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