CME Learning Cases April 2004

CONTINUING MEDICAL EDUCATION,
CMC, VELLORE

© Department of Continuing Medical Education, Christian Medical College, Vellore
For more information please email: cme@cmcvellore.ac.in

Learning Cases April 2004

Study 1
Forty Year Old Lady with Menorrhagia Gynaecology

Study 2
A Boy with Pain & Swelling in the Thigh Radiodiagnosis

Study 3
A Gentleman with Headache And Visual Impairment Endocrinology

Study 4
Young Girl with Pan & Swelling Right Elbow Orthopaedics

Study 1	Forty Year Old Lady with Menorrhagia	Gynaecology
Study 2	A Boy with Pain & Swelling in the Thigh	Radiodiagnosis
Study 3	A Gentleman with Headache And Visual Impairment	Endocrinology
Study 4	Young Girl with Pan & Swelling Right Elbow	Orthopaedics

STUDY 1: GYNAECOLOGY – CASE OF THE MONTH

Forty Year Old Lady with Menorrhagia

Courtesy: Department of Obstetrics and Gynaecology, CMC, Vellore.

(Please see “Approach to a patient with Uterine Bleeding – “Current Medical Issues” Vol 6: Issue 4. April 2004).

HISTORY

A 40 year old lady - P3 L3 - sterilised.

H/o increased menstrual bleeding for 8 –10 years
Menstrual cycles were regular 5-6 /28 to 30 days
Mild spasmodic dysmenorrhoea
Previous cycles were regular with moderate flow
No treatment in the past for menorrhagia
No known medical problems so far

PHYSICAL EXAMINATION

No pallor
BMI 24
General and systemic examination were within normal limits

PELVIC EXAMINATION

Cervix and vagina healthy
Uterus normal in size ,AV ,mobile
No palpable adnexal masses

1. What is your diagnosis?

2. What investigations would you like to ask for?

3. What are the options available to this patient?

4. How would you treat this patient?

5. Define and describe dysfunctional Uterine Bleeding.

Acknowledgement: Submitted by Dr. Lily Verghese, Department of Obstetrics and Gynaecology, CMC, Vellore.

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STUDY 2: RADIODIAGNOSIS - X-RAY OF THE MONTH

A Boy with Pain & Swelling in the Thigh

Courtesy: Department of Radiodiagnosis, CMC, Vellore.

CLINICAL DATA

16 year old boy with a 6 month history of history of pain and swelling in the right thigh. Figure 1 shows a radiograph of the right femoral shaft.

Figure 1.

1. Describe the findings.

2. What is the most likely diagnosis?

Figure 2.

3. Describe the finding that this lesion often demonstrates on MRI.

4. What is the most common age and site of presentation of this lesion?

Acknowledgement: Submitted by Dr. Rekha Cherian, Department of Radiodiagnosis, CMC, Vellore.

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STUDY 3: ENDOCRINOLOGY

A GENTLEMAN WITH HEADACHE AND VISUAL IMPAIRMENT

Courtesy: Department of Endocrinology, CMC, Vellore.

HISTORY

A 42-year-old gentleman presents with a history of headaches and visual impairment over a period of a year. He has also noticed lethargy, weight loss of 4 kilogrammes and impotence.

ON EXAMINATION

On physical examination he is a thinly built man with scanty facial hair, a blood pressure of 90/60mmHg. He also has scanty pubic and axillary hair. There is a scar of a previous transcranial surgery present for a ‘tumour’ explored at the age of 11years.

INVESTIGATIONS

Hormonal profile reveals:

T4: 3.0pmol/l (Ref: 8.0-21.0pmol/l)
TSH 0.5mIu/l (Ref: 0.5-4.5mIu/l)
8:00AM Cortisol: 180nmol/l (Ref: 200-490nmol/l)

CT Scan reveals the abnormality shown below.

1. What are the MRI findings?

2. Having made the diagnosis, which of the following statements is false

Androgen replacement therapy is inappropriate
Partial excision followed by radiotherapy is the treatment of choice
10-20% of individuals with this condition may present for the first time during adulthood
Visual impairment is a common presentation
Hypopituitarism is a common presentation

3. What do you know about craniopharingioma?

4. How would you manage this patient?

5. How would you manage the androgn deficiency?

REFERENCES

Crotty T, Scheitauer BW, Young WF, Davis D. Papillary craniopharyngiomas: a morphological and clinical case study of 46 cases. Endocr Pathol 1992,3,S6.
Baskin DS, Wilson CB. Surgical management of craniopharyngiomas: a review of 74 cases

Acknowledgement: Submitted by Dr. Nihal Thomas, Department of Endocrinology, CMC, Vellore, from Pituitary passions by Nihal Thomas, Chrisopher White.

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STUDY 4: ORTHOPAEDICS - CASE OF THE MONTH

YOUNG GIRL WITH PAIN & SWELLING RIGHT ELBOW

Courtesy: Department of Orthopaedics, CMC, Vellore.

HISTORY

This young girl presented with history of pain and swelling of the elbow of 4 months duration. She had a soft swelling in the region of the elbow extending up the lower arm, range of movement was from 30 degrees to 120 degrees associated with pain and spasm. There is history of loss of weight of 3 kg and low grade fever. The clinical photographs are given below.

1. What would be your differential diagnosis?

2. How do you proceed with further investigations?

3. What are the X-ray findings?

4. What are these findings suggestive of?

5. What should be the next step?

6. What should be the next step?

Acknowledgement: Submitted by Dr. Vrisha Madhuri, Department of Orthopaedics, CMC, Vellore.

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