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Child with Fever & Multiple Joint Pain

Friday, December 25, 2009

Emely 12 year old girl who was admitted to the hospital because of having high fever for 5 days.It was a constant Fever associated with Abdominal pain, nausea & Vomiting, Loss of appetite,headache, Joint Pain & Swelling.Fever was well  responded to the paracetamol.Her joint pain mainly restricted to the Knee Joint,Ankle  & Elbow.Joint pain started from the Right Leg & then moved to the Left Leg & It was Flitting in nature.Because Of the Joint swelling she had difficulty in walking.She  had mild back  pain also.Her abdominal pain was diffuse.She did not have any urinary symptoms.

PMHx - She has had sore thoart about 2 weeks back. 

On Examination she was ill loking & febrile.her pulse rate was about 102bpm.Her joints were tender ,warm & swallen.
There were no other significant clinical findings.

  1. What are the Differential Dx in this child???
  2. What are the most preferable Investigations that you would like to do???
  3. What should be the Rx regimen in this child???
  4. What are the complications that child may get???

Man with generalized Blisters

Wednesday, December 23, 2009

Mr. John 71 year old man who was earlier worked as a driver had been having generalized blisters for 5-6 month duration.As he told before appearing the Blisters,the skin became Itchy then spontaneously Blisters appeared all over the body including the scalp.And patient complained of burning type sensation also.He had not had fever.
No Hx of insect bites.
He was diabetic & hypertensive.But he idnot have any significant drug Hx or Allergic Hx.
On Examination of this patient,
Patient was ill looking ,mildly febrile, not icteric ,not pale But had bilateral pitting odema in the legs & his abdomen was midly disteneded.There was no mouth ulcers.
His Skin has generalized Hyperpigmented papular Blistering eruptions.And Hyperkeratative skin in the legs & arms.
Regarding the CVS,RS there were no abnormalites detected.

  1. What are your Differential Dx for this patient???
  2. What are the Ix needed you to come to a defenitive Dx???
  3. How you are going to Rx this patient???

ECG Abnormalities_Part02

Monday, December 21, 2009

A 58 year old man was immediately sent to the hospital by his GP because that person has had severe constricting type chest pain 36 hours earlier.The pain had lasted about 3hours.Previously he had been well and by the time he was seen he was pain free and there was no abnormalities on examination.

In the hospital ECG was recorded.

  1. What are the ECG changes that you would see in this ECG recording???
  2. What would be the conclusion???

ECG Abnormalities_Part01

Sunday, December 20, 2009

This is an ECG which is recorded from 20year old girl who had been  found to have a heart murmur at a routine medical examination.It was first Dx when she was in her early teenage, but no action had been taken.She was completely asymptomatic.
This time on examination of her cardiovascular system, identified that her heart was regular, there was no clinical evidence of cardiac enlargement.But there was a mild to moderate loud ejection systolic murmur at the left sternal edge.Murmur is more pronounced on inspiration.Second Heart sound was widely split withno variationwith respiration.

  1. Identify the abnormalities that can be seen in her ECG Strip???
  2. What could be the origin of her murmur???
  3. Why she is having fixed widely split 2nd heart sound???

Woman with Backache

Saturday, December 19, 2009

Mrs Valantine 50 year old housewife presented with backache for 1 month duration.She was previously well &  Backache has insidious onset which gradually worsened.She felt pain on the lower dorsal region.Not only that  but she complains of a band like constricting type pain going around her chest just below the costal margin.Initially the pain occured with movements.then experienced pain even at the rest.There was loss of appetite also.
No Hx of Trauma.She was not on long term drug Rx.

On examination
She had Localized Tenderness over the Dorsal Spine
She was found to have the signs of cord compression below the level of T10-11 vertebrae.
In other Systems there was no other abnormality detected.

These Investigations were done
HB - 13.5g/dl
WBC - 9800/ml
PLT - 252,000
ESR - 134mm/1 hour
AST - 12U/l
ALT - 17U/l

MRI Scan of the Thoraco - Lumbar Spine was done.

  1. What are the Changes that you can appreciate in this MRI Scan???
  2. What are the Symptoms & Signs of Cord Comperssion???
  3. What are the possible causes for her chronic back pain???
  4. How would you confirm the Dx???
  5. What Are the Rx option available for this patient & how you Mx this Patient???

Lady with knee joint pain

Friday, December 18, 2009

Here are the two Xrays of the Right Sided knee joint of a 58 year old lady who is complaining of Bilateral knee joint pain for more than10years.

Comment on these two Xrays???
What are the Expected Signs that you would probably elicite when you are doing the complete Knee joint Ex???
What is the Dx???

Lady with Jaundice

Thursday, December 17, 2009

Allen phoned his family doctor to say that his 68 year old mother was unwell.She had been detoriating over period of 7 months and recently she was very cranky and her memory had worsened.She seemed to be having shortness of Breath when she came to answer the door and he thougtht her eyes looked little yellowish colour.
There was no suggestive family Hx of Dementia.
She was brought to the doctor & Dr. carried out a full examination.And she was found to have slightly Jaundice & her Skin had a lemon yellow tinge.
Her BP was 130/80mmHg.her JVP was raised and there was minimal pitting Odema in both Ankeles.
Deep tendon reflexes in her ankles & knees were absent.The plantar reflex was extensor.(Babiniski's Sign)Appreciation of both Vibration & light touch was poor in both feet and Legs.HEr walk was slightly Ataxic.

These Investigations were done in this patient.
(FBC,Blood Picture,LFT,ECG,CXR)

Full blood Count
HB        7.2g/dl
MCV     112fl

MCH     30pg/cell

MCHC   32g/dl

RBC      2.2x1012/l

WBC     2.1x109/l

Plt          98x109/l

Reticulocyte count  25x109

This was the blood film of that patient

Bilirubin - 28umol/l (0-17 umol/l)
LDH-  >5000 IU/l (230-450IU/l)
Pottasium - 2.7mmol/l (3.5-5.0 mmol/l)
ECG - sinus tachycardia
CXR - Evidence of mild heart Failure

  1. What are the differential Dx in this patient??? 
  2. How you come to the defenitive Dx with the aid of these findings??? 
  3. what other tests you needed to confirm the Dx??? 
  4. what are the other physical signs you expect in this condition???

Lady with left sided complete weakness

Wednesday, December 16, 2009

43 year old lady who was Dx as hypertensive accidentally in the antenatal clinic & then admitted to the hospital.3rd day of admission developed a left sided focal fit which was 2ry generalized.Then on the 5th day of admission she developed left paralysis associated with Dysphagia & mouth deviation to the right side & Dysphasia.
PMHx - There was an episode of LOC in 2007 which was lasting for 2days.She is hypertensive.
She had a Hx of two abortions in 2005 & 2009.

On Examination
Patient was Drowsy

Cranial nerve Examination
    CN7- Forehead forrows were present & mouth deviates to the right side
    Other cranial nerves were normal.
Motor  examination 
     There was complete left sided muscle weakness associated with exaggerated reflexes & increase muscle tone.And the babiniski sign was elicited with completely normal right side.
There was no sensory impairment.

CT scan done in this patient & It is shown below

Other than the CT scan Dr. has asked to do these investigations in this patient.
(Serum electrolytes & blood urea,PT/INR,FBC & Blood Picture,ECG,ALT,AST,ALP & Chest X-ray)

  1. Where would be the lesion in this patient & which arterial terrorary is involved???
  2. What could be the possible aetiology for this patient???
  3. Reason out why Dr has asked to do these Ix in this patient???
  4. What should be suitable the Drug Mx in this patient???

Answer_Patient with Unilateral Proptosis

Tuesday, December 15, 2009

Common Causes of Unilateral Proptosis are

  • Orbital cellulitis
  • Sphenoid wing Meningioma
  • Orbital fracture: apex, floor, medial wall, zygomatic
  • Carotid cavernous fistula
  • Cavernous Hemangioma
  • Cavernous Sinus Thrombosis
  • Leukemias
A carotid-cavernous fistula (CCF) results from an abnormal communication between the arterial and venous systems within the cavernous sinus in the skull. Patients usually present with sudden or insidious onset of redness in one eye, associated with progressive proptosis or bulging.And there may be a bruit within the skull.And there may be a progressive visual loss also.
Usually It is dx by MRI scan with MRA/MRV, CT angiogram and a cerebral DSA.

Orbital cellulitis is a serious infection of eye tissues. When it affects the rear of the eye, it is known as retro-orbital cellulitis.Patients present with sudden onset of fever, proptosis, restricted eye movement, and swelling and redness of the eye lids.In this case patient did not have any Hx fever.So Orbital cellulitis is unlikely in this case.

Cavernous sinus thrombosis (CST) is the formation of a blood clot within the cavernous sinus.Cavernous sinus thrombosis causes decrease or loss of vision, drooping or bulging eyes, headaches, and paralysis of the cranial nerves which course through the cavernous sinus.Headache with nuchal rigidity may occur. Pupil may be dilated and sluggishly reactive. Papilledema, retinal hemorrhages may also occur.
Usually Dx made by Clinically.

Orbital Exploration and Bx done in this patient.Bony erosions noted in the lateral wall of the Orbit.
patient was Dx to have Sphenoid wing Meningioma.
A meningioma is a benign brain tumor. It originates from the archnoid granulation.Its much more common in females
Tumors growing Sphenoid Wing  cause direct damage to the optic nerve leading especially to a decrease in visual acuity, progressive loss of color vision, defects in the field of vision , and an afferent pupillary defect. Proptosis, and palpebral swelling may also occur when the tumor impinges on the cavernous sinus by blocking venous return and leading to congestion. Damage to cranial nerves in the cavernous sinus leads to diplopia.
Dx is confirmed by CT scan and MRI

Patient with Unilateral Proptosis

Monday, December 14, 2009

Rajeshwary 46 year old lady coming to a NHSL hospital complaining of recently developed Right sided Proptosis for 3weeks &On and Off Headache Which is lasting for more than 4 years.Headache was Progressive and not relieved by simple analgesics.She has not had any fits associated with these symptoms.

On examination the patient was found to have some degree of right side visual impairement.She was conscious.And her BP was 120/80mmhg.There were no other significant findings.

  1. What are the possibilities of unilataral Proptosis in this lady???
  2. What further Investigations you should order to confirm the Dx???  

Answer_Patient with Unilateral Proptosis | MediCases

A Child With Fever & Abnormal Behaviour

Wednesday, December 9, 2009

Azam 9 years old previously well & active Child was found to have fever for 2 days & abnormal Crying & behaviour pattern for 7 days.Child had constant fever temperaly relieved by paracetamol.While child was having fever there was one episode of vomiting.2days after setteling the fever child was become hyperactive & abnormal crying.Child did not have fits.
On examintion of this child, he was found to have no abnormal finding in CNS & other systems.There was no lymphoadenopathy also.
Following Investigations were done in this child:

EEG in Sleep - Generalized Diffused  Slow activity in the theta & delta range with suprerimposed faster activity.There was bilaterall excess of slowing over Occipital regions.

CSF -   Appearance Clear
          No polymorphs & lymphocytes
          RBC - 30
          Protein - 20mg/dl
          Direct smear Organisms not seen

ESR - 08mm/1st hour 

  1. What would be the differential Dx in this Child???
  2. What are the aetiologies???
  3. what other specific tests needed to identify the aetiological agents???
  4. What are the complications that he might get???
  5. What are the Mx options we can take for this child???


Sudden Attack Of Severe Headache

Tuesday, December 8, 2009

Edward 65 year male patient C/O of Sudden Attack Of Severe Headache around @ 10.00 pm which was associated with mild memory loss.There was no loss of consciousness during the attck.He had been vomiting once.He was having neck stiffness.Otherthan that he was apperently Ok.
He was a known patient with Hypertension, DM & Ischeamic Heart disease & was on Metformin & Aspirin.
PTCA to left circumflex Artery & direct Stenting done in 2004
He was asked to do a CT-brain by the Neurosurgeon.


  1. Comment on this CT Brain???
  2. What is the possible Dx in this patient ???
  3. What could be the possible causes for above condition???
  4. How would you confirm the Aetiology???
  5. What the Place for lumbar puncture in above situation???
  6. What are the LP changes that you would expect by doing LP???
  7. What are the things that you would consider when you manage this patient???


Monday, December 7, 2009

Jenny 35 year old who worked as a secretary.Over the last year She noticed a decrease in her energy, which has been more marked in the last few months.Normally a very active woman has refrained going hill walking because she is too tired at the end of the day.
She has been living with her partner for 5 years & has never been pregnant
She smokes 10 cigarette per day & drinks fairly amount of alcohol weekly.

No Hx of Cough or Sputum & Cardiovascular Symptoms
On Examination DR. revealed that She has Pallor & Carried Out a Blood test.
  • HB 8.0g/dl
  • MCV 62fl
  • MCH 19.0pg/cell
  • MCHC 30g/dl
  • RDW 21%
  • WBC 5.3 x 109 /L
  • PLT 550 x 109 /L
Her blood Film

  1. Comment on her Full blood Count & Blood Picture???
  2. In which Conditions the patient gets these kind of red cell indicies ???
  3. What can be the causes of the Aneamia of this patient???
  4. What furtherInvestigation you should do in this patint to confirm the Dx???
  5. How would you manage this patient???

Child presented with Fits

Sunday, December 6, 2009

Anne 7 months old girl Admitted to LRH  has been having fits for 1week duration.Mother has noticed that while  she was feeding the baby.
During the attack these things were observed:
                Flexion of the head
                Flexion of upper limbs
Lasting for 5-10 mins
Appeared in clusters(4/5 times a day)
Child usually getting the attack just after woke up or before going to the sleep
After the attack thechild looked drowsy
In betweeen attcks the child is normal
No cyonotic episodes,urinary or bowel incontinence,nausea/vomiting during the attack
Feeding normal

Child's Birth Hx 
  • Elected Cessarian Section was done
  • Child was preterm(4weeks before the predicted date)
  • Birth weight - 3.100kg
  • child had been kept in the baby room for 11 days due to cyanosis & apnoeic attack she developed.
  • O2 given in the baby room

No family Hx of Fits

Developmental Hx
  • Head Control Achieved at 5 months
  • Does not sit with or without support
  • Does not reach for the objects
  • Child can turn from supine to prone & vise versa;achieved at 6 months
  • Uttering monosyllable sounds
  • Doesnot turn thehead towards Sounds
  • Does not follow the Lights

Examination Findings
  • Afebrile Child with No Dysmofic Features
  • Moving All four Limbs but left arm movements were less & usually its kept in flexed position
  • OFC-41cm
  • Length-67cm
  • Weight-6.9kg
  • Two Hypo Pigmented patches Seen in R/S cubital fossa & Abdomen
  • Al cranial Nerve were normal,No sensory Signs
  • Only Right arm was hypertonic
  • Babiniski Sign positive Bilaterally
  • Respiratory,cardiovascular & Abdomen- no abnormality detected

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