CONTINUED PROFESSIONAL DEVELOPMENT PROGRAMME

SHARPEN YOUR CLINICAL SKILLS16TH FEBRUARY, 2012

Prof. Dr. S. Arulrhaj, MD., FRCP(Glasg)

X RAY55 Yr/M alcoholic admitted with C/O fever with chills, blood vomiting & tarry stools . O/E: BP: 80/50mmhg, pallor+, icterus+ RS: Bilateral crepts+.After primary resuscitation he was taken for gastroscopy which reveals Gr III oesophageal varices. banding done. Total 13 units blood transfused and IV fluids. On 4th day he developed breathlessness.

X ray for diagnosis? Bil. Lung opacity with mild cardiomegaly What are the posibilities?Fluid loadALI due to Sepsis ? Malarial ?Transfusion

?AspirationCVP was normal.What is the line of management?Antibiotics and PCV with PEEP, steroidsRead the Follow up X ray?Clearing lung fields, ET tube in situWhat is Final diagnosis?ALI Etiology? Sepsis, Blood TransfusionLESSON : MASSIVE TRANSFUSION ALI IS A RISK

X RAY33 Yr/M admitted with C/O breathlessness, abdominal pain & Lt knee joint swelling O/E: Pallor+, RS: Decreased Air entry on left sideX ray chest for diagnosis?Lt side mod. pleural effusionHow to proceed?ThoracocentesisWhat is the fluid seen here?Haemorrhagic fluid What are the causes?Bleeding / Coagulation DisorderTuberculosis, Neoplasm, Trauma, Sarcoidosis, ExanthemataEvaluation revealed low christmas factor 2nd Xray shows?Minimal Lt side pleural effusionFinal diagnosis?Haemophilia B, Haemorrhagic pleural effusion

LESSON : NEVER MISS HAEMOPHILIA

X Ray32Yr/M admitted with c/o cough with yellowish sputum & fever since 4 daysO/E: RT basal Bronchial breathing, fine crepts+, tachypnoea +.What does the X ray chest PA & LAT. Show ?RT basal opacity with cystic areasWhat are the causes?

Pneumonia - Staphylococcus, TuberculosisHepato-pulmonary amoebiasis Infected cystHow to proceed?Suitable antibioticsATA, sputum c/s & AFBCT Chest & BronchoscopyAfter course of antibiotics, read X- ray chest?Shadow cleared wellAntibiotics? - Targocid, CeftriaxoneFinal diagnosis?Right basal pneumonia with cavity- Staphylococcus.LESSON : CAVITATING PNEUMONIA REMEMBER

STAPH.

CT SCAN36 year male smoker, k/c/o DVT came with c/o breathlessness, persistant cramp in the lower calf, Rt sided chest pain. O/E: tachypnea, BP= 100/70mmHgRead his X ray chest?X ray chest showing dilated main PA with abrupt tapering of Rt decending PAWhat is the echo finding? severe PAH.What are the possibilities?Pulmonary Thromboembolism, Primary PulmonaryHTN, cor pulmonale, Pneumonia, COPDHow to confirm ? CT angiography of pulmonary arteryWhat are the findings?Dilated main pulmonary arteryPartial intra luminal filling defect in Rt sup. Lobar, Rt inf. Lobar & left inf. Lobar arteries.Final diagnosis?Embolic pulmonary HTNHow to manage? Adequate Anticoagulation

LESSON : DVT CAN PRODUCE PTE & PHT

MRI39 year female a case of MS, close MS commissurotomy done on regular treatment came with c/o backache, pain radiating through back of RT leg & numbness+.O/E: tenderness over the lumber spine+, SLR +ve 20 degree. X-ray LS AP & Lat shown here?Loss of lordosis, narrow Intervertebral spaces and Osteophytes Can you read her MRI LS?Sacralized L5 vertebre, Diffusely bulged annulus at L4-L5 level. Indenting thecal sac & compormising neural canal bilaterally.How to manage?Continuous Pelvic traction/ Discectomy LESSON : NEURO DEFICIT NEEDS INTERVENTION

USG ABDOMEN83 Yr/F, Diabetic, came with complaints of pain in left lumbar region & also lower back.O/E: Pallor+, Lt Lumbar Tenderness +What does the X ray KUB show?Lt. Staghorn calculus, Osteoporosis,Compression # L1Read her USG abdomen?Lt. GR II Hydronephrosis With Staghorn CalculusFinal diagnosis?Lt. Staghorn calculus, severe Osteoporosis,Compression # L1Procedure of choice will be useful?PCNL (Percutaneous nephrolithotomy)

LESSON: REMEMBER RENAL CAUSES IN LBA

GASTROSCOPY55 yr/M alcoholic admitted with C/O Fever, blood vomiting & tarry stoolsO/E: Icterus+, Pallor+, Liver palpable 2 cm below costal margin

What Gastroscopy shows?Fundal varicesoesophageal varices GR II - III

What is the procedure being done?Banding

LESSON: VARICEAL BLEED- EVL IS TREATMENT OF CHOICE

BRONCHOSCOPY65 Yr/M farmer by occupation, came with c/o cough with white sputum, breathlessness, loss of weight about 5 kg over 1month.Read his x ray chest PA?Cardiomegaly, bil. Pulmonary shadowWhat does the CT chest show?Soft tissue density lesion 5x4.5x5.5cm in post. Segment of lower lobe of left lung, irregular & speculated margin.Bil. Multiple small nodular soft tissue density lesionBronchoscopy done shows?White patchy lesion seen over Rt. Lower segmental bronchusWhat are the possibilities?Mass with intrapulmonary metastasisInfective granulomatous diseaseCandidiasisHow to proceed?Biopsy, HPELESSON: CT INVALUABLE IN RETRO CARDIAC

LESION

ECG76 Yr Male admitted with H/O chest pain followed by loss of consciousness, K/C/O Hypertension, Post PCI to RCA statusO/E: P-40/min,BP-60/?, Sweating+.

Immediately ECG taken shows?CHB, IWMI, RBBBHow to proceed?Thrombolysis & Temporary Pacemaker insertion.Read 2nd ECG?Intermittent Pacing rhythm, Resolving ST elevation, VPC+How to proceed further?C. AngiogramLESSON: TPI IN AMI IS LIFE SAVING

INVESTIGATION55 years old patient has recurrent cough & wheezing more in winter.

Can you read her PFT?Obstructive lung disease – severe

What is the benefit of PFT?Differentiate obstruction and Restriction.Follow-up therapy

LESSON: MONITORING LUNG FUNCTION IS VITAL

ECHOA 30 year old man presented with palpitation and on examination there were multiple heart sounds, Echo

done is shown for evaluation.

What is the Echo diagnosis?Ebstein’s Anomaly of Tricuspid valve.

What are the complications?Atrial and ventricular arrhythmia sudden death.

LESSON: PALPITATIONS CAN BE DUE TO STRUCTURAL HEART DISEASE

SUNDARAM

Arulrhaj Hospital CME

DATE : 11TH SUNDAY, MARCH 2012VENUE: SAH AUDITORIUM

Keep the date blocked. Excellent Scientific feast awaits you. Knowledge & skill updating for practicing Physicians,

Postgraduates & Students

Dr. T. Neelambujan, MD. DNB(Cardio) Dr. Archana Ambujan, MS., OG. Medical Director – SAH Executive Director – SAH

ACME 2012