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

Learning Cases July 2005

STUDY 1: SURGERY CASE OF THE MONTH

Courtesy: Department of Surgery, CMC, Vellore.

HISTORY
A 55 year old man has had an major operative procedure which was uneventful apart from a blood loss of 3 litres.

CLINICAL DATA
48 hours later, he becomes tachypnoeic with an increased heart rate. Arterial Blood Gas (ABG) was done.

ABG:
• pH 7.43
• PO2 55 mm Hg
• pCO2 29 mm Hg
• HCO3 19
• ABE -2.9

1. What investigations would you order?

   Chest x-ray.
   
   

The Chest X ray is shown below.




2. What are the findings?

   Multiple fluffy opacities in both lung fields.
   
   

3. What are your working diagnoses?

   * Acute Respiratory Distress Syndrome (ARDS);
   * Sepsis Inflammation Response Syndrome (SIRS);
   * SEPSIS.

4. What is your initial plan of management?

   * Oxygen therapy;
   * Positive pressure ventilation

He does not improve with this plan and a repeat x ray is done 24 hours later.
This is the repeat chest X-ray




5. What are the findings?

   Worsening of Acute Respiratory Distress Syndrome (ARDS); 4 zone injury.

OTHER RELEVANT MATERIAL & DISCUSSION
Teaching Point: ARDS can develop after major operations and massive transfusions.

Acknowledgement: Submitted by Dr. John Prakash Raj & Dr. Deepak Abraham, Department of Surgery, CMC, Vellore.

Top

STUDY 2: RADIODIAGNOSIS

spot the diagnosis

Courtesy: Department of Radiodiagnosis, CMC, 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.

1. What are the findings in this radiograph?

   IMAGING: Plain radiograph of the left knee joint showing a 6 cms multiloculated, subarticular expansile lytic lesion in the medial aspect of the tibia with a narrow zone of transition. Medial joint space is narrowed.

2. Describe the radiological features.

   * Eccentric, expansile, lytic, solitary lesion
   * Involving metaphysis , subarticular in position
   * "Soap bubble" appearance
   * Conspicuous peripheral trabeculae with no tumour matrix
   * No sclerosis / periosteal reaction
   * Pathological fracture may be noted
   * Cortical thinning with multiloculation
   

3. What is the diagnosis?

   Giant cell tumour(GCT) of upper tibia

4. Discuss other aspects of this case.

   * Also known as osteoclastoma
   * Histologically giant cells within fibroid stroma noted.
   * Located in long bones of lower extremity, flat bones.
   * Age group affected is usually 20-40 years.
   * Usually benign
   

5. What is your differential diagnosis?

   Chondromyxoid fibroma (CMF). CMF shares most of the features of GCT in terms of age of onset, location around knee, Subarticular, lytic expansile, eccentric etc. Calcification if present may be a clue for the diagnosis, which is not feature of GCT.

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

Top

Send response