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

Study 1: DERMATOLOGY

Hyperpigmented plaque on the face

Courtesy: Department of Dermatology, CMC Hospital, Vellore.

1. Describe the skin lesions in each of the following patients.

2. What is your diagnosis?

3. List 3 drugs that can be used to treat this condition along with sunscreens.

Acknowledgement: Contributed by Dr. Renu George, Professor & Head of Department of Dermatology, CMC, Vellore.

Study 2: RADIODIAGNOSIS

A Patient With Hemiparesis And Giddiness

Courtesy: Department of Radiodiagnosis, CMC Hospital, Vellore.

HISTORY

IMAGING: MRI of the brain

Fig 1:MR imaging T1W sagittal	Fig 2:MR imaging T2W axial

1. Describe the findings seen on the MRI image.

Fig 3: Digital
Subtraction
Angiography(DSA)

2. Describe the findings seen on the DSA image.

3. What is your diagnosis?

4. Discuss the salient features.

REFERENCE:

Acknowledgement: D. Ankamma Rao, Surendra Babu, Divyan Paul, Department of Radiodiagnosis, CMC, Vellore.

Study 3: ORTHOPAEDICS

Progressive Difficulty in Walking

Courtesy: Department of Orthopaedics, CMC Hospital, Vellore.

HISTORY

1. Describe the clinical features you see in the photograph?

2. What is your diagnosis?

3. What investigations would you ask for?

4. What is dystrophin and what does it do?

5. What are the differential diagnoses you would consider?

6. Discuss the prevalence and prognosis of Duchenne's muscular dystrophy?

7. How would you manage these patients?

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

Study 4: MEDICINE

The Security Guard

Courtesy: Department of Medicine, Unit 1 & ID, CMC Hospital, Vellore.

HISTORY

• Seen in August 2001 for infertility
• Married twice: first wife had 2 spontaneous abortions with no living children; second wife yet to conceive.
• Decreased ejaculation and absent hair growth
• Diabetic for 8 years on insulin
• No history of anosmia, headache and vomiting or visual disturbances.
• Smoker, but did not consume alcohol

CLINICAL FEATURES

• Height: 176 cm (upper segment - 88 cm and lower segment - 88 cm), arm span: 176 cm and weight: 60 kg.
• Eunuchoid body proportions
• No facial or chest hair. Axillary hair was sparse and pubic hair was Tanner's stage II.
• Systemic examination normal.
• Examination of the external genitalia: Both testes atrophic but penis of normal size.

INVESTIGATIONS

• T4: 7.1 ug%; FTC: 1.01 ng%
• 8 am serum cortisol 15.37 ug%
• SGPT: 131 U/L; SGOT: 97 U/L
• HbA1c: 12.1%
• Serum testosterone: < 0.2 ng/ml
• Serum LH: <0.1 mIU/ml; FSH: 0.05 mIU/ml
• Serum Prolactin (HPRL): 7.21 ng/ml
• Serum creatinine: 0.8 mg%
• Ultrasound abdomen: Fatty liver.

1. What is your clinical diagnosis?

2. How would you manage the patient?

PRESENTING COMPLAINTS (MAY 2002)

• Presented to the Emergency Services with h/o diarrhea for two days and fever for one day
• Diarrhea was large volume, watery and occurred 10 -12 times/day.
• No history of abdominal pain or blood in stools.
• Had not passed urine for 20 hours prior to admission.

CLINICAL FEATURES

• Conscious and alert.
• Pulse rate was 120/min, blood pressure 70 mm Hg systolic, and respiration 28/min.
• Abdomen was distended, tense and tender, with guarding and rigidity. Bowel sounds were absent.
• Examination of other systems was unremarkable.

INVESTIGATIONS

• Total WBC count: 5600/ cu mm.
• Bandforms: 12%, Neutrophils: 60%, Lymphocytes: 26%, Monocytes: 2%
• Random sugar: 281 mg%
• Serum creatinine: 1.3 mg%
• Sodium: 134m mol/L; Potassium: 2.5mmol/L

3. What would your clinical diagnosis be?

COURSE IN HOSPITAL

• Seen by the Surgeons in the ER-had a four quadrant tap; no blood or pus.
• Drain placed in the right flank under local anesthesia.
• Shifted to the ICU, was intubated and mechanically ventilated.
• Started on insulin , ampicillin 1 gm i.v. q6H, gentamicin 240 mg i.v. od, metronidazole 500 mg i.v. q8H, morphine, ranitidine, NaHCO3 and Dopamine infusion.
• Plain x-ray of the abdomen was reported as distended ileal and colonic loops.
• Had progressive metabolic acidosis, hypokalemia, recurrent hypoglycemia, DIC and worsening hypotension.
• Was taken up for an exploratory laporotomy under GA. No evidence of perforation or gangrene of the bowel.
• 100 ml serous fluid in the peritoneal cavity.
• Multiple punctate hemorrhages on the bowel wall and mesentery and a large retro peritoneal hematoma.
• Findings were described as consistent with enteritis.
• Gram stain of the ascitic fluid revealed Gram-negative bacilli, which was clarified as comma shaped Gram negative rod.
• Patient had a cardio-respiratory arrest after the laporotomy and could not be resuscitated.
• Ascitic fluid and a blood culture were reported as showing Gram-negative bacilli.

4. What other investigations would you like?

5. What is your final diagnosis?

Acknowledgement: Submitted by Dr. Subramaniam, Department of Medicine, CMC Hospital, Vellore.

Study 5: ENDOCRINOLOGY

Diabetes Insipidus

Courtesy: Department of Endocrinology, CMC Hospital, Vellore

SOURCE: "Pituitary Passions" by Dr. Nihal Thomas & Dr. Christopher P. White, Endocrine Educational Series (Volume I) - Pantheon Publication.

HISTORY

CLINICAL FEATURES

• tenderness over the occiput.
• a 2-hour postprandial blood sugar of 8.1 mmol/l,
• serum creatinine of 0.09 mmol/l, sodium:
• 147 mmol/l, potassium: 4.1 mmol/l,
• total calcium: 2.4 mmol/l,
• phosphorus: 1.0 mmol/l,
• normal full blood count, erythrocyte sedimentation rate and liver function tests.
• On admission to hospital he was found to have an urine output of 7 litres over 24 hours.
• His height was 168cm and weight: 61 kg.

1. What special investigation would you ask for?

2. Describe the radiological findings?

3. What is your diagnosis?

4. Which is the most appropriate line of therapy?

1. Cranial irradiation
2. Melphalan and prednisolone
3. Prednisolone alone
4. High dose chemotherapy
5. None of the above

5. What are causes for Diabetic Insipidus?

REFERENCES:

Acknowledgement: Submitted by Dr. Nihal Thomas, Department of Endocrinology, CMC, Vellore.