Causes of palpitation

 1.Extrasystoles- Atrial, ventricular

2. Tachyarrhythmias- Atrial, ventricular

3. Endocrine -

Pheochromocytoma

Thyrotoxicosis

Hypoglycaemia

4. High output states- Anaemia, pyrexia,

Aortic regurgitation,

Patent ductus arteriosus

5. Drugs -Atropine, adrenaline,

aminophylline, thyroxine,

coffee, tea, alcohol

6. Psychogenic -Prolonged anxiety state

(Soldier’s heart, neuro￾circulatory asthenia,

Da Costa’s syndrome)

Referenca: Davidson

Mechanism of action of Paracetamol

 Acetaminophen increases the pain threshold by inhibiting two isoforms of cyclooxygenase, COX-1 and COX-2, which are involved in prostaglandin (PG) synthesis. Prostaglandins are responsible for eliciting pain sensations.13 Acetaminophen does not inhibit cyclooxygenase in peripheral tissues and, therefore, has no peripheral anti-inflammatory effects.

acetaminophen selectively blocks a variant type of the COX enzyme that is unique from the known variants COX-1 and COX-2.6 This enzyme has been referred to as COX-3.

Serum cortisol

 Glucocorticoid synthesis is under inhibitory feedback control by the hypothalamus and the pituitary. Hypothalamic release of corticotropin-releasing hormone (CRH) occurs in response to endogenous or exogenous stress. CRH stimulates the cleavage of the 241–amino acid polypeptide proopiomelanocortin (POMC) by pituitary-specific prohormone convertase 1 (PC1), yielding the 39–amino acid peptide ACTH. ACTH is released by the corticotrope cells of the anterior pituitary. The release of CRH, and subsequently ACTH, occurs in a pulsatile fashion that follows a circadian rhythm under the control of suprachiasmatic nucleus (SCN), with additionalregulation by a complex network of cell-specific clock genes. Reflecting the pattern of ACTH secretion, adrenal cortisol secretionexhibits a distinct circadian rhythm, starting to rise in the early morning hours prior to awakening, with peak levels in the morning and low levels in the evening .

Reference: Harrison -21 st edition

CRPS

 Complex regional pain syndrome (CRPS) describes an array of painful conditions that are characterised by a continuing (spontaneous and/ or evoked) limb pain that is seemingly disproportionate in time or degree to the usual course of any known trauma or other lesion. CRPS had been divided into three stages of progression based on the duration of symptoms. 

Stage I (Acute stage, 0-3 months): It is characterised primarily by pain/ sensory abnormalities (eg: hyperalgesia, allodynia), signs of vasomotor dysfunction and prominent edema.

Stage II (Dystrophic stage, 3-9 months): It is characterised by more marked pain/ sensory dysfunction, continues evidence of vasomotor dysfunction with development of significant motor/ trophic changes.

Stage III (Atrophic stage, 9-18 months): It is characterised by decreased pain/ sensory disturbance, continued vasomotor disturbance and markedly increased motor/ trophic changes.

Reference: Harrison’s principles of internal medicine, 21st edition

Amphoric breathing

 Amphoric breathing is a high pitched, metallic sound that occurs when there is a tension pneumothorax over a collapsed lung, usually with an open bronchopleural fistula. 

Reference: Fraser and Pare, Volume 1

Causes of non pitting pedal edema

 1)Myxedema

2) Lymphedema

3)Angioedema

4)Lipedema

Ref-hutchison 25 edition 

 

Causes of Unilateral pedal edema

 Causes of Unilateral pedal edema

1. Thrombophlebitis
2. Varicose veins
3. Primary venous valve failure
4. Chronic lymphangitis
5. Resection of regional lymph nodes
6. Filariasis
7. Genetic /primary lymphedema
8. Trauma
9. Compartment syndrome
10. Cellulitis
11. Complex Regional Pain Syndrome
12. Lymphatic obstruction by tumor or lymph nodes

Anion gap

 Anion gap =( Na+) + (K+)  -  (Hco3 -) + (Cl-)

Normal range-8 to 12 mmol/L

Ref-MD Vasudevan textbook of biochemistry 6th edition 

Vesicular breath sounds - Physiology

Normal breath sounds originate from the larynx. When the sound leaves the larynx it travels down the trachea and then divides when the airway divides. Some sound must be transmitted through the lung parenchyma but most travels down the airway. Eventually the sound travels along airways of different lengths and therefore becomes out of phase. Next it arrives in the respiratory bronchioles and alveoli and then gets transmitted through the chest wall to your stethoscope. The fat layer filters out much of the high frequency sound (above 4 kHz). The resulting sounds are much softer (because the sound has effectively been diluted throughout the whole of the lungs). There is no gap between inspiration and expiration (because all of the sound has become out of phase and therefore ‘filled in’ the gap). Finally, the first third of expiration is now the only part that is audible because the latter two-thirds are much quieter.

REFERENCE: Chamberlain’s, 13th edition, page no: 97

Cough Reflex

Chemical (e.g., capsaicin) and mechanical (e.g., particulates in air pollution) stimuli leads to  Stimulation of sensory nerve endings (rapidly adapting receptors and C fibers) .

 Sensory signals  travel via the vagus and superior laryngeal nerves to brainstem in the nucleus tractus solitarius (cough center) and inputs from cortex 

 The vocal cords adduct, leading to transient upper-airway occlusion. Expiratory muscles contract,
generating positive intrathoracic pressures as high as 300 mmHg leading to cough.

Reference: Harrisons 

Causes of Orthopnea

 CAUSES OF ORTHOPNEA :

1. Left ventricular failure.

2. Asthma

3. COPD

4. Bilateral diaphragmatic paralysis in the absence of heart disease.

Ref : Fraser 4th edition page no. 388

Antitussives and doses

NONOPIOIDS

Dextromethorphan- 10-20mg/day

Chlophedianol-20-40 mg/ days

Noscapine- 15-30 mg/ day

OPIODS

Codiene -10-30mg/day

Pholcodiene-10-15mg/day

ANTIHISTAMINE

Chlorphenirmanine-2-5 mg/ day

Diphenhydramine-15-25mg / days

Promethazine-15-25 mg / days

Prenoxdiazine -100-200 mg tds

Ref:Tripathy

RADS-Definition and Criteria

 DEFINITION:

RADS (Reactive airway dysfunction syndrome) is characterized by the onset of asthma symptoms within 24 hours after a single, most often accidental, high level exposure to a wide variety of irritant substances in subjects without pre-existing asthma.

DIAGNOSTIC CRITERIA:

1. Absence of pre-existing asthma symptoms or a history of asthma in remission

2. Onset of asthma symptoms after a single specific inhalational exposure or accident

3. Exposure to an irritant vapor, gas, fume or smoke in a very high concentration

4. Onset of asthma symptoms within minutes to hours and less than 24 hours after the exposure

5. Presence of airflow limitation with a significant bronchodilator response or non specific bronchial hyperresponsiveness to histamine or methacholine

6. Exclusion of other pulmonary disorders that can explain the symptoms or simulate asthma.

REFERENCE: Murray and Nadel's Textbook of respiratory medicine, Seventh Edition, Page number 1404

Differential Diagnosis of Orthopnoea

 Orthopnoea is dypnoea on lying flat due     to Heart failure 

Differential include:

Acute Asthma

Diaphragmatic nerve palsy / diaphragmatic weakness

Gross ascites

Morbid Obesity

Ref: Macleods page 77 ,14th ed 

Platypnoea

 Platypnoea causes

a. Left atrial thrombus

b. Left atrial tumours—myxomas

c. Pulmonary arteriovenous fistula

Pre xdr tb

 TB caused by Mycobacterium tuberculosis strains that fulfil the definition of multidrug resistant and rifampicin-resistant TB (MDR/RR-TB) and which are also resistant to any fluoroquinolone.

Hematocrit in Hemothorax

 

HEMOTHORAX

The pleural fluid hematocrit is >50% of the simultaneous peripheral blood hematocrit.

If the pleural fluid  hematocrit value is not available , one can estimate the pleural fluid hematocrit by dividing the pleural fluid RBC count by 100,000.

If the pleural fluid appears bloody and the hematocrit is <50%, it is considered a hemorrhagic effusion but not a true hemothorax

Ref: Fishman 6th ed

Alveolar - arterial Oxygen gradient

A–a gradient measures the difference in alveolar oxygen tension and arterial oxygen tension 

A-a gradient = PAO2 - PaO2

Where 

PAO2 =(FiO2× [Patm - PH2O]) - (PaCO2/R)

FiO2 : Fraction of inspired oxygen

Patm : Atmospheric pressure (760 mmHg at sea level)

PH2O : partial pressure of water (47 mmHg at 37 degrees C)

PaCO2 :Arterial carbon dioxide partial pressure

R : respiratory quotient (which, in a normal resting steady state, is usually 0.8, depending on the patient’s nutritional intake, but may approach 1.0 with critical illness and high sympathetic tone)

A “normal” A–a difference on room air is often considered to be 10 mmHg.

Reference: Fishman 6th ed,page no. 2510

Bronchorrhea

 Definition:

Volumes in excess of 100mL daily are defined as bronchorrhoea 

Causes:

Chronic bronchitis 

Alveolar cell carcinoma

Bronchiectasis

Lung abscess

Empyema rupturing into the bronchus

Necrotising pneumonia

Acute organophosphate poisoning 

Follow ingestion of neurotoxins from eating exotic fish 

Refrence:

Crofton and Douglas's Respiratory diseases -5 th edition 

Connective tissue disorders - criteria

 Systemic sclerosis

Major

Thickening of the skin of the hands

Minor

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

2)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

3)Bibasilar pulmonary fibrosis

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

RHEUMATOID ARTHRITIS

(American Rheumatism Association revised criteria )

1)Morning stiffness (lasting at least 1 hr)

2)Arthritis (soft tissue swelling or fluid) of 3 or more joints (PIP, MCP,wrist, elbow, knee, ankle, MTP joints)

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

4)Symmetrical arthritis (i.e., simultaneous arthritis of the same joints on both sides of the body)

5)Rheumatoid nodules

6)Serum rheumatoid factor positivity (at a level such that < 5% of normal controls are positive)

7)Radiographic hand or wrist changes typical of rheumatoid arthritis

At least 4 criteria for a minimum of 6 weeks

SLE (American College of Rheuma￾tology criteria )

1)Malar rash

2)Discoid rash

3)Photosensitivity skin rash

4)Oral or nasopharyngeal ulceration

5)Non erosive arthritis involving ≥ 2 peripheral joints

6)Serositis (pleuritis or pericarditis)

7)Renal disorder (persistent proteinuria or cellular casts)

8)Neurologic disorder (unexplained seizures or psychosis)

9)Hematologic disorder (hemolytic anemia, leukopenia, lymphopenia,or thrombocytopenia)

10)Immunologic disorder (positive LE cell, anti-DNA antibody, anti-Sm antibody, false-positive syphilis serology)

11)Elevated antinuclear antibodies

*Minimum of 4 criteria required.

POLYMYOSITIS WITH DERMATOMYOSITIs

1)Symmetrical proximal muscle weakness

2)Muscle biopsy specimen showing myositis

3)Elevation of serum skeletal muscle enzymes

4)Characteristic electromyographic pattern of myositis

5)Typical rash of dermatomyositis

definite diagnosis - first four features are present

Probable diagnosis - if any three of the first four features are present

 possible diagnosis - if any two of the first four features are present

MIXED CONNECTIVE TISSUE DISEASE

Presence of antibody to the U1 ribonuclear protein together with the clinical features of hand edema, synovitis, Raynaud phenomenon, acrosclerosis, and myositis

At least three of these clinical features are needed in addition to the autoantibody finding.

A fourth clinical feature is required if the initial three are Raynaud phenomenon, edema, and acrosclerosis

RELAPSING POLYCHONDRITIS

The diagnosis of relapsing polychondritis requires the presence of three or more of the following clinical features269:

bilateral auricular chondritis nonerosive seronegative inflammatory polyarthritis

nasal chondritis

 ocular inflammation

respiratory tract involvement (either upper or lower respiratory tract)

cochlear with or without vestibular abnormality

 positive biopsy specimen

The presence of anti cartilage antibodies may be helpful in the diagnosis 

BEHÇET SYNDROME

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 att he 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)

SJÖGREN SYNDROME

 sicca symptoms are mandatory

 supportive evidence including ocular signs (positive Schirmer test testing reduced tear formation, rose bengal score > 3 for staining of conjunction and cornea)

 typical histologic appearances  salivary gland biopsy

antibodies to Ro (SS-A) or La (SS-B) or

 reduced salivary flow.

Gastro Intestinal Tract and abdominal symptoms

1)Dysphagia and odynophagia.

2)Heartburn and reflux

3)Indigestion

4)Flatulence

5)Vomiting

6)Anorexia

7)Constipation

8)Diarrhea

9)Alternation of bowel pattern

10)Abdominal pain

11)Abdominal distention

12)Weight loss

13)Hematemesis

14)Rectal bleeding

15)Malena

16)Jaundice

17)Itching

18)Urinary symptoms

Ref :Hutchison's clinical methods 24th edition

Perception of Dyspnoea

How do we perceive Dyspnoea

       Sensory afferent signals are transmitted to the brain. Simultaneously, the brain generates predictions about the sensations the body should be feeling. When comparison between predictions and sensory information shows a mismatch , a neuro - cortical feedback loop is involved and  dyspnoea is perceiced .

In short, Dyspnoea occurs when there is a mismatch between afferent and efferent signals ,whrn the need for ventilation is not being met by physical breathing.

Which part of the brain are involved in perception of dyspnoea

1. Anterior insula, posterior insula, mid insula,among which the right anterior insular cortex seems to be the most consistent structure across studies.
2. Higher brain structures including the anterior cingulate cortex and the orbitofrontal cortex
3. Brain stem nuclei and midbrain structures, such as the periaqueductal gray matter

REF: American Journal of Respiratory and Critical Care Medicine 

Nephrotic syndrome

 Nephrotic syndrome is defined by a triad of clinical features: oedema, substantial proteinuria (> 3.5 g/24 hours) and hypoalbuminaemia (< 30 g/L)

Reference: Ghai textbook of pediatrics

Diaphragmatic referred pain

Nerve supply of diaphragm

Motor supply - phrenic nerve 

Sensory supply

Central tendon- phrenic nerve(ventral rami of c3,c4 and c5

Peripheral- lower 5 intercoastal nerve

Referred pain-

Sensory fibers which supply the diaphragm and enter the cord at the C 3, 4 and 5 segments. This segment of the cord also supply's the supraclavicular nerves (medial, intermediate and lateral) via the cervical plexus. The lateral supra-clavicular nerve supply's the skin directly over the acromium process. Irritation of the diaphragm can be experienced as pain over the acromium process.

Borg dyspnoea score

 Borg Dyspnoea Score

•  Borg Dyspnoea Score is a self reported measures of one’s difficulty in breathing upon exertion

• Developed by Swedish researcher Gunnar Borg
• It is a categorical scale with a score from 0 to 10, where 0 represents no dyspnoea and 10 represents maximum dyspnea
• In Modified Borg Dyspnoea Score ,the scores are obtained at the end of the 6MWD test and reflect the maximum degree of dyspnea at any time during the walk test.
• These instruments also perform the function of outcome marker in patients undergoing pul rehabilitation

Reference: Crisafulli E, Clini EM. Measures of dyspnea in pulmonary rehabilitation. Multidiscip Respir Med . 2010;5(3):202–10

Apical Impulse

 APICAL IMPULSE

Normal :  Fifth left intercostal space at, or medial to the mid-clavicular line (halfway between the suprasternal notch and the acromioclavicular joint)
Absent : D(dextrocardia) ,O (obesity),P( pericardial effusion and tamponade ,pneumothorax,E ( emphysema,effusion)
Heaving : Forceful but undisplaced palpable apical impulse that noticeably lifts your hand . It is noted in LV Pressure overload - Left ventricular hypertrophy, as in hypertension , severe aortic stenosis or Coarctation of aorta
Hyperdynamic : Seen in LV volume overload - AR ,MR,VSD,PDA,High output states
Diffuse : Occupies more than 1 ICS
Seen in Left ventricular dilatation as in AR
Tapping : Represents a palpable
first heart sound seen in Mitral stenosis and is not usually displaced.
Double apical impulse : Hypertrophic cardiomyopathy.

How to Differentiate Hyperdynamic apical impulse and Heaving Apical impulse clinically
Hyperdynamic : Increased Amplitude,Occupy more than 1 intercostal space,Duration of more than >1/3rd but  <2/3rd of the systole
Heaving :
Increased Amplitude,Occupy more than 1 intercostal space,Duration of > 2/3rd of systole

Reference: Macleod's clinical examination -14th ed,Clinical Examination in Cardiology 

Pleural fluid: amount that can be drained at once

It is rec­ommended that no limit to be placed on the amount of pleural fluid withdrawn during a therapeutic thora­centesis. However, the procedure should be stopped if the patient develops more than minimal coughing, chest tightness, chest pain, or shortness of breath.

Measurement of Pulsus Paradoxus

  For patients without an indwelling arterial access, pulsus paradoxus is best measured with a manual sphygmomanometer and stethescope. Automatic blood pressure cuffs cannot accurately measure pulsus paradoxus. 

Assessment is made by inflating the cuff until all Korotkoff are absent, then very slowly releasing pressure from the cuff. The first sounds auscultated will be heard only during expiration, and this pressure should be noted. Next, as cuff pressure is dropped further, the pressure should be noted when Korotkoff sounds are heard during both inspiration and expiration. The variation between these 2 systolic pressure is what quantifies pulsus paradoxus. 

Colour coding for inhalers

 COLOUR CODING OF INHALERS

Blue🔵-Relievers

 Brown 🟤- Inhaled steroids.

Green🟢 - LABA

Yellow 🟡-Anticholinergics

Black⚫ - Long-acting anticholinergics

Red🔴-To keep in reserve

Reference :

Jayakrishnan B, Al-Rawas OA. Asthma inhalers and colour coding: universal dots. Br J Gen Pract. 2010 Sep;60(578):690-1. doi: 10.3399/bjgp10X515449. PMID: 20849698; PMCID: PMC2930224.

Major mines in India

 

Iron ore

1. Ghoraburhani Orissa,

Sundergarh district

2. Pathuripenth-

Madhyapur

Orissa,

Kendujhar district

3. NMDC Block,

Sandur Schist Belt

Karnataka,

Bellary district

4. Valayapatti and

Rajampalayam

Tamil Nadu,

Namakkal

District

5. Kelur Tamil Nadu,

Tiruvannamalai

district

6.Iron ore

(magnetite)

Thattayendertettai-

Valasivaramani-

Mahadevi area

Tamil Nadu,

Namakkal

District

7. Manganese Bonai-Keonjhar Orissa,

Kendujhar

district

Mn

8. Gangas

Block/Jasma-

Bhupal Sagar Belt

Rajasthan,

Rajsamand

district 

copper

9. Dhani Basri Rajasthan,

Dausa district

10.Baniwala ki Dhani Rajasthan,

Sikar district 

11. Dokan Rajasthan,

Sikar district

12. Dokan North Rajasthan,

Sikar district

13. Kundla ki Dhani Rajasthan,

Sikar district

14. Thanewasna Maharashtra,

Chandrapur

district

15. Dubarpeth-Karanji Maharashtra,

Chandrapur

district

16. Gangutana Haryana,

Mahendragarh

district

17. Ghagri Rajasthan 

Zinc ore

18. Muariya, Betul belt

Madhya Pradesh,

Betul District

19. Parsola Rajasthan,

Udaipur district

20. Bhuyari Madhya

Pradesh,

Chhindwara

district

21. Dehalwara Madhya

Pradesh,

Betul district

22. Koparpani Madhya

Pradesh,

Chhindwara

district

23. Bis-khan-khari Madhya

Pradesh,

Betul district

24. Jangaldehri Madhya

Pradesh,

Betul district

25.Ghisi

Madhya pradesh,

Betul district 

Gold

26. Ajjanahalli Central

Sector

Karnataka,

Tumkur district

27. Ajjanahalli East Block

(East,West,Main &

North Sector)

Karnataka,

Tumkur district 

28. Ajjanahalli

Block-C

Karnataka,

Tumkur district

29. Delwara West,

Bhukia Gold Belt

Rajasthan,

Banswara

district

30. Delwara Block,

Bhukia Gold Belt

Rajasthan,

Banswara

district

31. Khankariya Gara,

Bhukia Gold Belt

Rajasthan,

Banswara

district

32. Dugocha Main

and Dugocha

North Block

Rajasthan,

Udaipur

district

33. Gundelpara Block,

Bhukia Gold Belt

Rajasthan,

Banswara

district

34. Bharkundi Rajasthan,

Dungarpur

district

35. Baghmara Chhattisgarh,

Raipur district

36. Sonadehi Chhattisgarh,

Kanker district

37. Sonapahari Uttar Pradesh,

Sonbhadra

district 

38. Sindauri East Jharkhand,

Ranchi district

39. Parasi Jharkhand,

East

Singhbhum

district 

Diamond

40. Chagapuram,

Pebberu Block

Andhra pradesh,

Mahboobnagar

district

Kimberlite pipes identifies 

CGK-1 &CGK-2

41. Maldakal and

Penchukalpadu,

Chagapuram sub block

Andhra Pradesh,

Mahboobnagar district

Kimberlite pipes

identified CGK-3 & CGK-4 

42. Turkandoni Karnataka,

Raichur district

Two kimberlite pipes

identified 

Bauxite

43. Bauxite Kadalia Orissa,

Kendujhar district 

44. Platinum Group of Elements

Hanumalapura Block A & B)

Karnataka,

Devnagere

district 

molybdenum

45. Velampatti Tamil Nadu,

Dharmapuri

district

46. Molybdenum

Harur Tamil Nadu,

Dharmapuri

district 

Graphite

47. Arasanur Tamil Nadu,

Sivaganga

district 

Limestone

48. Uchichimedu,

Vridhachalam sub

basin

Tamil Nadu,

Cuddalore

district

49. Lum Syrman Block

Meghalaya,

Jaintia Hill

district

50. Nimar Madhya

Pradesh,

Katni district

51. Miniyun ki Dhani Rajasthan,

Jaisalmer

district

52.

Miniyun ki Dhani Rajasthan,

Jaisalmer

district

Mines in Tamil Nadu

 Limestone : Coimbatore, Cuddalore,Dindigul, Kanchipuram, Karur, Madurai,Nagapattinam, Namakkal, Perambalur, Ramnathapuram, Salem, Thiruvallur, Tiruchirapalli,Tirunelveli, Vellore, Villupuram

Quartz/silica sand: Chennai, Coimbatore, Cuddalore, Dharmapuri,
Dindigul, Erode, Kanchipuram, Karur, Madurai,Namakkal, Periyar, Perambalur, Salem, Thiruvallur ,Thiruvarur,Nagapattinam, Tiruchirapalli,Villupuram,

Virudhunagar  & Vellore districts

Bauxite : Dindigul, Namakkal,Nilgiris & Salem districts

Lignite deposits : Cuddalore,Thanjavur,Thiruvarur, Nagapattinam ,Ramanathapuram

Bentonite - Chengai-Anna district

Reference:

Indian Minerals Yearbook 2012 

GOVERNMENT OF INDIA 

MINISTRY OF MINES 

INDIAN BUREAU OF MINES 

Velcro crackles

 Velcro crackles 

Slow,  inspiratory, fine crackles best heard over basal regions, with a sound similar to the sound heard when gently separating the strip of velcro attached to the blood pressure cuff

Ecg findings

 RVH: V1-r wave>7mm

LVH: V5orV6-r +v1S=>35 mm 

RBBB: V1-rSr' - rabbit ear pattern 

LBBB: V5or V6-rR' -M pattern

Aggrevating and relieving factors for chest pain

 Aggrevating factors for chest pain

1) Position

2) Inspiration

3) Cough

4)Cold

5)Food

6)Exertion

7) Emotion

Relieving factors for chest pain

1)Rest

2)Drugs

3)Posture

4)Food

Reference: Hutchison 

Cough - Aggravating factors

 Pneumonic : PDFC

P3

Pollen

Pollution 

Posture

D2

Drugs

Diurnal variation

F

Food

C2

Common cold

Cold weather 

ASTHMA PEF Variablity

 Def

Excessive variablity in twice daily PEF over 2 weeks

Adults- >10%

Children->13%

Celsius and centigrade

 Centigrade is the old fashioned name of celsius where 0 deg is considered as boiling point of water and 100 deg as melting point of snow.

In celsius scale 0 deg considered as freezing point of water and 100 deg as boiling point of water.

Prophylaxis of rheumatic fever

 American Heart Association Recommendations for Duration of Secondary Prophylaxisa 

 Rheumatic fever without carditis 

DURATION OF PROPHYLAXIS 

For 5 years after the last attack or 21 years of age (whichever is longer) 

Rheumatic fever with carditis but no residual valvular disease 

For 10 years after the last attack, or 21 years of age (whichever is longer) 

Rheumatic fever with persistent valvular disease, evident clinically or on echocardiography 

For 10 years after the last attack, or 40 years of age (whichever is longer); sometimes lifelong prophylaxis

Penetration and Exposure in Chest Xray

 Penetration is assessed by visualising  the lower thoracic vertebral bodies, whose outline should just be visible through the heart  on a PA projection

If  the outline of  spine cannot be visualised  through the heart, the film is underpenetrated

In underpenetrated film,pulmonary vessels and interstitial markings appear more prominent, loss of detail at the lung bases and vertebrae, results in increased density.

Strap muscles of neck

 Strap muscles of neck

Sternohyoid

Sternothyroid

Thyrohyoid

Omohyoid

Pulsus Paradoxus - Measurement

 For patients without an indwelling arterial access, pulsus paradoxus is best measured with a manual sphygmomanometer and stethescope. Automatic blood pressure cuffs cannot accurately measure pulsus paradoxus. 

Assessment is made by inflating the cuff until all Korotkoff are absent, then very slowly releasing pressure from the cuff. The first sounds auscultated will be heard only during expiration, and this pressure should be noted. Next, as cuff pressure is dropped further, the pressure should be noted when Korotkoff sounds are heard during both inspiration and expiration. The variation between these 2 systolic pressure is what quantifies pulsus paradoxus. 

Dyspnea- Causes of Acute Dyspnea

 1. Pulmonary edema

2. Asthma

3. Injury to chest wall and intrathoracic structures

4. Spontaneous pneumothorax 

5. Pulmonary embolism 

6. Pneumonia 

7. Adult Respiratory distress syndrome 

8. Pleural effusion 

9. Pulmonary hemorrhage

10. Foreign body aspiration

11. Vocal cord dysfunction 

Hydatid cyst- Radiological signs

 1.Crescent sign

2. Inverted Crescent sign

3. Cumbo (Onion peel, double arch) sign

4. Water lily (Camalote) sign

5. Empty cyst sign

6. Serpent (snake) sign

7. Spin (whirl) sign

8. Ball of wool (yarn) sign

9. Honeycomb pattern (wheelspoke, rosette, racemose)

10. Double line sign 

Air crescent sign and Monod sign

 Air crescent sign also known as Meniscus sign or Cap sign, appears on xray or CT of the chest as air interposed between an intracavitary ball like mass and the cavity wall.

Most common cause is fungal ball of invasive aspergillosis. Other causes are pulmonary hydatid cyst, other fungi, blood clot or Rasmussen aneurysm in a tuberculous cavity, lung abcess with inspissated pus, staphylococcal pneumonia, nocardial infection, carcinoma of the lung, pulmonary gangrene or hematoma.

In aspergilloma, this mass usually moves within the cavity when the patient changes position and the sign is called Monod sign. A CT scan of the chest can be performed in prone position and if the mass moves to dependent area, diagnosis can be confirmed.

SILHOUETTE SIGN

The phenomenon of the loss of the normal radiographic silhouette (contour) when two substances of the same density are in direct contact is called Silhouette sign.

Right heart border  silhouette sign- RML lesion

Left heart border silhouette sign - Lingular lesion

Descending Aorta and Left Diaphragm - Left lower lobe

Right Diaphragm- Right Lower lobe

Upper Right tracheal lung interface  and Ascending Aorta- Right Upper lobe

Left atrium ,aortic knuckle,Upper Left tracheal lung interface - Left Upper lobe

Reference: Felson’s Principles of Chest Roentgenology ,5th edition