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 September 2003

Study 1

A Patient with Abdominal pain and bone pains

Radiodiagnosis

Study 2

Biliary stones & colic

Surgery

Study 3

The difficult pleural effusion

Medicine



Study I: A Patient with abdominal pain and bone pains

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

A 45-year-old man presents with severe abdominal pain diagnosed as peptic ulcer. He has h/o left loin to groin pain, episodes of epigastric pain and generalised bone pains. One year ago he had an episode of 'psychiatric illness'. Plain radiographs of the hands and skull are shown below. Click on the pictures for bigger views.

1. What are the radiology findings?

2. What is your diagnosis?

3. What are the key imaging features that confirm diagnosis ?

4. What are the types of hyperparathyroidism?

5. What is tertiary hyperparathyroidism?

Acknowledgement:Dr. George Koshy & Dr. Shyamkumar NK, Deparment of Radiology, CMC, Vellore




Study II: Biliary stones & colic

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

1. A forty year old lady is advised to undergo an ultrasound of the abdomen and pelvis by her gynaecologist because her periods are irregular and heavy. She also complains of dyspeptic symptoms and mild upper abdominal discomfort of long standing.  The ultrasound detects gallstones in a contracted gallbladder. Her doctor advises her to undergo a cholecystectomy. She comes to you for a second opinion. What would you advise?

2. Which of the following is the most accepted indication for cholecystectomy in a patient with asymptomatic gallstones?

3. Five years later the patient develops severe right sided abdominal pain that wakes her from sleep, lasts all night, and is associated with vomiting. By the morning her pain has almost resolved. You examine her and find her abdomen is soft and no mass is palpable. What is your diagnosis and what would you advise?

4. Her total bilirubin is 3 mg% with a direct bilirubin of 1.5 mg%. Her serum alkaline phosphatase is 180 U/L ( normal upto 120U/L). Her ultrasound demonstrates a distended gallbladder with a stone impacted at its neck . The common bile duct is 8mm in diameter. Does she have stones in her common bile duct?

5. How can you clarify whether or not she has stones in the bile duct?

6. In view of the low probability of a common duct stone in this patient and the rapid resolution of her symptoms you decide against any further investigations. You advise her to have a cholecystectomy. When is the ideal time?

7. At operation you find the gallbladder plastered to the colon and duodenum with dense inflammatory adhesions. You are unable to safely dissect the gallbladder. What should you do?

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




Study III: The difficult Pleural Effusion

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

CHIEF COMPLAINTS

HISTORY

PRESENTING COMPLAINTS

  • Presented with worsening breathlessness of 1 week
  • Rapid deterioration in effort tolerance and severe orthopnea.
  • He had loss of appetite and 3 Kg weight loss
  • Negative history: He had no associated
    Respiratory symptoms - cough, sputum, fever, haemoptysis
    Cardiac symptoms- Retrosternal chest pain, palpitations, oedema or abdominal distension
    GI symptoms - Abdominal pain, jaundice, GI bleeding
    Collagen vascular disease- Joint pain, malar rash or alopecia

    PAST, PERSONAL AND FAMILY HISTORY:

    PHYSICAL EXAMINATION

    General examination Negative Findings

    Chest X-ray. Click on the pictures for bigger views.

    1. What are the radiological findings?

    COURSE IN HOSPITAL

    LABORATORY INVESTIGATIONS

    Haemogram

    Serology

    Urine analysis- negative

    Stool occult blood- negative

    Biochemistry

    ECHO

    Massive pericardial effusion. RA and RV collapse: -> RV collapse-tamponade. No evidence - adhesions,tumour, aneurysm or thrombus
    Pericardiocentesis Pig tail inserted Immediate drainage of Pericardial Effusion required
    Symptoms dramatically improved -> The dyspnea is due tamponade

    2. What is your interpretation of the signs & symptoms?

    3. What is your clinical diagnosis?

    4. What diagnosistic tests would you suggest?

    5. How can the pleural fluid help in making a diagnosis?



    6. How would you interpret the findings?

    7. What is your final diagnosis?




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