Kamineni Institute of Medical Sciences

• Clinical case:
  40 yrs old obese female patient
  Presented with pain abdomen (2 days), fever with chills (2 days) yellowish discoloration of eyes (2 days)
  Past H/O recurrent attacks of colicky abdominal pain for the last 6 months
  O/E temp – 380C, Icterus +,
  P.A: Rt. Upper quadrant Tenderness +,
  Murphy’s sign +ve,
• Points for discussion: -
  What is the management? (Diagnosis and treatment)
  Case of jaundice in this case
  Complications of Ac. Cholecystitis
  Complications after cholecystectomy (Open / Lap)
  Causes of obstructive jaundice

Clinical case:

1. .Un booked case – Primigravida with 34 weeks of GA perceiving good fetal movement
   C/o of sudden onset of pain abdomen and giddiness and presented with mild bleeding PV reported to labour room on 03.03.2015 at 9.45 PM. Her recent CBP report showed Hb 8.2% gms. Usg 30 weeks revealed twin gestation dichronic and diamniotic both placenta was fundal anterior grade II. Both the babies were in breech presentation.
2. On examination: Vitals: 88/min BP 130/90 mm hg
   P/A examination: Uterine height more than POG. Over dustended abdomen and tense. P/V patient was found to be in early labour.
   Cervix soft mid position
   30% effaced
   2 cm dialated
   Date: 03-03-2015
   CBP report blood group O+ve
   HB 8.4% TC 150000 Platelet count 1.2 lakhs
   Usg – twin gestation with twin a breech presentation and twin B transverse lie
   Gestational Age 32 weeks 4 days
   Placenta both anterior upper segment Grade II fundal
   Getal weight twin A 1.1 kg Twin B 1.4 kg
   AFI 20-21 cm

• 2years old child admitted in the hospital with H/O fever, recurrent infections, bleeding nose, poor weight gain & maculopapular rash.
• O/E-Pallor is present, Lymphadenopathy present, Moderate hepatomegaly, Marked Splenomegaly, Maculopapular rash present, skin nodules present, Ophthalmoscopic examination revealed optic disc changes, Tinytan colored spots on the Iris.
• Lab findings : Hb (less than 8 mg%)
  TWBC count (> lakh/Cumm with precuesor cells) with Monocytosis

Clinical situation:

A train travelling from Chennai to Hyderabad meets with an accident, when the train is hit by an oncoming goods train on the same track. It is learnt that four (04) bogies of the passenger train have derailed and over turned.

The incident took place at about 6.00 PM approximately 50 kilometers from Narketpally.

The site of the accident is in accessible as there are no roads upto the accident site. The information of the accident is received in our hospital by 7.00 PM it has already become dark and there is no report on the number of people and injured.

We discuss the challenges of administration; Triage, casualty evaluation & role of radiology in such a clinical situation.

Presenting complaints: Fever / Feverish feel 2 months Cough with expectoration 1 ½ month
Weakness/malaise unable to work 25 days Reddish blood in sputum thrice in the past two days
History:
Asymptomatic 3 months back when noticed loss of appetite then gradually started feeling weak and lost weight 3 kgs in 3 months

Fever: low grade in the evenings past two months occasionally associated with chills but no rigors Cough: developed 1 ½ month initially dry for a week then started getting whitish pale sticky and frothy mucoid expectoration Alarmed in the past 2 days as he found blood in sputum on cough

Past History: Nil significant as he led a healthy life except for some seasonal fever and malaise twice in past 5 yrs. Had ? typhoid at the age of 11.

Personal History: Married 2 children aged 3 and 1Studied upto 2nd standard in village school

Agricultural labourer since the age of 15. Was a smoker for brief period of 2 – 2 ½ yrs at age 18 – 20. Occasional alcoholic. Had few extra marital encounters with more than three different partners prior to marriage and when wife was away.

Examination: Average height and built Well nourished but appears pale, PR = 93, RR = 23, BP = 120/76, Temp = 99*F, SaO2 = 96%, No other significant finding, RESP SYST ::: URT – Normal

Lungs – Bil equal air entry in all the zones Medium to coarse crepts in the right Infra clavicular, Axillary & Rt upper inter scapular areas.

Investigations: Hb 11.2 gms%, TC & DC : WNL, LFT : Normal, Renal Func : Normal, Sputum AFB +ve, Retrovirus 1 & 2 : +ve, CXRay : Multiple infiltrates / Patchy consolidation and a 2.5 cm cavity in the RT UL

Chief complaints: Distension of abdomen since 3 days Vomiting Pain in epigastric region
History of parents illness: Patient was referred from medical ward as a case of acute abdomen who was apparently alright 2 months back to start with pain in epigastric region since 2 months which is aggravated by food intake, on and off relieved by vomiting which is sometimes bilious in nature. Patient also started experiencing marked distension of abdomen since 3 days.

Past History: He suffered from similar complaints and visited many hospitals since 10 years.

Personal History: Loss of weight 10 kgs during past 2-3 months, Occasional smoker – No H/O Bronchial asthma and TB / HTN / DM

Family History: His father had similar complaints who was operated twice but no details were available.

General Examination: Patient is conscious, coherent, co-operative, well oriented to time, place, person, Afebrile, dehydrated, emaciated and cachetic.
System Examination:

• Per abdomen:
  • Tenderness over epigastric region
  • Abdomen grossly distended with visible left to right peristalsis
  • RTA – 1200 cc bile stained food
  • No palpable lump / no organomegaly / no free fluid
  • Virchow’s negative
  • Both testes are normal
• Respiratory system: Air entry equal on-both sides, no added sounds
• Cardiovascular system: s1 and s2 are normal. No added murmurs
  • Per rectal: NAD
  • Routine investigations: Normal

• 60 years old female patient came with complaints of vertigo and tinnitus for the past one week which was gradual in onset.
• H/o cerebrovascular accident 1 year age.
• K/C/O Hypertension.
• K/C/O Diabete & Hypothyroidism
• K/C/O cervical spondylosis
• No H/O ear discharge or head injury or surgeries on ear.

O/E:

• • Pallor +
  • Neck stiffness +
  • Cautions gait
  • Romberg test +
  • Cerebellar function test - Normal
    No manifest nystagmus

Audiometry

• Puretone audiometry - moderate to severe SNHL

• Impedance audiometry - Normal middle ear pressure

ENG - Sinessoidal wave form