This PA Chest X-Ray demonstrates a left sided pleural effusion. In this condition fluid collects between the parietal and visceral pleura and appears as a shadowy fluid level on the X-Ray with obliteration of the costophrenic angles. If you were to examine this patient they might be in respiratory distress from reduced oxygen uptake (so have low sats, high resp rate, possible cyanosis and accessory muscle useage) - they may have reduced chest expansion on the affected side and it would be stony dull to percussion. Fluid transmits sound poorly so breath sounds would be decreased as would vocal resonance/fremitus. Someone with consolidation may have very similar clinical findings but the underlying area of lung is almost solid due to pus from the infective process - as sounds travel well through solids they would have increased vocal fremitus which is how you can clinically differentiate between the two conditions. Clinical examination and understanding of conditions is paramount to practice effective medicine. Before you recieved this X-Ray you should be able to diagnose the condition and use the X-Ray to confirm your suspicions.
over 11 years ago
Surface anatomy cardio respiratory system IVC- approx 20cm runningdownon righthandside of vertebral column. Sternal angle Suprasternal/JugularNotch Apex of the…
almost 10 years ago
http://www.acadoodle.com The different leads of the ECG examine cardiac electrical activity from different perspectives. In this video we teach you the perspectives of the 12 ECG leads on cardiac depolarosiation and repolarisation. We consider the 12 leads in two groups of six, with the six chest leads (V1-V6, also referred to as the precordial leads) examining the flow of cardiac depolarisation and repolarisation in the horizontal plan and a second group of six leads (the standard leads and augmented leads) which examine these events in the vertical plane. For the experienced practitioner, looking at different areas on the ECG readout is like looking at different anatomical regions of the heart. Also, understanding the lead perspectives is crucial in the interpretation of cardiac arrhythmias. Acadoodle.com is a web resource that provides Videos and Interactive Games to teach the complex nature of ECG / EKG. 3D reconstructions and informative 2D animations provide the ideal learning environment for this field. For more videos and interactive games, visit Acadoodle.com Information provided by Acadoodle.com and associated videos is for informational purposes only; it is not intended as a substitute for advice from your own medical team. The information provided by Acadoodle.com and associated videos is not to be used for diagnosing or treating any health concerns you may have - please contact your physician or health care professional for all your medical needs.
about 7 years ago
In this Chest X-Ray we can identify a left sided pneumothorax - there is absence of lung markings in the periphery and we can also see a shadow which outlines the edge of the lung. A pneumothorax is caused when air enters the potential space between the viceral and parietal pleura and causes the lung to collapse down under the pressure of it's elsatic recoil. In this case it is likely that the pneumothorax has been caused by trauma as we can see air in the soft tissues on the left side (surgical emphysema - clinically feels like bubble wrap). A pneumothorax can be a life threatening condition. The patient presents in respiratory distress with decreased expansion on the affected side. There will be hyperresonance to percussion on that side but absent breath sounds. The emergency treatment is decompression with a large bore cannula in the 2nd intercostal space mid-clavicular line followed by insertion a chest drain in the 5th intercostal space mid-axilllary line
over 11 years ago
An introduction to the interpretation of chest X-rays, covering the basic principles of using X-rays in medical imaging, as well as the conventional X-ray vi...
almost 7 years ago
This video is part of a playlist of short videos which are intended to combine multiple choice questions' answering experience with an improved understanding...
almost 5 years ago
Worst experience ever? - this is pretty difficult as I've worked in some of the poorest countries in the world and seen some things that should never happen like children dying of dehydration and malaria. But this recent experience was definitely the worst. It was midnight and I was trying to get my 16 month old to sleep having woken up after vomiting in his cot. Despite paracetamol, ibuprofen, stripping to nappy, damp sponging and having the window open he went rigid and started fitting. It only lasted a minute or two yet felt like an eternity as he was unable to breathe and became progressively blue as my mind raced ahead to brain damage or some other horrible sequalae. The fitting stopped and my mind turned to whether I was going to have to start CPR. I lay him on the floor and put my ear to his chest and was glad to hear a strong heartbeat but he was floppy with a compromised airway so I quickly got him in the recovery position. The ambulance arrived in 8 minutes and after some oxygen and some observations he was strapped in and ready to go. He had been unconscious for about 15 minutes but was starting to come round, much to my relief. The ambulance crew were great and their quick response made all the difference but then they took nearly half an hour to get to A&E in the middle of the night because they took the most awkward route imaginable. I don't know if it was a deliberate delaying tactic or just a lack of local knowledge but even without a blue light I could have done it in half the time! Why do ambulances not have GPS - ideally with local traffic info built in? We arrived in A&E and were ushered to a miserable receptionist who took our details and told us to have a seat. I noticed above her head that the wait time was 3.5 hours, though we did see a junior nurse who took his observations again. Not long after the screen changed to a 5 hour wait and a bit later to a 6 hour wait! I am glad to say that by about 3 hours my little man was back to his usual self (as evidenced by his attempts at destroying the department) and so after getting the nurse to repeat his obs (all normal) we decided to take him home, knowing we had a few more hours to wait for the doctor, and that the doctor was now unlikely to do anything as he was now well. I tell the story in such detail in part for catharsis, in part to share my brief insight into being on the other side of the consultation, but also because it illustrated a number of system failures. It was a horrible experience but made a lot worse by those system failures. And I couldn't help but feel even more sorry for those around me who didn't have the medical experience that I had to contextualise it all. Sickness, in ourselves or our loved ones, is bad enough without the system making it worse. I had 3 hours of walking around the department with my son in my arms which gave me plenty of time to observe what was going on around me and consider whether it could be improved. I did of course not have access to all areas and so couldn't see what was happening behind the scenes so things may have been busier than I was aware of. Also it was only one evening so not necessarily representative. There were about 15 children in the department and for the 3 hours we were there only a handful of new patients that arrived so no obvious reason for the increasing delay. As I walked around it was clear to me that at least half of the children didn't need to be there. Some were fast asleep on the benches, arguably suggesting they didn't need emergency treatment. One lad had a minor head injury that just needed a clean and some advice. Whilst I didn't ask anyone what was wrong with people talk and so you hear what some of the problems were. Some were definately far more appropriate for general practice. So how could things have been improved and could technology have helped as well? One thing that struck me is that the 'triage' nurse would have been much better as a senior doctor. Not necessarily a consultant but certainly someone with the experience to make decisions. Had this been the case I think a good number could have been sent home very quickly, maybe with some basic treatment or maybe just with advice. Even if it was more complex it may have been that an urgent outpatient in a few days time would have been a much more satisfactory way of dealing with the problem. Even in our case where immediate discharge wouldn't have been appropriate a senior doctor could have made a quick assessment and said "let's observe him for a couple of hours and then repeat is obs - if he is well, the obs are normal and you are happy then you can go home". This would have made the world of difference to us. So where does the technology come in? I've already mentioned Sat Nav for the ambulance but there are a number of other points where technology could have played a part in improving patient experience. Starting with the ambulance if they had access to real time data on hospital A&E waiting times they may have been able to divert us to a hospital with a much shorter time. This is even more important for adult hospitals were the turnover of patients is much higher. Such information could help staff and patients make more informed decisions. The ambulance took us to hospital which was probably appropriate for us but not for everyone. Unfortunately many of the other services like GP out of hours are not always prepared to accept such patients and again the ambulance crews need to know where is available and what access and waiting times they have. Walk-in patients are often also totally inappropriate and an easy method of redirection would be beneficial for all concerned. But this requires change and may even require such radical ideas as paying for transport to take patients to alternative locations if they are more appropraite. The reasons patient's choose A&E when other services would be far more appropriate are many and complex. It can be about transport and convenience and past experiences and many other things. It is likely that at least some of it is that patients often struggle to get an appointment to see their own GP within a reasonable time frame or just that their impression is that it will be difficult to get an appointment so they don't even try. But imagine a system where the waiting times for appointments for all GPs and out of hours services were readily available to hospitals, ambulances, NHS direct etc. Even better imagine that authorised people could book appointments directly, even when the practice was closed. How many patients would be happy to avoid a long wait in A&E if they had the reassurance of a GP appointment the next day? And the technology already exists to do some of this and it wouldn't be that hard to adapt current technology to provide this functionality. Yet it still doesn't happen. I have my theories as to why but this is enough for one post. In case you were wondering my son appears to have made a full recovery with no obvious ongoing problems. I think I have recovered and then he makes the same breathing noises he made just before the fit and I am transported back to that fateful night. I think it will take time for the feelings to fade.
Dr Damian Williams
almost 8 years ago
Left Sided Pleural effusion. The most common cause of this presentation is malignancy. It is important to consider the source of a possible primary. It may also be necessary to obtain a sample of the effusion fluid to determine whether it is a transudate or an exudate, using Light's criteria as a guide. Exudate contains greater levels of protein than a transudate reflecting it's often inflammatory origin as the blood vessels become 'leaky' to protein molecules. The differential diagnosis for bilateral pleural effusions is different again. Consider 'failure' e.g. heart, renal or hepatic.
about 11 years ago
Learn to: Locate midclavicular line, sternal angle, trachea, clavicle, sternoclavicular joint, xiphoid process of sternum, and costal margin. Count the ribs and intercostal spaces. Describe the surfaces markings of the heart: borders, apex, location of the valves, auscultatory areas. Trace the surface markings of the lung and pleura. Trace the surface markings of the lung fissures and lobes. Locate the position of the costodiaphragmatic and costomediastinal recesses of the pleura.
almost 7 years ago
A review of cardiomegaly, left atrial and right ventricular enlargement, mediastinal masses, and hilar enlargement. Video includes the following images (amon...
almost 7 years ago
Commencing the first clinical year is a milestone. Things will now be different as your student career steers straight into the unchartered waters of clinical medicine. New challenges and responsibilities lie ahead and not just in an academic sense. After all this is the awaited moment, the start of the apprenticeship you have so desired and laboured for. It won’t be long before these clinical years like the preclinical years before them, will seem just as distant and insular, so why not make the most of it? The first days hold so much excitation and promise and for many they deliver, however, it would be wise not to be too optimistic. I am afraid your firm head standing abreast the doors in a prophetic splaying of arms is an unlikely sight. In this new clinical environment, it is natural to be a little flummoxed. The quizzical looks of doctors and nurses as you first walk in, a sure sign of your unexpected arrival, is a recurring theme. If the wards are going to be your new hunting ground, proper introductions with the medical team are in order. This might seem like a task of Herculean proportions, particularly in large teaching hospitals. Everyone is busy. Junior doctors scuttling around the ward desks job lists in hand, the registrar probably won’t have noticed you and as luck would have it your consultant firm head is away at a conference. Perseverance during these periods of frustration is a rewarding quality. Winning over the junior doctors with some keenness will help you no end. What I mean to say is that their role in our learning as students extends further than the security of sign-off signatures a week before the end of the rotation. They will give you opportunities. Take them! Although it never feels like it at the time, being a medical student does afford some privileges. The student badge clipped to your new clinic clothes is a license to learn: to embark on undying streaks of false answers, to fail as many skills and clerkings as is required and to do so unabashed. Unfortunately, the junior doctors are not there purely for your benefit, they cannot always spare the time to directly observe a history taking or an examination, instead you must report back. With practice this becomes more of a tick box exercise: gleaning as much information and then reconfiguring it into a structured presentation. However, the performance goes unseen and unheard. I do not need to iterate the inherent dangers of this practice. Possible solutions? Well receiving immediate feedback is more obtainable on GP visits or at outpatient clinics. They provide many opportunities to test your questioning style and bedside manner. Performing under scrutiny recreates OSCE conditions. Due to time pressure and no doubt the diagnostic cogs running overtime, it is fatefully easy to miss emotional cues or derail a conversation in a way which would be deemed insensitive. Often it occurs subconsciously so take full advantage of a GP or a fellow firm mate’s presence when taking a history. Self-directed learning will take on new meaning. The expanse of clinical knowledge has a vertiginous effect. No longer is there a structured timetable of lectures as a guide; for the most part you are alone. Teaching will become a valued commodity, so no matter how sincere the promises, do not rest until the calendars are out and a mutually agreed time is settled. I would not encourage ambuscaded attacks on staff but taking the initiative to arrange dedicated tutorial time with your superiors is best started early. Consigning oneself to the library and ploughing through books might appear the obvious remedy, it has proven effective for the last 2-3 years after all. But unfortunately it can not all be learnt with bookwork. Whether it is taking a psychiatric history, venipuncture or reading a chest X-ray, these are perishable skills and only repeated and refined practice will make them become second nature. Balancing studying with time on the wards is a challenge. Unsurprisingly, after a day spent on your feet, there is wavering incentive to merely open a book. Keeping it varied will prevent staleness taking hold. Attending a different clinic, brushing up on some pathology at a post-mortem or group study sessions adds flavour to the daily routine. During the heated weeks before OSCEs, group study becomes very attractive. While it does cement clinical skills, do not be fooled. Your colleagues tend not to share the same examination findings you would encounter on an oncology ward nor the measured responses of professional patient actors. So ward time is important but little exposure to all this clinical information will be gained by assuming a watchful presence. Attending every ward round, while a laudable achievement, will not secure the knowledge. Senior members of the team operate on another plane. It is a dazzling display of speed whenever a monster list of patients comes gushing out the printer. Before you have even registered each patient’s problem(s), the management plan has been dictated and written down. There is little else to do but feed off scraps of information drawn from the junior doctors on the journey to the next bed. Of course there will be lulls, when the pace falls off and there is ample time to digest a history. Although it is comforting to have the medical notes to check your findings once the round is over, it does diminish any element of mystery. The moment a patient enters the hospital is the best time to cross paths. At this point all the work is before the medical team, your initial guesses might be as good as anyone else’s. Visiting A&E of your own accord or as part of your medical team’s on call rota is well worth the effort. Being handed the initial A&E clerking and gingerly drawing back the curtain incur a chilling sense of responsibility. Embrace it, it will solidify not only clerking skills but also put into practice the explaining of investigations or results as well as treatment options. If you are feeling keen you could present to the consultant on post-take. Experiences like this become etched in your memory because of their proactive approach. You begin to remember conditions associated with patient cases you have seen before rather than their corresponding pages in the Oxford handbook. And there is something about the small thank you by the F1 or perhaps finding your name alongside theirs on the new patient list the following morning, which rekindles your enthusiasm. To be considered part of the medical team is the ideal position and a comforting thought. Good luck. This blog post is a reproduction of an article published in the Medical Student Newspaper, Freshers 2013 issue.
almost 7 years ago