Journal of Rawalpindi Medical College
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Eagle’s Syndrome: A Diagnostic Dilemma in Chronic Throat and Neck Pain
Full text linkEagle’s syndrome is caused by either elongation of the styloid process or calcification of the stylohyoid ligament. It is a rare and important cause of chronic neck, pharyngeal, and cervicofacial pain. Its vague symptoms often simulate neurologic pain and temporomandibular joint disorders, delaying diagnosis. We present a case report of a 21-year-old male with a one-year history of neck and facial pain that was not responding to medication. It was eventually diagnosed on imaging and successfully managed by styloidectomy via trans-oral approach. This case was selected because such cases often remain undiagnosed for many months due to symptoms that cannot be attributed to any routine disorders. This case report highlights the importance of delayed diagnosis and reinforces the need for a detailed history, comprehensive intra-oral examination, and investigations in cases of persistent neck pain.
Keywords: eagle’s syndrome, elongated styloid process, stylohyoi
Endocrine Dysregulation and Functional Ovarian Cyst: A Case from Adolescent Gynecology
Full text linkFunctional ovarian cysts are common in reproductive-age women, but their occurrence secondary to hypothyroidism is rare. We report a case of a 21-year-old female with poorly controlled hypothyroidism who presented with bilateral multiloculated ovarian cysts mimicking neoplastic pathology. Emergency laparotomy was performed due to worsening symptoms, and bilateral cystectomy with ovarian conservation was achieved. Histopathology confirmed corpus luteal cysts. Postoperative thyroid hormone replacement led to normalization of menstrual cycles and resolution of cysts. This case highlights the importance of thyroid evaluation in young women with ovarian masses to avoid unnecessary surgery and preserve fertility.
Keywords: Ovarian Cysts, Corpus Luteum, Hypothyroidism, Thyroid Hormones/therapeutic use, Adolescent, Young Adult, Gynecology, Fertility Preservation
The need for a Clinical Case Reports Journal from Pakistan
Full text linkIt is with a sense of quiet satisfaction and shared responsibility that we present the first issue of JRMC Case Reports, a special supplement of the Journal of Rawalpindi Medical College devoted exclusively to clinical case reporting. At Rawalpindi Medical University, our affiliated hospitals Holy Family Hospital, Benazir Bhutto Hospital, and Rawalpindi Teaching Hospital serve a very large and diverse patient population. Every day, clinicians working in these settings encounter patients who challenge routine thinking and remind us that medicine is learned most deeply at the bedside. Some encounters offer small but practical insights, while others fundamentally change how we understand a disease process. This journal has been created to capture those lessons, document them with care, and share them with colleagues who face similar realities in their clinical practice.
Clinical case reports hold a modest but powerful place in medical literature. They translate everyday clinical complexity into structured, meaningful narratives that can be easily understood and remembered.1,2 For medical students and early career doctors, writing a case report encourages close observation, ethical sensitivity, disciplined engagement with literature, and clarity in clinical communication.3 For practicing clinicians, particularly those working in resource constrained environments, a well written case report often provides timely guidance when standard protocols do not fully apply, such as in patients with unusual presentations, overlapping comorbidities, or limited diagnostic options.4 Through JRMC Case Reports, we aim to link bedside learning with scholarly writing and connect local clinical experience with the wider medical community.
The cases presented in this inaugural issue reflect the breadth and relevance of focused clinical reporting. They include a young patient with primary AL amyloidosis presenting with macroglossia and spontaneous chest wall bruising, an early and severe ocular manifestation of Behçet’s disease identified through occlusive retinal vasculitis, a child with Budd–Chiari syndrome secondary to Burkitt’s lymphoma, a life threatening postpartum choriocarcinoma initially mistaken for retained products of conception, and an infant who developed iatrogenic Cushing syndrome following inappropriate use of topical steroids. Each report is concise, clinically grounded, and rooted in local practice realities. Collectively, they represent a growing body of practical knowledge that we believe will be of value to a wide range of readers.
Publishing case reports from RMU affiliated hospitals offers a particular strength. Our institutions receive patients from varied socioeconomic backgrounds, often presenting late and with complex clinical needs. This diversity naturally produces cases that are educational and clinically relevant. While rare and striking cases deserve attention, equal importance must be given to well documented presentations of known conditions, clear descriptions of clinical techniques, transparent reporting of complications, and honest reflections on decision making in difficult situations. Such reports strengthen everyday clinical judgment and support safe patient care.
Upholding ethical and scientific standards remains central to this initiative. JRMC Case Reports is firmly grounded in principles of responsible publishing, transparency, and integrity.5 All submissions are expected to meet established requirements including informed consent where applicable, appropriate ethical oversight, clear disclosure of conflicts of interest, and accurate attribution of authorship. The editorial team is committed to guiding authors through a supportive and constructive review process, particularly for trainees and early career clinicians. Attention to clinical images, timelines, and evidence based conclusions will remain a priority, with patient dignity always at the centre of our work.
For postgraduate trainees and young clinicians who may be unfamiliar with academic writing, this journal provides an accessible and meaningful starting point. Preparing a case report allows authors to reflect on their clinical reasoning and communicate it in a structured manner that benefits others. Through mentorship and editorial guidance, we hope to build confidence and competence in clinical scholarship across our institutions.
To our readers, we invite you to approach this journal as you would a trusted colleague. Read with curiosity, reflect critically, and contribute when possible. In Pakistan, the medical knowledge we most urgently need often grows from our own clinical experiences. By sharing these experiences with honesty, humility, and academic rigour, we strengthen not only our literature but also our collective practice. We hope JRMC Case Reports becomes a dependable companion for trainees preparing for assessments, clinicians navigating complex decisions, and small research teams documenting local challenges.
With sincere appreciation for the authors who entrusted us with their work, and for the reviewers and editorial colleagues who shaped this issue, we welcome you to JRMC Case Reports. We look forward to its growth as a platform that remains relevant, ethical, and consistently present in the service of patients and the medical communit
Leadership Roles in Medical Academia: Qualification, Experience, Administration, or Research?
Full text linkMedical academic excellence is based on leadership. This is because the appointments of department heads, deans, senior faculty administrators, and faculty members directly impact the quality of teaching and faculty motivation. A fundamental question is unanswered in Pakistan: what truly qualifies individuals to lead - higher academic qualification or experience? What about administrative abilities and research accomplishments?
A Case for Qualifications and Competencies Beyond Years of Experience
In some institutions, the majority of leadership positions are still awarded on the basis of chronological seniority and length of service. This is often done without taking into consideration academic qualifications or leadership capabilities. Years of service are equated with expertise in this long-standing, but flawed practice.
The time spent at a job does not translate into a productive contribution. Many individuals have accumulated years with no measurable contribution to academic or scientific research, innovative teaching methods, or roles in institutional leadership. The higher the qualifications, whether it's a doctorate, a specialized fellowship, advanced training in health administration, medical research, education methodology, or research, then, the more likely you are to have the ability and capacity for transformative leadership.
The expectation is that academic leaders will not just serve, but achieve have producing impactful work, obtaining grants, mentoring and supporting younger faculty, or representing their institution within scholarly communities. It is far more beneficial for an institution to have leadership that focuses on academic depth and excellence.
Integrating Administrative and Research Competence
Leadership is not possible without administrative expertise and research involvement. The ability to effectively manage academic teams and handle complex academic systems is essential for effective governance. Leadership with advanced degrees but without managerial skills may have difficulty implementing policies, and an administrator who lacks academic background or research knowledge risks turning academia into bureaucracy. The ideal leader of medical education should be an academically qualified, administratively skilled, ethically grounded professional with a strong research focus.
PM&DC Needs to Define Standards
It is critical that Pakistani medical educators fill the gap of a lack of nationally recognized criteria to determine academic leadership. Pakistan Medical and Dental Council's (PM&DC) role in setting leadership criteria must be based more on documented contribution and demonstrated expertise than just job longevity.
Key policy recommendations include the following:
Benchmarks for mandatory higher education (e.g., PhD or FCPS certification, or the equivalent advanced certification), required of Deans. Principals and Directors
There are weighting systems that give more importance to research, postgraduate supervision, or scholarly output than simple seniority.
Processes of selection transparently incorporating peer-review, academic audit, leadership interviews, etc.
Continuous professional growth in academic leadership and healthcare administration with requirements for revalidation, impactful, research-based publications, not just the quantity of publications.
The succession planning process identifies future leaders and prepares them based solely on performance and merit.
Conclusion
It is a common practice to confuse "years" of service with "experience". The result has been a decline in leadership standards across medical institutions. Academic leadership requires not only tenure but advanced knowledge, intellectual rigor, and a vision for transformation.
For Pakistan to raise the quality and credibility of its medical system, it must switch from a time-based selection to a qualification-based and competence-based meritocracy. PM&DC is both mandated and obligated to implement these standards in order to ensure that the leadership of medical academia goes to the most competent individuals who can advance education, professional ethics, and research. Leadership isn't measured by the number of years you have served. It's about impact, and this can only be achieved by a higher-level qualification
Pleural Adenocarcinoma Presenting with Deep Venous Thrombosis: An Unusual Incidental Finding
Full text linkDeep venous thrombosis (DVT) is a common vascular condition with recognized risk factors such as immobility, trauma, and hypercoagulable states. However, in patients without identifiable causes, the possibility of an underlying malignancy should be strongly considered. We report the case of a 50-year-old non-smoker male who presented with lower limb swelling secondary to extensive DVT and was incidentally diagnosed with pleural adenocarcinoma following evaluation of a right-sided pleural effusion. This case highlights the importance of maintaining a high index of suspicion for occult malignancy in patients with unprovoked DVT to enable early diagnosis and timely management.
Keywords: Adenocarcinoma, Pleural Neoplasms, Venous Thrombosis
Eye as the First Clue: Behçet’s Disease Unveiled by Retinal Vasculitis and Vein Occlusion
Full text linkBehçet's disease is a multisystem vasculitis of unknown etiology that is chronic and recurrent. One of the most severe and vision-threatening implications is ocular inflammation. We present a case of severe ocular Behçet's disease with occlusive retinal vasculitis in a young male. A 20-year-old boy had gradually deteriorating vision in both eyes for three months before experiencing a sudden loss of vision in the left eye for two weeks. Ocular examination showed bilateral anterior uveitis with vitritis and perivasculitis. Branch retinal vein occlusion (BRVO) with macular edema and macular pseudohole was seen in the left eye, which was confirmed by fundus fluorescein angiography and optical coherence tomography. A positive pathergy test, as well as repeated oral and vaginal ulcers, confirmed the diagnosis of Behçet's syndrome with panuveitis and occlusive vasculitis. Adalimumab, azathioprine, and systemic corticosteroids were used to treat the patient; this led to a partial recovery of vision and a noticeable reduction in inflammation. Early detection of Behçet's uveitis and timely beginning of immunomodulatory therapy are essential to prevent irreversible retinal damage and subsequent visual loss.
Keywords: Behçet’s Disease, Retinal Vasculitis, Branch Retinal Vein Occlusion, Macular Edema, Adalimumab, Uveiti
Retrocaval Ureter: Diagnostic Dilemma - A Case Report
Full text linkRetrocaval ureter is one of the unique and rarest congenital anomalies resulting from abnormal development of the inferior vena cava. The characteristic J-shaped or fishhook appearance is pathognomonic for this on CT urogram.1Case presentation: A middle-aged man with a prolonged history of right lumbar pain spanning over three years presented to us. CT urogram depicted right moderate hydronephrosis with a fish-hook ureter. Subsequently, open surgical repair was performed successfully. At 6 months follow-up, he was pain-free with improvement in RFTs. In patients with progressive hydronephrosis or declining renal function, surgical repositioning of the ureter, either by open or laparoscopic method, is the treatment of choice.
Keywords: Retrocaval ureter, congenital anomaly, inferior vena cava, hydronephrosi
Sheehan’s Syndrome with Dilated Cardiomyopathy: An Overlooked Sequela of Postpartum Hemorrhage
Full text linkWe present the case of a 43-year-old female who developed panhypopituitarism as a sequela of postpartum hemorrhage. She manifested with recurrent vomiting, diarrhea, hypotension, and hypoglycemia, and was subsequently diagnosed with Sheehan’s syndrome complicated by dilated cardiomyopathy.Prompt initiation of hormonal replacement therapy resulted in remarkable clinical improvement. This case emphasizes the critical need for early recognition of Sheehan’s syndrome in women with a history of obstetric hemorrhage, particularly when presenting with chronic, nonspecific complaints, to prevent life-threatening complications.
Keywords: Sheehan syndrome; postpartum hemorrhage; hypopituitarism; dilated cardiomyopathy; heart failur
When Identity Feels Divided: A Case Report On Gender Dysphoria
Full text linkA psychological condition in which an individual's feeling of gender is not in congruence with the assigned biological sex is known as gender dysphoria.
We shall present the case of a 17-year-old girl who presented with primary amenorrhea to the endocrinology department and was referred to psychiatry. This case report highlights the importance of a multidisciplinary approach
Chance For Some Faith And Possibilities?!
Full text linkDoes Zohran Mamdani Mayoral's win in the USA have any bearing on Medicine or Pakistani society? Well, sometimes lessons from seemingly distant, unrelated events may have ripples that can help shape minds or forge traits far away, with transformative results. The overarching lesson from “Mamdani effect “ is that with substance, thoroughly positive and dedicated struggle, one could overcome seemingly impossible, absolutely dominating, and deeply manipulated circumstances to make one's mark. Does that help give us hope? Of course, the unbelievable patience and unwavering belief of the people of Gaza give this gloomy globe ample lessons in the strength of perseverance.
Keeping an “Open mind” and “Anchoring bias”. In my 15 year experience of medicine and rheumatology I have come across cases which may not fit into one particular diagnosis and several times I’ve had to reconsider diagnosis that I may have made or previously given by other clinicians, which leads me to share two terms introduced to me by my late Program Director of Internal Medicine namely, Hickam’s dictum and Occam's razor.
In Occam’s razor, the idea is to try to conclude analysis of the data to try to find one common answer, while in the case of Hickam’s Dictum, it is possible to conclude that there is more than one diagnosis (or maybe several possibilities). In this regard, I would like to briefly present a case of a middle-aged woman whom I have been treating with the previous diagnosis of SLE with overlapping Sjogren’s syndrome, but she also has had a family history of ankylosing spondylitis. Although her peripheral joint pain was controlled, she had this persistent low back pain for quite some time, seeing a previous clinician and a working diagnosis of degenerative arthritis of the low back. Keeping an open mind and challenging previous diagnosis fresh workup was initiated, and she was found to have HLA B27 antigen, and the MRI showed that she had bilateral Sacroiliitis consistent with Ankylosing Spondylitis (AS). This becomes a challenge to treat this but fortunately she was enrolled in trial at my practice studying Upadacitinib in SLE (phase 3),1 which is effective for AS but we were studying this for lupus and we found that after 6 months months of treatment although we were blinded the patient had improvement in back pain and subsequent resolution of the sacroiliitis likely indicating that she was in the treatment arm with improvement in the manifestations of SLE and serologies.
Separately I recently encountered a patient being treated in Pakistan for last 20 years for psoriasis and psoriatic arthritis ( PsA) an after seeing a few different clinicians and due to lack of complete control the patient reached out to me for evaluation and on assessment the patient classically had deformities more pertaining towards rheumatoid arthritis as well as rheumatoid nodules and on simple investigation was found to be strongly fasted for Rheumatoid factor and anti CCP antibodies cementing diagnosis of Rheumatoid arthritis ( possible overlap with PsA ).
Thirdly I’m working with the medical students at UIC for article with literature review on a case which the patient had longstanding diagnosis of Radiographic Ankylosing Spondylitis ( AS) presenting with worsening of back pain with the MRI concerning for metastatic disease in his spine which upon biopsy found to have non caseating granulomas and on further investigation was found to have mediastinal Lymphadenopathy on CT chest and elevated is ACE level cementing diagnosis of Spinal Sarcoidosis and his spinal disease responded to steroids and maintain a low dose Prednisone (failed anti TNF agents due to his diagnosis for heart failure ). The estimated co-occurrence of sarcoidosis with ankylosing spondylitis is ~0.12%.2
I want this to be an opportunity for me and my readers, which may include practising clinicians and students, to never be overconfident in making a diagnosis or never challenge a previously made diagnosis (Anchoring Bias).
It is hard to miss a certain feeling of discontent and hopelessness when I am visiting Pakistan. Some of this could be justified, but it is possible that part of this could be related to people’s expectations, which sometimes are based upon comparisons that may not be truly reflective or fair, especially if we are not comparing apples to apples but rather comparing apples to oranges (in a country's perspective, possibly not comparing the country regionally but to distant developed countries). I have been travelling back and forth between the US and Pakistan for the last 15 years and feel heartened by some improvement, generally speaking, in infrastructure and services. Visiting RMU and seeing its improvement over time and growth, and development of different specialities and services, and production of high-quality clinicians makes me think that there is real hope in our future. One could try to be positive in one’s outlook, thinking (half glass full?!) and be hopeful. We are certainly encouraged to be hopeful as believers in any case.
Let there be an opportunity to yield a culture of positivity, open-mindedness, critical thinking, self-reflection, self-improvement, patience, and perseverance not only in our professional lives but also at a community and national level. These traits shown by maybe distant person or group of people can have a positive rippling effect in our institutions and nation-building. As believers, we have been commanded to sow the seeds of the future even in the face of impending doomsday.
Family of Imran (3:200)
O ye who believe! Persevere in patience and constancy; vie in such perseverance; strengthen each other; and fear Allah; that ye may prosper.
Yusuf Ali.3
In the words of Iqbal.4
nahīñ hai nā-umīd 'iqbāl' apnī kisht-e-vīrāñ se
zarā nam ho to ye miTTī bahut zarḳhez hai saaqī
Translation:
Iqbal is not hopeless about his barren land; If it receives even a little moisture, this soil is extremely fertile