Ctd criteria from Murray and nadal

 Systemic Sclerosis (Scleroderma)

CRITERIA FOR DIAGNOSIS*

Major

Thickening of the skin of the hands

Minor

Sclerodactyly (i.e., the changes of the major criterion but limited to

the fingers)

Digital pitting scars or loss of substance from the finger pad:

depressed areas at tips of fingers or loss of digital pad tissue as a

result of ischemia

Bibasilar pulmonary fibrosis

LUNG MANIFESTATIONS

Interstitial pulmonary fibrosis

Organizing pneumonia

Isolated pulmonary vascular disease

Aspiration pneumonia (secondary to esophageal dysmotility)

Chest wall restriction

*The major or ≥ 2 minor criteria required for diagnosis.

Rheumatoid Arthritis

CRITERIA FOR DIAGNOSIS*

Morning stiffness (lasting at least 1 hr)

Arthritis (soft tissue swelling or fluid) of 3 or more joints (PIP, MCP, 

wrist, elbow, knee, ankle, MTP joints)

Arthritis of hand joints (swelling of at least 1 wrist, MCP, or PIP joint)

Symmetrical arthritis (i.e., simultaneous arthritis of the same joints on 

both sides of the body)

Rheumatoid nodules

Serum rheumatoid factor positivity (at a level such that < 5% of 

normal controls are positive)

Radiographic hand or wrist changes typical of rheumatoid arthritis

LUNG MANIFESTATIONS

Interstitial pulmonary fibrosis

Organizing pneumonia

Obliterative bronchiolitis

Follicular bronchiolitis

Bronchiectasis

Vasculitis

Nodules

Pleural disease

Lymphocytic interstitial pneumonia

Drug induced

*At least 4 criteria for a minimum of 6 weeks.

Systemic Lupus Erythematosus

CRITERIA FOR DIAGNOSIS*

Malar rash

Discoid rash

Photosensitivity skin rash

Oral or nasopharyngeal ulceration

Nonerosive arthritis involving ≥ 2 peripheral joints

Serositis (pleuritis or pericarditis)

Renal disorder (persistent proteinuria or cellular casts)

Neurologic disorder (unexplained seizures or psychosis)

Hematologic disorder (hemolytic anemia, leukopenia, lymphopenia, 

or thrombocytopenia)

Immunologic disorder (positive LE cell, anti-DNA antibody, anti-Sm 

antibody, false-positive syphilis serology)

Elevated antinuclear antibodies

LUNG MANIFESTATIONS

Acute lupus pneumonitis

Interstitial pulmonary fibrosis

Pulmonary vasculitis

Diffuse alveolar hemorrhage

Pulmonary hypertension

Shrinking lung syndrome

Antiphospholipid antibody syndrome

Organizing pneumonia

Pleural disease

*Minimum of 4 criteria required.

Polymyositis with Dermatomyositis

CRITERIA FOR DIAGNOSIS

Symmetrical proximal muscle weakness

Muscle biopsy specimen showing myositis

Elevation of serum skeletal muscle enzymes

Characteristic electromyographic pattern of myositis

Typical rash of dermatomyositis

LUNG MANIFESTATIONS

Interstitial pulmonary fibrosis

Acute pneumonitis (with diffuse alveolar damage)

Organizing pneumonia

Aspiration pneumonia

Pulmonary vasculitis and alveolar hemorrhage

Respiratory muscle weakness

Behçet Syndrome

CRITERIA FOR DIAGNOSIS

Major (required)

Recurrent aphthous ulceration at least 3 times in a 12-mo period

Minor (2 of 4)

Recurrent genital ulceration

Ocular disease

Skin lesions (erythema nodosum, skin ulcers)

Positive pathergy test (a 2-mm erythematous papule or pustule at

the prick site 48 hr after the application of a sterile hypodermic

20- to 22-gauge needle that obliquely penetrated avascular

antecubital skin to a depth of 5 mm)

Cardinal symptoms of Gastrointestinal system & Tree in bud opacities

Cardinal symptoms of Gastrointestinal system

 Abdominal pain

Dysphagia 

Heartburn

Nausea and vomitting 

Alteration of bowel habits

GI bleeding 

Abdominal distension 

Jaundice

Loss of appetite and weight 

Mechanism of tree in bud opacities 

They occur due to infectious bronchiolitis leading to filling of terminal bronchioles with mucous, pus, or fluid

They indicate endobronchial spread of infection 

1)Cardinal symptoms of cns 2) Acceptble pH range in type 2 respiratory failure

 1) Cardinal symptoms of CNS disease:

Headache, vomiting, seizures, altered consciousness, focal neurological deficit (motor or sensory), visual disturbance, and gait or balance disturbance.

2) Acceptable pH range in Type 2 respiratory failure:

pH 7.25 – 7.35 (permissive hypercapnia range during management).

Massive hemoptysis

Massive hemoptysis - definition

      Massive hemoptysis is blood loss of 400 mL in 24 hours or 100–150 mL expectorated at one time.

Causes-

Bronchiectasis, 

Bronchogenic Carcinoma,

Eroding Tuberculous cavity,

Rasmussen's aneurysm,

mycetoma

Ref: Harrison's principles of internal medicine(20th edition)

TYPES OF FEVER

Types of fever 

Continuous (Sustained) Fever

Definition:

Fever in which the temperature remains above normal throughout the day and does not fluctuate more than 1°C in 24 hours.

2. Remittent Fever

Definition:

Fever in which the temperature fluctuates more than 1°C in 24 hours but never returns to normal

3. Intermittent Fever

Definition:

Fever in which the temperature elevation is present only for several hours of the day and returns to normal for the remaining hours.

4. Relapsing Fever

Definition:

Fever characterized by episodes of fever lasting several days separated by periods of normal temperature lasting several days.

Causes of Trepopnea and platypnea

Platypnea - Dyspnea in upright position 

Always associated with Orthodeoxia

Occurs in 

- Hepatopulmonary syndrome

- Pulmonary AV malformations

Trepopnea- Dyspnea in Lateral decubitus position 

- Unilateral severe pneumonia or pleural effusion 

Patient feels better on lying on normal side to improve V/Q matching 

Define small airways and % of small airways in lungs, Terminal vs Respiratory bronchioles

 Small airways are defined as airways with an internal diameter less than 2 mm and lacking cartilage, consisting mainly of the terminal bronchioles and respiratory bronchioles located distal to the segmental bronchi. Although individually small, they collectively contribute to about 98–99 % of the total cross-sectional airway area of the lungs, which is why they normally produce little airflow resistance and are called the “silent zone” of the lung. Terminal bronchioles represent the last part of the conducting zone, are lined by simple cuboidal epithelium with club (Clara) cells, contain smooth muscle, do not have alveoli in their walls, and therefore do not participate in gas exchange. In contrast, respiratory bronchioles are the first part of the respiratory zone, arise from terminal bronchioles, have scattered alveoli opening from their walls, and therefore participate in the beginning of gas exchange, eventually continuing as alveolar ducts and alveolar sacs.

Collapse Radiologic signs

Direct signs

1.Displacement of interlobar fissures

2.Crowding of vessels and bronchi

Indirect signs

1.local increase in opacity

2.elevation of hemidiaphragm

3.displacement of the mediastinum

4.compensatory over inflation

5. Approximation of the ribs

6.Absence of  an air bronchogram(resorption atelectasis only)

7.Absence of visibility of interlobar artery(in lower lobe atelectasis only)

Reference -Fraser volume 1 page 529

SURFACE MARKING OF SPLEEN

 CASTELL’S METHOD:

    Patient lying on supine position, asked to do expiration and full inspiration. Percussion at left lower intercostal space along anterior axillary line. 

      Positive if it Becomes dull 

lateral winging of scapula

 Lateral winging of scapula

Lateral winging → lateral border of scapula protrudes

• Cause: paralysis of trapezius (due to spinal accessory nerve injury, CN XI).

• Also from rhomboid paralysis (dorsal scapular nerve),

• Scapula drifts laterally and downward, shoulder droops, difficulty elevating arm above head.

• Bedside evaluation - Ask the patient to push against a wall

• Causes of lateral winging -

Neck dissection / lymph node biopsy (iatrogenic CN XI injury).

Trauma to posterior triangle of neck.