© Department of Continuing Medical Education, Christian Medical College, Vellore
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Learning Cases December 2004

STUDY 1: ORTHOPAEDICS - CASE OF THE MONTH

A boy with short stature

Courtesy: Department of Orthopaedics, CMC, Vellore.

CLINICAL DATA

This 15 year old boy was referred to the orthopaedic surgeon for short stature.

1. What are the initial observations?

   Misshappen head, coarsening of the facial features, thick projecting eyelids, and a flat nose. This child also had mental retardation.
   
   

The pelvic x-rays had been done and are shown.





2. What are the findings on the hip X-ray?

   The hip X-ray shows fragmented capital epiphysis of the head of femur. Normally by 15 years of age the hip development is nearly complete and the growth plate is about to fuse.

3. What is your diagnosis in this child?

   The short stature, mental retardation, delayed maturation and presence of fragmented epiphysis seen in this case is indicative of hypothyroidism.

4. What test would you do to confirm this?

   * TSH estimate in blood.
          TSH values in this patient were 6190 UI U/ml
          Normal TSH value should be less than 5 UL U/ml.
   * T4 < 1.00 ug%
   * FTC < 0.20 ng

5. How would you treat the patient?

   Treatment is with replacement doses of thyroxine.

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

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STUDY 2: SURGERY – CASE OF THE MONTH

A woman with ptosis

Courtesy: Department of Surgery, CMC, Vellore.

Click on the picture to enlarge.

1. Identify this condition.

   Horner's syndrome - sympathetic paresis of the pupil.
   
   

2. What are the components of this syndrome?

   * Ptosis – due to unopposed activity of sphincter pupillae.
   * Miosis - paralysis of levator palpebrae superioris
   * Anhidrosis of the face - due to involvement of sympathetic fibres below bifurcation of carotid.
   
   Other rare findings include:
   * Hyperemia of the involved eye.
   * Increased amplitude of accommodation.

3. What are the common causes?

   * Neck or upper chest trauma
   * Thyroid or pulmonary neoplasm
   * Carotid vascular disease, including angiography
   * Cervical bony abnormalities
   * Neoplasm of base of skull
   * Following neck surgery including cervical sympathectomy
   * Intra cranial lesions involving brain stem
   
   

4. What is your diagnosis in this patient?

   The patient shown in the picture had intra-oral malignancy with neck node producing Horner’s syndrome. Management of the condition would depend on the cause.

5. What is the message of this learning case?

   The learning point here is that this syndrome has findings which are subtle but when suspected and looked for, the findings are obvious and that should lead to investigation to identify the cause.

Acknowledgement: Submitted by Dr. Deepak Abraham, Department of Surgery VI, CMC, Vellore.

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STUDY 3: RADIODIAGNOSIS - X-RAY OF THE MONTH

What's the Diagnosis?

Courtesy: Department of Radiodiagnosis, CMC, Vellore.

Click on the pictures to enlarge.

1. What are the findings in these MRI images?

   Findings:
   * High riding of 3rd ventricle.
   * Radial, spoke-like orientation of gyri
   * Parallel, non -converging lateral ventricles.
   * Probst bundles indents the superomedial aspect of the lateral ventricles
   * Colpocephaly (prominent occipital horns)

2. What is your diagnosis?

   Agenesis of Corpus Callosum

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

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