Continuing Medical Education, CMC-Vellore

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

Cases for August 2003

1. Case I: A Patient with Pain in the Knee Joint
2. Case II: A Student with Fever
3. Case III: Multiple swellings in a boy of 13
4. Case IV: A Patient with Acute Abdominal Pain

Case I: A Patient with pain in the knee joint

A Case from the Department of Radiodiagnosis, CMC Hospital, Vellore

A 19 year old male presented with pain and swelling of the left knee joint for 3 months and on examination was found to have restricted movement and tenderness. Radiograph of the left knee joint is shown below. Click on it for a bigger view.

What is your diagnosis?

Answers

Acknowledgement : Submitted by Dr Divyan Pancharatnam and Dr Shyamkumar N.K., Department of Radiodiagnosis

Case II: A STUDENT WITH FEVER

A case from the Dept. of Medicine Unit I & ID, CMC Hospital, Vellore

HISTORY:

A 28 year old student from Ranchi presented with fever of five months duration.

May 2000

• She developed bloody diarrhoea.
• Haemoglobin was noted to be 7.5 gm% and she was treated with oral iron;
• The fever subsided after treatment for malaria.

October 2000

• She had tiredness and asthenia, improving with oral iron.
• No history of blood loss.

March 2002

• She developed intermittent low grade fever with loss of appetite and weight.
• No history of blood loss.
• History of purpuric spots on the body.
• Evaluated outside and cultured S.faecalis and treated with iv ciprofloxacin for 2 weeks.
• Fever subsided initially but recurred again.
• Referred to CMCH, Vellore in July 2002.

CLINICAL EXAMINATION

• Thin built and pale.
• No purpuric spots or signs of infective endocarditis.
• No bone pains.
• Short systolic murmur at the apex.
• CVS examination otherwise normal.
• Mass in left hypochondrium, 6 cm below costal margin, consistent with spleen.
• No hepatomegaly or free fluid.

Questions

1.What are the investigations you would like to do?

2. What is your prelimininary diagnosis?

3.What is your final diagnosis?

Acknowledgement: Submitted by Dr. Subramanian Swaminathan, Lecturer in Medicine, CMC, Vellore.

Case III: Multiple swellings in a boy of 13

A case from the Dept. of Orthopaedics, CMC Hospital, Vellore

• This 13 year old boy presented with progressively increasing swelling of posterior aspect of right thigh and knee of 2 years duration.
• There is a past history of excision of a swellings over the trochanteric regions.
• 4 other siblings are normal.
• Redness and swelling of the right elbow was noticed at the time of planning for surgery on this patient.
• There was also firm swelling over the extensor aspect of left elbow

His clinical photographs are shown below. Click on them for bigger views.

The X-rays are shown below. Click on them for bigger views.

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

Case IV: A PATIENT WITH ACUTE ABDOMINAL PAIN

A case from the Dept. of Surgery, CMC Hospital, Vellore

History

• Anorexia, nausea & abdominal pain of 12 hours duration localising to the right iliac fossa.
• Her last period was 2 weeks ago.

PHYSICAL EXAMINATION

• tenderness and guarding in the right iliac fossa.

INVESTIGATIONS

• Her peripheral WBC count is 8000/cc with 75% neutrophils and 10% band forms.

The diagnosis is acute appendicitis

Q1. Which of the following is the most specific symptom of acute appendicitis?

1. Anorexia
2. Nausea and vomiting
3. Periumbilical pain localising to the right iliac fossa
4. Fever

Q2. A clinical diagnosis of acute appendicitis may be wrong in up to a third of young women of child bearing age. Do the following methods of make the diagnosis more accurate?

1. Graded compression ultrasound
2. CT scan
3. Diagnostic laparoscopy

The patient underwent laparoscopic appendicectomy.

Q3. Which of the following is not a benefit of laparoscopic appendicectomy?

1. More rapid recovery in obese patients
2. Fewer postoperative intra-abdominal abscesses
3. Fewer postoperative wound infections
4. More accurate diagnosis

Acknowledgement : Submitted by Dr. Sanjay Govil, Professor, Department of Surgery.