribs – left lower two ribs.

9. Case No - 3
• A 33 yrs old male patient investigated for
PUO.
• He had persistently high ESR over
100mm/1st h.
• Renal and liver functions were normal.
• Describe the abnormalities you see in the
CT-Brain.

12. Non-contrast CT-Brain

13. IV Contrast CT-Brain

14. A hypodense area seen in the region of posterior limb
of the left internal capsule.
Small hypodensity also seen in the region of right
internal capsule as evident in non contrast film.
No other enhancing lesions, no midline shift.
ventricular systems, basal cisterns are within normal
limits, no haemorrhages are seen.
CT appearance – left and right internal capsule
infarction.

15. Case No - 4
• A 37 yrs old male presented with fever with
chills and rigors for 2 wks.
• There was firm splenomegaly.
• PMH – Typhoid 1yr back.
• Describe the CXR abnormalities.
• What is the differential diagnosis?

16. Don’t read description first: Cavitating lesion of active TB

17. Case No - 5
• A 50 yrs old male patient admitted with signs and
symptoms of urinary tract infections (UTI) for 5
days.
• PMH – patient with chronic renal failure due to
bilateral obstructive uropathy identified about 13
yrs back.
7 months back he underwent left urethrolithotomy
and right nephrostomy due to acute on chronic
CRF.
• Describe the abnormalities.

19. Case No - 6
• A 44 yrs old male patient presented with
increased frequency of fits and left
hemiparesis for 1day.
• PMH – known patient with epilepsy not on
regular treatment.
he has history of frequent falls and injury to
right side of the head.

20. Don’t read description first: Frontal infarction and a depressed fracture

21. Case No - 7
• A 38 yrs old male patient presented with
severe occipital headache, neck pain and
blurring of vision for about 1 wk duration.
• Clinically he had hepatosplenomegaly and
retinal infarcts.
• Comment on the FBC report.

22. Don’t read description first: This is from a patient with polycythemia complicated
with superior sagital sinus thrombosis. He is on anticagulation therapy.

23. Case No - 8
• This patient was investigated for apperently
elevated diaphragm in the CXR.
• She had persistently elevated ESR and CRP
with marginal elevation of transaminases.
• Then CT-abdomen done.
• Examine and describe the abnormalities.

25. Case No - 9
• A 54 yrs old male patient admitted with
shortness of breath, cough, and fever for 2
wks.
• PMH – non insulin dependent diabetes
mellitus for about 8 yrs, hepatitis B, left
side bronchial carcenoma which was
declared cleared 2 years back.
• Describe the CXR. What are the findings,
how are you going to manage this patient?

27. Don’t read description first: Nodular shadows at right hilum, with effusion and
consolidation.

28. Case No - 10
• A 26 yrs old patient admitted with fever and
myalgia for 3 days.
• His platelet count has dropped to 19,000
cumm, PCV was at upper limit of normal,
transaminases increased about three times.
• Look at the puncture site in the next slide a
peculiar lesion. it recurred once it has been
broken by patient.

29. Don’t read description first: Peculiar lesion at puncture site It is not just a bulb of
blood, macroscopically it has a membrane

30. Case No - 11
• A 74 yrs old male patient presented with
productive cough and shortness of breath for 1
month duration.
• He also had backache and high ESR for about 1
month.
• Mantoux was 22mm,
• Describe the abnormalities in the lumbosacral
spine of this patient and comment on the serum
electrophoresis report.
• How are you going to investigate this patient.

32. Don’t read description first: There is slight increase of alpha-2 globulin, no
monoclonal band ?infection

33. Case No - 12
• A 75 yrs old male patient admitted with
bilateral chest pain which is like lightening
pain for about 1wk.
• PMH – TB was completely treated 10 yrs
back.
• Describe the abnormalities in the CXR,
what is your differential diagnosis and how
are you going to investigate this patient ?

35. Don’t read description first:
Multiple hyperdense circualar
shadows at the apex of both
lungs.

36. Case No - 13
• A 22 yrs old patient admitted with diarrhoea
for 2 wks and fever for 1day.
• Look at the CXR identify abnormalities.
(history is not related to findings in the
CXR).

37. Don’t read description
first:
Note that anterior ends of the
3rd and 4th ribs of right side
are more wider.

39. Case No - 14
• A 66 yrs old male patient came with
polyuria, polydipsia for 1 yrs duration.
• On investigation – patient had diabetes
mellitus and urinary tract infections.
• Describe the abnormalities in the X-ray
KUB (kidney, bladder, ureter).
• How are you going to manage this patient?

40. Don’t read description first:
You can see bilateral Staghorn
calculi.

41. Case No - 15
• What is your spot diagnosis?

42. Don’t read description first: Scar of herpes zoster. In fact he had this active
lesion about 1yrs ago, which was not a complicated one, rash only lasted about 5
days.

43. Case No - 16
How do you collect
sputum for AFB?

44. Case No - 17
• A 60 yrs old female fat lady presented with chest
pain for 1 day.
• PMH – hypertension for 5 yrs, ischemic heart
disease for 1 ½ yrs.
• Patient didn’t tolerate exercise ECG.
• Next slide you will see a coronary calcium score
of this patient.
• Interpret the results.
• What is the significance of coronary calcium
score.
• How you perform coronary calcium score?

45. Coronary Calcium Score
Left Main Artery (LMA) 0
Left Anterior Descending (LAD) 0
Left Circumflex (LCX) 0
Right Coronary Artery (RCA) 102
Posterior Descending Artery 0
(PDA)
TOTAL 102
The diagram demonstrate the general location of
coronary artery calcification only. Does not necessarily
indicate the presence or location of a stenotic lesion.

47. Coronary calcium score is performed as same as CT scanning is performed,
but only chest is scanned and score is calculated by a different software.
Information is based on analysis of the coronary arteries. Calcium deposits
do not correspond directly to the percentage of narrowing of arteries only.
They do correlate directly to the amount of coronary plaque and to the risk of
future coronary disease. These calcium deposits usually begin to form years
before any symptoms develop. Early detection and modification of risk
factors such as smoking , high cholesterol can slow the progress of coronary
artery disease.
A low score suggest a low likelihood of coronary artery disease but does not
exclude the possibility of significant coronary artery narrowing. The results
should be discussed with your physician taking into account other risk factors
such as age, gender, family history, diabetes, smoking or high cholesterol
levels.

48. Case No - 18
Note any abnormality

50. Case No - 19
• A 26 yrs old male patient admitted with
right hypochondrial pain for 1 wk.
• Describe the CXR.
• How would you investigate this patient.

51. Don’t read description first: There is a small pleural effusion in right side of the
lung, Can you assess the amount of fluid?

52. Case No - 20
• A 78 yrs old male patient presented with
polyuria, polydipsia and body weakness.
• PMH –diabetes mellitus for 5 yrs. and
pulmonary TB completely treated about 50
yrs back.
• Describe the CXR abnormalities.

54. Case No - 21
• Identify the lesion

58. Case No - 22
• Describe the following two FBCs.
• How are you going to identify the patient’s
condition.
• What further investigation do you need to
confirm your diagnosis.

61. Case No - 23
• Comment on the following serum
electrophoresis report.

62. Don’t read description first: Slight polyclonal increase of Gamma globulin, No
monoclonal bands ?infection

63. Case No - 24
• Identify the clinical sign
• What could be the causes for the appearance
• How would you grade that.

65. Finger clubbing could be due to
A. Congenital – no disease
B. Lung disease – bronchial carcenoma, chronic
suppurative lung disease (bronchiectasis, lung abscess,
empyma), pulmonary fibrosis, pleural and mediastinal
tumours (mesothelioma), cryptogentic organizing
pneumonia
C. Heart disease – cyanaotic heart disease, subacute
infective endocarditis, atrial myxome,
D. Liver disease – Cirrhosis
E. Bowel disease – inflammatory bowel disease

66. Thanks