ACUTE FLUID OVERLOAD SIMULATING UPPER LOBE CONSOLIDATION

A 50 yr old female underwent an operation under ga for fracture rt olecranon.In the immediate postoperative period she started having respiratory distress and falling spo2.On examination bp was160/100,pulse96/min,regular,respiratory rate 46/min,afebrile,no pallor,jvp normal.auscultation revealed bl coarse crepts,more in the basal regions.On investigation tlc21400,n88,lft-wnl,rft-wnl,urine showed6-7 pus cells/hpf.Her chest xray revealed dense consolidation rul and streaky opacities lul.She had no cardiac or pulmonary ailment in the past.She was managed with niv,o2,antibiotics and diuretics. she was relieved within a few hours and the opacities in the chest xray disappeared in the same day. our diagnosis was fluid overload acute heart failure.However what appears confusing is the upper lobe distribution of the opacities,

If you observe carefully the initial xray was taken in the supine position.[ap view].In supine position there is equalization of blood flow in all the lung zones and the effect of gravity is abolished.This gave us the false impression of bacterial consolidation.The raised tlc was probably due to uti where urine c/s showed rich growth of Ecoli.

PULMONARY TUBERCULOSIS WITH LEFT RECURRENT LARYNGEAL NERVE PALSY

A 36 year old female presented with dry cough ,irregular fever,progressive weakness and anorexia since last 6months and hoarseness of voice since 7 days. On examination there was a2*1.5cm lymph node in the right posterior cervical region.Her ESR was 92 and chest xray showed lt upper lobe opacity and elevated lt hemidiaphragm. Lymph node biopsy wasd consistent with granulomatous lymphadenitis with caseation necrosis. Sputum for AFB wasnegative.

So this case was dignosed as SPUTUM NEGATIVE PULMONARY TUBERCULOSIS with TUBERCULOUS LYMPHADENITIS with LEFT RECURRENT LARYNGEAL NERVE PALSY.

BEWARE OF ARTIFACTS ON CHEST XRAY

A very unusual and unsuspecting artifact was seen in the x-ray of a female patient. Artifacts are very common in chest xrays and you need to suspect them whenever you find an unusually clear cut shadow in chest xray
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PULMONARY TUBERCULOSIS WITH NORMAL CHEST XRAY

A 25 year old male presented with high grade intermittent fever with dry cough since 10 days.There was no significant joint pains and bladder and bowel habbits was normal.He was treated with ofloxacin and cefixime for 5 days with no relief in fever.His lab reports were TLC8400,n70,l29,e1%,ESR45,MP,optimal,dengue igm-ve.widal test was -ve and urine RE was within normal limits.LFT was a bit deranged- total bilirubin was 4.2,sgpt152u\l,sgot104u\l..His chest xrays were apparently normal.His usg abdomen showed mild hepatomegaly.Considering cough as a prominent symptom,we did a CT scan of chest.The scan showed bilateral patchy pulmonary infiltrates.His sputum,which was mostly serous did not reveal any AFB.He was treated with inh,ethambutol and streptomycin(altered ATD regime due to deranged LFT).His fever subsided in 2 days and did not return again.
CLINICAL PEARLS: always search for tuberculosis in a patient with pyrexia of unknown origin
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http://www.sustain2green.com/2011/12/pulmonary-tuberculosis-with-normal.html

CHILAIDITI'S SIGN

The interposition of a loop of large gut between the liver and diaphragm is sometime visible in chest xray or straight xray abdomen and is referred to as chilaiditi's sign.This condition is usually asymptomatic.When chilaiditi's sign is symptomatic(usually abdominal pain),it is called chilaiditi,s syndrome. 


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http://www.sustain2green.com/2011/12/chilaiditis-sign.html

BEWARE OF SPURIOUS HYPERKALEMIA

A 40 year old smoker,nonalcoholic male presented with an episode of generalized tonic clonic convulsions followed by unconsciousness(first episode). he regained consciousness after 2-3 hours and had no significant complaints.His CT SCAN brain showed a ring enhancing lesion with surrounding cerebral oedema in left parietal region which was suggestive  of neurocysticercocis.he had no significant past history and was not on any medications.his TLC was 19800,N82%,urea 25,cr0.8,na+135,and most suprisingly k+8.7. His ECG was normal and his urine output was adequate.We panicked and immediately sent a repeat k+ and gave the patient a10%calcium gluconate 10ml i.v. slowly over 3minutes. The repeat k+ was 4.09.
                   So this is a case of spurious hyperkalemia and we must all be very cautious about it.Before jumping into any conclusions and be very aggressive in management we must always do a repeat test.

                   The causes of spurious hyperkalemia are:     

               1.hemolysis during venipuncture

                     2.release of k+ from muscle during the seizure attack.

                     3.release of k+ from muscle distal to the tourniquet.

                      4.release of k+ from clotted blood during severe leucocytosis(>50,000) or thrombocytosis

                        (>10,00,000)

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BACTERIAL PNEUMONIA MIMICKING PULMONARY TUBERCULOSIS

A 30 year old muslim female presented with low grade fever,cough with expectoration and myalgias.Her chest xray revealed right upper lobe consolidation,TLC15700,n80%,ESR130,MT 17*19mm,sputum for AFB was negative on 3 consequetive days,sputum for gram stain showed gram positive cocci in pairs.She was treated with coamoxyclav625 bid for 3 days-there was no relief in symptoms.she was then given cefpodoxime-clavulanate200 bid for 10 days.there was almost complete clearance of RUL opacity after 10 days.
http://www.sustain2green.com/2011/12/bacterial-pneumonia-mimicking-pulmonary.html
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