- Module 3
CBL 17: Viral Vaccines
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CBL 17 SENARIO: A Final year medical student accidentally got needle-stick injury (NSI), while on clinical rotation in gastroenterolgy ward. The patient is a known case of hepatitis B virus infection with elevated ALT levels. The student had previously received complete hepatitis B vaccination around 5 years ago. The student is quite anxious now about this NSI incident and seeks medical advice from registrar in the ward. Learning Outcomes: What should be done to alleviate his anxiety? What tests should be performed on the patient and the student who received NSI?
How many types of vaccines are available for Hepatitis B?
What is the appropriate protection level of post-vaccination anti-HBs?
Who are the non-responders to hepatitis B vaccine and what can be done to offer protection to non-responders?
CBL 16: Viral Haemorrhagic Fever
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CBL 16 SENARIO: Case scenario: (A patient with fever, severe myalgia and headache) History: A 40-year-old male, presented soon after monsoon season with fever, severe myalgia, arthralgia, vomiting and headache for 3 days. The patient had been taking tablet paracetamol but the fever did not resolve.
Physical Examination: Upon physical examination, he had temperature of 39.8°C, hypotension (90/50 mmHg), tachycardia and generalized petechial hemorrhages on the skin.
Laboratory Investigations: Blood complete picture showed mild leukocytosis, normocytic anemia and thrombocytopenia. No malarial parasites were seen. Tests for typhoid were also negative.
Treatment: The patient was admitted and samples were taken for other tests. The patient was continued on Paracetamol.
Learning Issues: What other tests could be done to reach a definitive diagnosis. What is your provisional diagnosis? What other differential diagnosis come to your mind?
What is viral haemorrhagic fever? Name organisms causing viral haemorrhagic fever.
Name common viral haemorrhagic diseases in our setup.
What is Crimean-Congo haemorrhagic fever? How is it spread?
How will you diagnose CCHF? How will you treat it and what is its prevention?
Describe pathogenesis of Dengue fever.
How will you diagnose a case of dengue fever?
What is the treatment and prevention of dengue?
What is Ebola? How is it transmitted and how will you prevent its spread?
CBL 15 :Environmental Diseases - II
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CBL 15 SENARIO: Case scenario: A 54 years old male was admitted to a hospital. His chief complaints were dry cough and shortness of breath especially upon exertion for the last 3 years with progressive weakness and loss of weight History: The family and past history were not contributory except that he had worked in the dusty atmosphere of a tile factory for 26 years before the onset of the present illness. Physical examination: Pulse rate: 100 beats/ min, regular, Respiratory rate 30/min,temp: 98.6 F, BP: 110/80 mmHg, weight: 97 pounds , Breath sounds slightly diminished on right side. Bilateral lower rales were present on auscultation.
Laboratory investigations:
· Blood CP: Normal
· ESR: 30 mm at the end of 1st hour
· ABGs: Mild hypoxia with respiratory alkalosis
Mantoux Test: Negative
Learning Outcomes Most likely diagnosis Possible causes
Further investigations
What are chemical carcinogens
CBL 15: Environmental Diseases - I
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CBL 15 SENARIO: Case Scenario: (A patient having long standing environmental substances effects) HISTORY: A 65 years old male sweeper of NWFP is using Naswar for the last 40 years mainly inside of his lower lip. He is also a known smoker and smokes 15 cigarettes per day for the last 30 years. His cigarettes index was…Now he presented with complains of an ulcerated lesion under his tongue. He also complains of chronic cough with yellow colored sputum, breathlessness on exertion and had experienced severe chest pain about 2 years ago which was thought to be probably of cardiac origin.
EXAMINATION: On examination, blood pressure was 280/140 mm Hg and cervical lymph node was palpable. His chest examination (auscultation) showed rhonci as well as crepitations. Examination of his ulcer showed.
CYTOLOGY of scrap from the ulcer showed atypical squamoid cells having large vesicular nuclei with high N:C ratio. And were labeled as…MCC
FNA of cervical lymph node showed mature lymphoid cells with some atypical squamoid cell groups in between and areas of necrosis and was labeled as….
BIOPSY of the ulcer showed……………….and labeled as SCC (Well differentiated).
TREATMENT: Excision of the ulcer with clear margins was done and whole specimen was sent for histopathological studies……… After the receipt of result the patient was referred to oncology department.
Learning Issues: Explain the above signs & symptoms and their causes. What is the cause of his increased blood pressure?
What type of ulcer does he have?
What is the importance of cytology, FNA and biopsy in this case?
What will you study from the whole specimen sent for H/P?
What is pathogenesis of different complications caused by agents the patient was using?
What are possible other complications?
CBL 14: Ascariasis
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CBL 14 SENARIO: Case scenario: An 08 years’ old boy presents to the emergency room with abdominal pain and vomiting History: An 08 years old boy presents to the emergency room with abdominal pain and vomiting. He was ill for a day but his symptoms have worsened in the past few hours and his parents panicked when they saw a worm in his vomitus.
Examination: On examination he appears very ill and in obvious pain. His temperature is 37.7 C and his blood pressure is normal. He is tachycardiac and his lungs are clear. His abdomen has high pitched tinkling bowel sounds on auscultation and is diffusely tender on palpation.
Investigations: An abdominal X-ray shows air-fluid levels consistent with small bowel obstruction.
Learning Issues: What organism is most likely responsible for patient’s illness? How did the patient become infected?
What will be the diagnostic test for a patient with this infection?
What are the treatment options?
What are the preventive measures?
CBL 13: Neoplasia-II
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CBL 13 SENARIO: History: A 28 years young serving soldier presented at MRC with complaints of fever, weight loss and night sweating for the last 02 weeks. He states that he has noticed a nodular swelling on right side of neck. Examination: On physical examination, there was bilateral cervical lymphadenopathy, the largest lymph node measuring 3 x 2 x 2 cm in right anterior cervical triangle.
Investigations: His routine laboratory investigations were normal, except mildly raised Erythrocyte Sedimentation Rate (ESR).X Ray chest revealed bilateral mediastinal lymph node enlargement also.
Learning Issues: What is the differential diagnosis with above mentioned scenario? What investigations will be required for making a diagnosis?
What will be the Gross and Histological Features of likely diseases, which can occur in this patient with this scenario?
What will be the Specialized tests required for confirmation of diagnosis on lymph node biopsy?
What will be the management and prognosis of the likely diseases?
CBL 12: Neoplasia-I
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CBL 12 SENARIO: Case Scenario:(A patient with malignant tumour – diagnostic approach) History: A 45 years old female had lump in the breast, which she noticed during shower. There was family history of malignant tumour of the breast in her close relative.
Examination: On examination it was palpable lump in the upper outer quadrant. It was firm in consistency and was irregular. It was fixed to the underlying breast tissue but not to the chest wall. Other breast was normal and no other viscera were palpable. Lymph nodes in the axilla were not palpable. Ultrasound abdomen and whole-body scan were normal
Investigations:
Fine needle aspiration (FNA) was performed. Cytological category C-4 breast lesion (suspicious for malignancy) was labelled by cytopathologist and it was advised to have frozen section of diagnostic biopsy before radical surgery.
Peroperative frozen section was reported as malignant.
Radical mastectomy was done with sentinel lymph node biopsy.
Breast specimen measured 15x10x08 cm. The resection margins were painted with India ink. On slicing upper outer quadrant showed a gray white tumour measuring 4x3x2.5 cm. Resection margins were grossly clear. Sections were taken for histopathology.
The sections showed proliferation of atypical cell forming tubules in 20% areas, nuclear pleomorphism was moderate and 1-2 mitoses per 10 high power field were found.
Learning Issues: Explain above signs & symptoms What is the importance of lymph node in axilla, USG and whole-body scan?
What is FNA, cytological category C-4
What is meant by malignant report on frozen section, what is diagnostic biopsy?
What is concept of Sentinel Lymph node?
Morphology of tumours (Gross & morphology)
Other Laboratory diagnostic modalities?
- Module 2
CBL 11: Infarction
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CBL 11 Infarction SENARIO History: A 57 years old man presented with 4hrs history of chest pain radiating to his neck, with associated diaphoresis and dyspnea. His Troponin T & Myoglobin are mildly elevated, and his ECG shows ST elevation in anterior chest lead. He could not survive and died due to cardiac fibrillation / arrest. His Post – mortem was performed and gross appearance of the heart shows an area of dark mottling consistent with MI in the anterior surface of the heart. Learning Objectives: What is an infarction? What is the likely cause of dark discoloration of heart?
What type of necrosis is this?
What are the factors that influence development of an infarct?
How do you classify infarcts?
What are the possible causes of infarction in different tissues?
CBL 10: Typhoid
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CBL 10 Typhoid SENARIO (A patient with fever, myalgia and headache) HISTORY: A 20 years old student residing in a hostel is admitted to the hospital with history of fever for the last seven days. The fever was low grade initially becoming high grade later. It was accompanied with headache and malaise. EXAMINATION: Examination revealed a pulse rate slower as compared to the body temperature, coated tongue and fine red colored spots on the upper body. Liver and spleen were mildly enlarged.
INVESTIGATIONS: Blood was collected for complete picture, culture, Liver function tests and Serology (Wilda / Typhi dot test.)
TREATMENT: After collection of the samples he was provisionally put on Tablet Ciprofloxacin-500mg twice daily (BD), to be reconsidered after sensitivity results.
RESULTS OF INVESTIGATIONS: The titer of Wilda was TO-1/320, AO-1/20 and BO-1/20 and TH-1/160. The blood culture yielded growth of non-lactose fermenting, motile bacteria producing H2S. It was found to possess a Vi antigen. The isolate showed following antibiogram
AMP- SXT- CAP
CIP –OFX –CRO …………sensitive
Learning Objectives: Explain the above sings & symptoms. (type of fever and red spots) What is your provisional diagnosis and what other conditions come in your mind?
What is the interpretation of Wilda /Typhi dot?
Why the patient was provisionally put on one antibiotic and to be reconsidered?
CBL 9: Tuberculosis
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CBL 9 Tuberculosis History: A 30 years old male has anorexia and evening rise of fever for the last three months and productive cough. He has lost two kg of weight during this period. He has used antibiotics and antimalarials but with no improvement. On examination he has temperature of 100 ̊ F and pulse rate of 100 beats/ minute.
Investigations revealed Hb 9.8 g/dl, WBC’s: 6500/cm and platelet count: 100,000. ESR is 120 mm fall at the end of ist hour. X-ray chest was advised which showed opacities in the right upper lobe.
He was put on ant tuberculous therapy and his symptoms improved in 2 months.
Learning Objectives: What is the organism which causes tuberculosis and name its various species? Name the medium which is used for growth of this organism
What conditions you can consider in differential diagnosis
What is multidrug resistant tuberculosis?
What are growth requirements of the organism of tuberculosis?
Elaborate upon the intradermal test which is used in tuberculosis
What are preventive measures which can be taken in preventing tuberculosis
Name five sites in the body where one can get tuberculosis?
CBL 8: Watery Diarrhea
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CBL 8 Watery Diarrhea SCENARIO: Patient with severe watery diarrhea HISTORY: A 30 years old women presented to hospital `with 10 hours of sudden onset of voluminous diarrhea and vomiting. Since onset the patient had experienced seven episodes of diarrhea and two episodes vomiting, and has taken ingested approximately 2 liters of oral rehydration solution at home. She had not urinated since of onset of illness. The family would often drink unboiled tap water stored in open large containers, and shared a toilet with approximately 20 other families.
The patient’s past medical history was unremarkable.
EXAMINATION: On examination, the patient was lethargic and thirsty, and had sunken eyes, dry buccal mucosa, reduced skin turgor, deep and rapid breathing, and a feeble pulse. She had nor urinated since onset of illness. Other systemic examination findings were normal.
INVESTIGATIONS: Stool was taken for culture and routine examination. On direct microbiology rapidly motile organisms were seen. Culture was done on a special medium.
Learning Objectives: What is your provisional diagnosis? Name of organisms causing acute diarrhea.
What is the pathogenesis of this disease?
What are the laboratory tests for this organism?
What treatment should be given to this patient?
How can this disease be prevented?
- Module 1
CBL 7: Pneumonia
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CBL 7 Pneumonia Scenario: A 52 years old male presented to a local clinic for complaints of 5 days history of worsening productive cough with rusty sputum, breathlessness, fever with rigors and chills for the last two days. He is a chronic smoker with history of 20 cigarrettes for the last twenty years. Examination: temp 101 ̊F, pulse: 110/min
Investigations:
Complete blood counts
Sputum for RE and culture
Chest X-ray PA view
Blood culture
Treatment: After collection of sample, he was empirically started on Inj Levofloxacin 500 mg IV OD with antipyretics and supportive therapy
Results of investigations:
WBC’s: 15000/cmm with 85 % neutrophils on DLC
X-Ray chest showed consolidation in right lower lobe
Sputum RE showed blood stained sputum with numerous pus cells and gram positive lancet shaped cocci arranged mostly in short chains and pairs
Culture yielded growth of small alpha haemolytic colonies, while there was no growth on Mac Conkey agar. There wasa zone of inhibition around Optochin disk on primary culture plate. The organisms were soluble in 2% bile.
Sensitivity testing showed the following antibiogram:
Pen (oxa)-S
COT- S
ERT-R
CLINDA-S
Learning outcomes: Name of the organism and what other infections can it cause? How this organism is identified in clinical laboratory?
Source of infection and how this infection develops?
What other bacteria can cause such infections?
How will you treat this patient?
CBL 6: Meningitis
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CBL No. 6 Meningitis Case scenario: A patient with fever, headache and vomiting) History: A 15 years old male was admitted to the hospital with history of fever, headache and vomiting for two days and was in semiconscious state. A few days back he had suffered from upper respiratory infection.
Examination: on examination temperature was 102 F with a pulse rate of 120/ min. There were sub-conjunctival haemorrhages noted bilaterally. There was neck rigidity and Kernig’s sign was positive. His breathing was laborious. Considering the diagnosis of….LP(……) was carried out.
Laboratory examination:
Blood complete picture yielded leukocytosis
Spinal fluid analysis
On gross examination the fluid was turbid
Chemically yielding a high protein and low glucose content
Microscopy showed increased cell count, mostly neutrophils
Gram stain showed gram negative diplococcic intracellularly as well as extracellularly. Fluid culture was carried out and blood culture requested
Treatment: Considering an acute infection of………… antibiotic treatment was suggested in the form of………
Learning Objectives: Explain above signs and symptoms? What is likely diagnosis and causative organisms?
What does the turbidity of fluid indicate?
What do you expect in the culture and why a blood culture advised?
What are the treatment options in such patient?
What are possible complications?
CBL 5 : Edema
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CBL 05 History: A 4-year-old boy present with generalized swelling of the body for 1 week. Initially swelling started on the face. It gradually extended to the face, abdomen and extremities were the last to be involved. There were also complaints of anorexia and mild abdominal pain. Examination:
Blood pressure: 120/80 mmkg.
Per orbital edema and pitting of extremities present.
Shifting dullness is present on abdominal examination.
Laboratory investigations: Urine – severe proteinuria (4.0 g/ day).
Serum: Hypoalbumia and Hyperlipidemia.
Learning Objectives: Definition of edema? Causes of generalized swelling in above case?
Difference between exudates and transudate?
Pathophysiological categories/ types of edema?
Morphology of edema in various organs?
Complications of above disease?
CBL 4: Wound Infection
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CBL 04 SENARIO: (A patient with fever and wound infection) History: Four days following a surgical operation a patient developed fever and noticed discharge of pus from wound. The pus was yellow in colour thick and copious.
Examination: Revealed a temperature of 101˚F and pulse rate of 110/min.
Investigations: Blood was taken for complete picture. Pus was collected and sent for Gram stain and culture.
Treatment: After collection of samples the wound was cleaned thoroughly, pus was drained and he was empirically started on Amoxicillin/ clavulanate 1 Gm, 12 hourly pending antibiotic sensitivity results.
Results of investigations: Blood CP showed a Total Leukocyte Count of 15000/L. The Gram stain of the pus showed Gram Positive cocci arranged mostly in clusters. The culture yielded the growth of smooth, white shiny non haemolytic colonies and the Mac Conkey’s agar yielded colonies which were pinkish in color. The organism showed the following antibiogram.
Pen – R, Met – S, Gen, Cip and AMC – S.
Learning Issues: What could be the source of infection in this case? What is this organism and what infections it can cause?
What is the significance of methicillin sensitivity and resistance?
To which group of antibiotics Amoxicillin/ clavulanate belong?
CBL 3: Thrombosis
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CBL 03 Scenario History: A 26 years old male developed severe right sided chest pain and breathlessness which were worsened on deep inspiration. Family history revealed that one of his first cousin had a similar episode. Examination: Physical examination was unremarkable apart from thereduced air entry in her left lung. She was hypoxaemic with 88 % O2 saturation on room air (normal > 96 %).
Investigations: The chest radiograph was normal and the ECG showed asinus tachycardia. Her blood counts revealed Hb 11.2 g/dl, WBC’s 15.7 × 109/l and platelets 365 × 109/l. The V/Q scan indicated perfusion defects consistent with an embolus in the pulmonary circulation. Doppler ultrasonography of legs revealed deep vein thrombosis in his right leg.
Learning outcomes/issues 1. What is a thrombus? 2. What could be its cause in this young patient?
3. What caused his pulmonary symptoms?
4. What other investigations should be done?
5. What is the pathogenesis of this condition?
6. What are different types of emboli?
7. What is the long term management of this patient?
CBL 2:
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CBL 02 Scenario A 45 year old patient admitted in oncology ward receiving radiation or therapy for carcinoma hydroid was referred to dental surgeon with complaints of extremely dry mouth, oral mucosal ulcers and recently developed dental cases. The dentist after detailed history and examination counseled her that these symptoms are side effects for neck irradiation. She was managed conservatively with medicine and was advised to receive intervention dental therapy after her radiotherapy sessions are over. Learning outcomes/issues 1. What is pathological cause of their radiotherapy induced damage to the normal issue? 2. How would you define this type of cell injury? 3. What are other physiological & pathological causes of their process? 4. What is the pathogenesis involved? CBL 1: ACUTE INFLAMMATION
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CBL 01 CASE: A person having complaints related to his/her health who seeks attention of health professionals (Health Experts).OR An instance of particular situation: an instance of something occurring. CLINICAL SENARIO: A 20-year-old male presented with complaints of pain in right iliac fossa (RIF) for the last 12 hours. Pain started initially around the umbilicus and then radiated towards the RIF. Pain was accompanied by low grade fever, nausea & vomiting. ON EXAMINATION: Febrile – 100 F Tenderness in RIF Rebound tenderness in RIF, Localized guarding,
RELEVANT LABORATORY INVESTIGATIONS SHOW…
i. USG Abdomen – Target sign +ve ii. CBC with platelets – TLC –Leukocytosis DLC – Neutrophilia
iii. Complete serum profile and all other Baseline Investigations are within normal limits
Learning Objectives: i. What are causes of inflammation? ii. What are the outcomes of this inflammation response?