© Department of Continuing Medical Education, Christian Medical College, Vellore
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Learning Cases June 2005

STUDY 1: SURGERY CASE OF THE MONTH

Courtesy: Department of Surgery, CMC, Vellore.

HISTORY
A 45 year old man presents to the casualty with a history of:
* Acute onset of epigastric pain and vomiting
* Decreased urine output for the last 12 hours

CLINICAL DATA
On Examination:
* Dehydrated and hypotensive
* Tachypnoeic
* Tender abdomen with guarding and rebound tenderness

1. What is your differential diagnosis?

   Hollow viscus perforation; Acute pancreatitis.
   
   

2. What investigations will you order?

   Chest X-ray & X-ray abdomen
   
   

   This is the chest X-ray
   
   



3. What are the findings?

   Normal chest x-ray.

This is the X-ray of the abdomen




4. What are the findings?

   Normal x-ray. NG Tube was put in and 200 ml of air was insufflated.

This is the repeat chest X-ray




5. What are the findings?

   Gas under the diaphragm.

6. What is your diagnosis?

   Hollow viscus performation.
   
   

7. How will you proceed?

   * Rehydration
   * Correction of electrolytes and acid based imbalance.
   * Laparotomy

OTHER RELEVANT MATERIAL & DISCUSSION
Teaching Point: Repeat CXR after injecting air through a nasogastric tube if there is a strong suspicion of a duodenal ulcer perforation.

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

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STUDY 2: GENETICS

Syndrome of the month

Courtesy: Department of Clinical Genetics, CMC, Vellore.

CLINICAL PHOTOGRAPHS

1. Identify the Syndrome.

   Robert syndrome/Pseudothalidomide syndrome/Cleft lip/tetraphocomelia/Long bone deficiencies associated with cleft lip/palate

2. What is the differential diagnosis?

   Foetal Thalidomide syndrome (maternal exposure to the teratogenic drug thalidomide in pregnancy)

3. Discuss the features of this syndrome.

   Rare single gene disorder in the newborn born to consanguineous parents with multiple congenital abnormalities.
   • Phocomelia (severe shortening) of upper and lower limbs.
   • Radial defects, oligodactyly/syndactyly
   • Other notable features are (*seen here):
        Hypertelorism*, cloudy cornea or cataracts, prominent premaxilla*, cleft lip and palate*, dysplastic or small ears*,large genitalia*, congenital heart disease, cystic kidneys
   
   

4. What is the mode of inheritance?

   Autosomal recessive, Recurrence risk 25%

5. What is the follow-up

   Genetic counseling is indicated.

Acknowledgement: Submitted by Dr. Sumita Danda, Professor in Clinical Genetics, CMC, Vellore.

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STUDY 3: RADIODIAGNOSIS

spot the diagnosis

Courtesy: Department of Radiodiagnosis, CMC, Vellore.

An elderly gentleman, diagnosed to have carcinoma of the prostate, presented with hip pain and painful restriction of movements. Plain radiograph of the pelvis is shown below.

1. What are the findings?

   IMAGING:Plain radiograph of the pelvis - multiple sclerotic areas in both iliac bones and right trochantric region. A 1 cm well-defined calcification in the pelvis medial to the left acetabulum, - could represent a calcified lymph node/phlebolith.

2. What is your diagnosis?

   Osteoblastic metastates probably due to prostatic carcinoma.

3. Discuss other features of this case.

   * The most common bone tumour is metastases
   * Spread is usually by blood stream / lymphatics / direct extension
   * Predilection for marrow containing skeleton
   * Lesions can be single / multiple of varying sizes
   * Metastases be of the following types:
        Osteolytic - from lung cancer, breast cancer, thyroid cancer
        Osteoblastic - from prostate, breast, bronchus, bowel, bladder, lymphoma,
        Mixed - from breast, prostate, lymphoma
        Expansile - from kidney, thyroid
        Permeative - Burkitt's lymphoma, Mycosis fungiodes
        Calcified - from breast, osteosarcoma, testicular, thyroid, ovarian, mucinous adenocarcinoma of GI tract
   * Joint spaces and inter-vertebral spaces usually not involved.

Acknowledgement: Submitted by Dr. Divyan Paul Pancharatnam, Dr. George Koshi, Dr. Shyamkumar NK and Dr. R. Sudheer, Department of Radiodiagnosis, CMC, Vellore.

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