Chest x-ray - mnemonics - Pulmonary edema

Alveolar edema (bat's wing or butterfly)

These are pulmonary opacities seen in bilateral perihilar areas. Outer third of the lung usually spared in pulmonary edema.

Kerley B lines

Kerley B lines are short (1-2 cm) horizontal linear shadows, perpendicular to the pleura, seen close to costo pherenic angles caused by thickened interlobular septae, due to accumulation of fluid (transudate). Other than pulmonary edema rare causes of kerley B lines are lymphangitis carsinomatosis, sarcoidosis, viral and mycoplasmal pneumonia.

 Cardiomegaly

In normal individuals cardio thoracic ratio(CTR) is less than 50%. CTR is the maximum transevers diameter of the heart divided by the greatest internal diameter of the thoracic cage. In cardiomegaly CTR is more than 50%.

Dilated prominent upper lobe vessels

In a patient with congestive heart failure, the pulmonary capillary wedge pressure rises  and the upper zone veins dilate and are equal in size or larger than lower zone pulmonary veins, also termed as cephalization.In normal individuals, the lower zone pulmonary veins are larger than the upper zone veins due to gravity.

Pleural effusion

Thia is due to increase hydrostatic pressure in pulmonary vasculature so it is a transudate.

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Snake Bite.....Prevention and First Aid

Most snakes avoid people if possible and bite only when threatened or surprised and most of snakes are not poisons.

To prevent snakebite

• Avoid places where snakes may live. (tall grass or brush, rocky areas, bluffs, marshes, and deep holes in the ground)
• When moving through places where snakes may live, poke at the ground in front of you with a long stick to scare away snakes. 
• Watch carefully your step and where you sit when outdoors.
• Wear long trousers, boots and gloves when necessarily. Snake fans does not directly contact with you. So chance of poisoning is less after a snake bite.
• Use a torch when walking outside at night.
• Do not touch a snake, even if you think it is dead.
• Reduce rubbish materials where a snake could shelter.

 

If a snake bites you 

• Note the Snake's Appearance. Do not try to catch them. It can cause further bites.
• Remain calm.
• Reassure the patient.
• Immobilize the bitten part and keep it below the heart. It will keep the poison from spreading through your body.
• Apply a splint to reduce movement of the affected area, but keep it loose enough and to see the toes.
• Remove rings and anklets before you start to swell.
• Wash the wound with a clean cloth soaked in water and covers it with a clean, dry dressing.
• Seek medical advice as soon as possible.  

Do not

•  use a tourniquet or apply ice after a snake bite.
•  cut the wound or attempt to suck out venom.
•  give alcohol, aspirin or caffeinated drinks.
•  clean wound with flushed water or condys.

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Delusional Perception

Delusional Perception Delusional perception is the misinterpretation of the significance of something perceived normally. For example, a person may be convinced that the particular color of books on a table indicates that he is going to die.
Delusional perception is a symptom that come under Schneider's first rank symptoms of schizophrenia. Having this symptom push the diagnosis more toward the schizophrenia. 
  

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Thought Block

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Catatonia, Waxy flexibility, Opposition, Negativism

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Acute dystonia, Extrapyramidal side effect of antypsychotic

Sustained, often painful muscular spasms,producing twisted abnormal postures. This usually occur within few hours to few days. Reversible and self limiting.
Management 
 Reduce the dose or change to a atypical antypsychotic.
 Emergency treatment with IM or IV anticholinergic (benzatropine)

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Medicine OSCE 2

Write the answers your self and compare......

1.What is the abnormality seen in this chest radiograph

2. Give two likely causes for this condition


Answer

1) Air- fliud level in the left hemithorax (6)

2) Hemopneumothorax(2), pyopneumothorax (2)  

Discusion

            

Collection of fluid in the pleural space with an air- fluid level is seen with lung abscess, hemopneumothorax and pyopneumothorax.

 Lung abscess is characterized by a such collection with a well demarcated capsule and when the air fluid level is seen across the hemi thorax without a capsule it is due to hemopneumothorax and pyopneumothorax. These can arise as a rupture of lung abscess (pyopneumothorax) or following trauma ( hemopneumothorax)

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Medicine OSCE 1

52 year old patient presented with cough and several bouts of haemoptysis of four month duration.  

1. Describe two abnormalities on chest Xray

2.  Give a likely diagnosis     

Answer

1. a) Two opacities in the upper zones of the left lung

   b) cavitations with thick walls in the left upper zone 

2. malignant lesions with central cavitations

 
Discusion

Lung opacities with irregular margins are features of either primary or secondary malignancy. Cavitations within the lesion also favor this. Cavitations with thick irregular walls are more in favor of a malignant lesions. Always look for erosion of ribs, hilar lymph node enlargement, calcifications and plural effusion(which are not present in this case) when there is suspicious malignant lesions in the lung.

Squamous cell carcinoma commonly present as a large peripheral mass with central cavitation.

primary sites of pulmonary metastasis

female- breast, tthyroid

male- testis, colon

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