Ward round (2/7/09) with Joel

8 am - 11.45 am

Hand over meeting, X-ray meeting, ward round, MDM (multi-discipline meeting), X-ray tutorial

1) Venous insufficiency - heamosiderin deposition (dark brown colour, swollen, venous ulcer over lateral maleolus) , fluid tablet given), risk factor of the pt = weight

2) Clot in lower limb's vessel (vein? artery?) - Use D-dimer test, risk factor for coagulopathy( stasis, hypercoagulability, pregnancy etc), use Well's Criteria for DVT/PE

3) HSV encephalitis - sad case, nursing home soon, palliative care for next episode of infection, do not come back anymore (presentation handout given)

4) Diabetes - poorly controlled? pt have AF ( use CHADS 2 score to assess AF stroke risk), from CHADS 2 - use warfarin if high risk, aspirin for lower risk, remember HbA1c (average blood glc level over last 3 mths), diabetes - micro (peripheral neuropathy, retinopathy, nephropathy), macro (heart, brain and peripheral such as intermittent claudication)

5) Hyperobstructive cardiomyopathy - extra heart muscle, stress echo ordered, narrowing of blood outlet due to extra muscle

Extra:

1) check CTPA
2) check normal glc level (6-7?), CO2 (35-45?)
3) Anticoagulation ( start with LMW Heparin - Clexane)

X-ray:

1) Use ABCDEF guideline (Airway, Bone, Cardio, Diaphragm, Everythingelse, Fluid/Fat)

2) Do not forget fat esp breat tissue (turning X-ray brighter/white), so lower or middle lobe of lungs reduced penetration !!!! do not assume that's pneumonia) - how to diff pneumonia at these regions for female pt? compare both side's density

3) Nasogastric tube in wrong position

4) Cardiomegaly - >60% width of AP film, use thumb and little finger

5) Hyperinflated lungs - lungs expand below 6th anterior rib, COPD female pt - breasts small due to thin and cachexia, will get barrel chest, diaphragm flatten

6) Cardiomegaly witth heart failure - pul. edema with deposition of interstitial fluid, normally base of the lung - auscultation - crackle sounds, can see lung fissures!, hilum enlarged (same size as lower vessels) esp the vessels going to upper lobe (use Newton's gravitational theory), clearly suggestive of pulmonary hypertension

7) Pneumothorax - lung's edge clearly visible, not "attach" to the chest cavity

8) Atherosclerosis - aortic wall calcification, ring of calcification

9) Kyphosis - Osteoporosis a risk factor - do not forget post menopausal OP, on X-ray size of vertebrae smaller, wedge compression fracture?, normally anteriorly, hyperdensed vertebrae

10) learn air bronchogram - visible air-filled rings

11)Visible enlarged bronchi - risk factor = cystic fibrosis, Diagnosis = bronchiectasis， on auscultation - trachea breath sounds, not vesicular

Cool!!!!!!!!!!