After stopping treatment she developed resistant to all possible first line and second line cough and progressive dyspnea generic exforge 80 mg on line. The patient was consuming drugs A diagnosis of Wegener’s granulomatosis was regularly; his fever had responded to the treatment cheap exforge online visa. On examination the patient was febrile lesions were suspected to be due to “paradoxical and had signs of right- sided pleural effusion and response purchase exforge. A biopsy of the chemotherapy, she was reevaluated clinically and right temporal artery showed changes of giant cell radiologically. Investigations: Laboratory investigations showed eosinophilia and microscopic hematuria. A sural nerve biopsy confirmed vasculitis and perivascular granulomas consistent with the diagnosis of Churg Strauss syndrome. Noninfective Identify the radiographs given below and study • Sarcoidosis • Wegener’s granulomatosis their explanation. They may be distinct or confluent (patchy opacities/ consolidation), may show signs of collapse (with signs of volume loss) or cavity. Infections: • Miliary tuberculosis • Interstitial pneumonia often atypical pneumonia 2. Air surrounding the • Bacterial (anaerobes, gram negative bacilli) heart could be • Protozoal (ameobic and hydatid) a. If air-fluid level is equal in all views • Elevated left diaphragm it is a cavity, if not it is a loculated hydropneumothorax Note the lucency in the left paracardiac area also called ‘Luftsichel sign’ Fig. It is chronic diagnosis is a cavity hydropneumothorax because of lucency with air-fluid level with pleural thickening evident on the visceral and parietal pleura and rib crowding. Isolated pulmonary metastasis from bronchogenic carcinoma without metastasis in other organs may occur due to spread through pulmonary artery Fig. The most likely diagnosis in this case is bronchogenic carcinoma with involvement of rib cage, pulmonary metastasis/lymphangitis carcinomatosis and pleural effusion. Interstitial opacities in relation to thoracic malignancy are due to following reasons: 1. Silicosis, (lymph node may show egg shell calcification) Note: Heart appears normal. Retrocardiac triangular shadow (homogeneous opacity– with absent fifth rib most likely diagnosis is post pneumo- direct sign) nectomy status 2. This sign is called as “sarcoid sign” and lymph of fissure, shift of hilum, heart or diaphragm or shift of trachea. When the volume of fluid increases one can see fluid as a straight line (air fluid level) 410 Textbook of Pulmonary Medicine c. Area of increased lucency in the left base without clear margins, suggest a basal bulla. These abnormalities are not fool proof, as costal cartilages may calcify in younger persons too and the shape may not always be accurate Fig. The slip occurs in the right main bronchus due to anatomy of right main bronchus i. Primary due increased tone of the esophageal sphincter Note: Silhouette sign can be applied to a fluid filled cavity, or ‘achalasia cardia’ or as the density is same as that of heart density. In this case the dilated esophagus is uniformly placed adjacent to each other and in same plane ill obliterate opacified, because it is filled with only food. Sometimes there each others borders is speckled appearance due to food mixed with air or air- fluid level may be seen clearly. The erosion of lateral aspect of the left 6th rib suggests for dianosil but unlike dianosil where alveorization is cleared that the lesion is arising from the rib. Learn to count ribs (you quickly, barium persists for years causing persisting opacities can do it visually but will often miss one rib, use your finger and confusion in interpreting future chest radiograph, hence or pen to trace the first rib from anterior to posterior, then use of barium sulfate was abandoned without lifting your finger count 2,3,4 _ _ _ribs) Fig. There tension pneumothorax as position of both mediastinum and is also a left pleural effusion and fracture of the 3rd, 4th and diaphragm is normal perhaps 5th ribs on the left and also 6th and 7th ribs on the right side Chest Radiographs 413 Fig. Right gram (arrows) basal pleural thickening with calcification (dense opacity with rib crowding) is also seen Fig. Note: The apparent coin lesion (arrow) is present bilaterally and is due to nipple shadows in Figure 25. Immunocompromised status with infective complication like interstitial pneumonia (atypical organisms like mycoplasma/virus) Figs 25. Removal of open pin is difficult as the sharp border can traumatize the tracheobronchial tree. Fissural effusion would show similar opacity; the only difference is that the opacity is biconvex in fissural effusion (as shown by the upper line) 418 Textbook of Pulmonary Medicine Fig. It shows multiple coin lesions over the lungs fields in the subcutaneous tissue due to neurofibromas and reticulonodular opacities in right lower zone and left mid zone Figs 25. Note Note: Look for the subcutaneous lesions on right side outside the apparent diaphragm elevation (a clue is that in this case the lung fields confirming their presence in the subcutaneous the outline of diaphragm is not clear). In a more advanced case the entire calcified lymph nodes (though not classically egg shell lung is opaque with “black pleura sign. Note the black pleura sign lily sign” (“ice berg sign”/ Sign of Camelot) suggestive of hydatid cyst in addition there is a small hydropneumothorax suggestive of rupture of the cyst (in this case was due to an attempted aspiration causing severe anaphylaxis, which is well known with aspiration of hydatid cysts) Fig. Differential diagnosis is cyst (fluid filled) and fissural effusion 420 Textbook of Pulmonary Medicine Fig. Due to the diaphragm, lower part of the mass is not pneumonia in emphysema shows air lucencies within the visualized hence appears as half mass over the diaphragm opacified lung due to destruction of lung architecture hence looking like a setting sun. A lateral view shows the complete appear like cheddar cheese lesion This case was an intralobar sequestration. This possibility should always be kept in mind in lower lobe mass lesions, which are often accidentally discovered Figs 25. When activated the liquid converts to aerosol again 422 Textbook of Pulmonary Medicine Fig. In opacification, erosion of posterior ends 2nd and 3rd rib and addition erosion of the posterior part of the left 9th rib can be erosion of 2nd and 3rd hemivertebrae appreciated. Since the eroded rib is not overlying the lesion, Note: it can be presumed to be a metastatic lesion a. Due to the invariable presence of chest wall invasion, this tumor at presentation is almost always stage 3b b. Pancoasts’ tumor is associated with Horner’s syndrome with brachial plexus involvement and C8, T1, and T2 nerves causing pain and later wasting of the medial aspect of the forearm Fig. In addition, right-sided pleural effusion and left fissural effusion (biconvex opacity in region of anterior aspect of the oblique fissure) are also seen. This is also called as “phantom tumor” as it looks like a tumor lesion but disappears after therapy (diuretics) Fig. In this case it was related to Marfan’s syndrome (round lesion with comet tail sign) Figs 25. Coronary artery disease is the leading cause of death in the United States and has been for the past 90 years.
They include progressive spinal muscular atrophy cheap 80 mg exforge otc, amyotrophic lateral sclerosis order exforge canada, Werdnig–Hoffmann disease order exforge without prescription, and syringomyelia. C—Congenital disorders suggest Werdnig–Hoffmann disease, spondylolisthesis, and other anomalies of the spinal cord that may compress the anterior horn and roots. A—Autoimmune disorders recall transverse myelitis, myasthenia gravis (under treatment), periarteritis nodosa, and Guillain–Barré syndrome. T—Trauma suggests herniated discs and fractures that compress the anterior horn or roots. Approach to the Diagnosis Deciding on the cause of fasciculations will usually be based on other neurologic symptoms and signs. Muscular atrophy without sensory changes suggests progressive muscular atrophy, whereas atrophy and fasciculations with sensory changes suggest syringomyelia, peripheral neuropathy, and root compression (e. Serum electrolytes, calcium, phosphorus, and magnesium levels are useful in selected disorders. Physiology: Increased heat in the body is caused by increased production or decreased elimination or dysfunction of the thermoregulatory system in the brain. Increased production of heat occurs in conditions with increased metabolic rate such as hyperthyroidism, pheochromocytomas, and malignant neoplasms. Most cases of fever are caused by the effect of toxins on the thermoregulatory centers in the brain. These toxins may be exogenous from drugs, bacteria (endotoxins), parasites, fungi, rickettsiae, and virus particles, or they may be endogenous from tissue injury (trauma) and breakdown (carcinomas, leukemia, infarctions, and autoimmune disease). Also, when the physician attempts to recall the specific infections, he or she can group them into six categories beginning with the smallest organism and working up to the largest as follows: viruses, rickettsiae, bacteria, spirochetes, fungi, and parasites. Endogenous toxins released by infarctions of various organs form another convenient group. Finally, the 351 most common neoplasms to cause fever (by tissue breakdown) are illustrated on page 172. Approach to the Diagnosis There are certain things to remember when a patient with fever is approached. Second, one should rule out malingering by the patient or incorrect recording by hospital personnel. If possible, a careful chart of the fever should be made with the patient off all drugs (especially aspirin and steroids). Conditions with intermittent or relapsing fever such as brucellosis, malaria, and Mediterranean fever will be elucidated in this fashion (see Table 28). Fever, right upper quadrant pain, and jaundice suggest cholecystitis or cholangitis, whereas fever with right-sided flank pain suggests pyelonephritis. After taking a few moments to jot down the differential diagnosis before launching into the history and physical examination, one can question and examine the patient more appropriately. The differential diagnosis will also lead to more appropriate use of laboratory testing. A serum procalcitonin will distinguish bacterial infections from viral infections. He was treated with penicillin by his family physician 1 week ago but failed to respond. Utilizing the methods discussed above, what is your list of possibilities at this point? However, if the clinician immediately focuses on the kidney, he or she may be sadly mistaken because one forgets the other significant organs in the area. Looking at the adrenal gland, one need only recall the tumors of this gland such as a neuroblastoma, adrenocortical carcinoma, or pheochromocytoma. Surprisingly, other organs located near the flank may be palpated as a flank mass. As in the right upper quadrant, a carcinoma or collection of stool can be palpated in the flank. Moving into the retroperitoneal area, we again may find hematomas of the wall of the flank, bony tumors, and retroperitoneal sarcomas. Approach to the Diagnosis The history of trauma will be helpful in narrowing the diagnosis. Obviously, if there is fever a perinephric abscess, pyonephrosis, or tuberculosis is more likely. It is wise to consult an urologist before ordering any x-ray procedure to help decide which is the most cost-effective approach. Exploratory surgery Case Presentation #28 A 46-year-old male executive was found to have a large right flank mass 359 on routine physical examination. Visualizing the anatomy of the right flank and cross- indexing each structure with the etiology classification, what would be your list of possible causes at this point? Further history reveals the patient has noted painless hematuria on a couple of occasions but is otherwise asymptomatic. Physical examination is unremarkable aside from the large nontender mass in the right flank. As is shown in Table 29, however, jumping to that conclusion in any given case may be hazardous. In addition to the kidney (pyelonephritis and perinephric abscess), inflammation of the skin (herpes zoster), the colon (diverticulitis and colitis), the gallbladder (cholecystitis), and the spine (epidural abscess and Pott disease) may also cause flank pain. Neoplasms of the kidney and colon are less likely to produce pain unless they are complicated by infection. However, trauma of the kidney and spine and renal calculi—whether due to hyperparathyroidism, idiopathic etiologies, or hyperuricemia—are important causes. If these are negative, bone scans, arteriogram, and other tests listed below may be 362 required. Protein electrophoresis (multiple myeloma) Case Presentation #29 A 36-year-old black woman complained of severe left flank pain for 3 days. Utilizing the methods discovered above, what would be your list of possibilities at this point? Physical examination is unremarkable except for hyperesthesia and hyperalgesia in the distribution of T12 dermatome on the left. Retina: Conditions of the retina to be considered in this symptom are exudative choroiditis, retinal detachment, venous thrombosis, and embolism. Optic cortex: Transient ischemic attacks in the posterior cerebral circulation and epileptic auras may cause this symptom. Arterial circulation to the eye and brain: Migraine, cerebral thrombosis, and emboli present with this symptom. Approach to the Diagnosis This is similar to the workup of blurred vision (see page 76). The increase of gas in the intestinal tract depends on three physiologic mechanisms: 1.
Monoarticular pain in adults • Acute pain and swelling of a joint follows intra-articular trauma such as cruciate or meniscus tears in the knee buy exforge overnight delivery. Stress fractures occur as the result of repetitive loading of bone generic 80mg exforge with mastercard, and can be found with occupational best 80mg exforge, recreational, or athletic activities. Non-gonococcal septic arthritis is a rheumatological emergency (see Chapters 17 and 25), and should be treated with intravenous antibiotics immediately on suspicion. The great toe is very commonly affected in PsA—check if digit is dactylitic and there is nail disease—see Chapter 8. This inflammation may be a consequence of a range of cellular processes, and is not specific for any one diagnosis. Enthesitis (inflammation at a tendon or ligament insertion into bone) or tenosynovitis (inflammation of the tendon itself) may be the most prominent feature. History: general points • Pain and stiffness are typical features of synovitis and enthesitis. The presence or absence of stiffness does not discriminate between different causes of synovitis. In chronic situations, pain may be less severe (due to mechanisms that increase physical and psychological tolerance). There are no specific descriptors that discriminate pain from synovitis or enthesitis. Patients with carpal tunnel syndrome, for example, will frequently report that their hands are swollen, even when no swelling is visible. Synovial swelling needs to be discriminated from bony swelling, fat, and other connective tissue swellings (e. Without imaging or attempting to aspirate joint fluid, it may be difficult to discriminate synovial thickening from effusion. Joint erosions and tophi occur in chronic disease Spondyloarthritis Age <40 yrs, men more than women. May 8) occur with sacroiliitis, urethritis or cervicitis, uveitis, gut inflammation, psoriasis (scaly or pustular). Oligoarticular, acute monoarticular (see Chapter (25%), and occasionally polyarticular patterns of synovitis 7) Haemarthrosis Obvious trauma does not always occur. Can rarely present as an Chapter 5) acute monoarthritis Septic arthritis Most common cause Staphylococcus aureus. Associated (excluding with chronic arthritis, joint prostheses, and reduced host Neisseria immunity. Synovial fluid is Gram +ve (see Chapter in 50% of cases and culture +ve in 90% of cases 17) Gonococcal Age 15–30 yrs in urban populations and with inherited arthritis (see deficiency of complements C5 to C9. Organism detected by Gram stain of joint fluid in 25% and by culture in 50% in the second group • Tenderness of thickened synovium is common, but is not always present. Severely tender swelling suggests joint infection, haemarthrosis, or an acute inflammatory reaction to crystals. The degree to which passive and active range of motion is reduced depends on a number of often interdependent factors (e. Affected joints will demonstrate reduced range on active or passive range of motion exercises; moving the joint beyond that point will elicit pain. SpA, especially reactive arthritis, is likely to be the main cause; 75% of patients who develop reactive arthritis are <40 years old. Large effusions can also be seen with septic and psoriatic arthritis (see Chapter 8). History: preceding factors Factors preceding swelling of a single joint or oligoarthritis may be highly relevant. These include trauma and infection: • Acute non-traumatic monoarticular synovitis is most commonly due to crystal- induced synovitis or synovitis associated with SpA. History: family and social history There may be important clues from the family and social history: • Both gout and SpA have a familial component. History: ask about other associated features Associated extra-articular features include previous eye, gastrointestinal, cardiac, and genitourinary symptoms: • Low-grade fever, malaise, and anorexia occur commonly in both septic arthritis and gout. Marked fever can occur in gout and only occurs in about a third of patients with septic arthritis. Examination: general • Always compare sides, to establish if the changes are symmetric or asymmetric. A history of swelling is not always reliable and other, non-synovial, pathology can present with single or oligoarticular joint pain. Check passive range of motion for evidence of locking or instability: • Acute processes such as crystal arthritis, infection, and post-traumatic effusion often lead to painful swelling, marked tenderness of swollen soft tissues, and painfully restricted active and passive movement of the joint. Examination of other musculoskeletal structures • Examine the low back and typical sites of bony tenderness—sacroiliitis and enthesitis are common features of SpA. Examination: look for skin rashes and any inflammation Oligoarthritis may be part of a systemic inflammatory or infectious condition: • Temperature and tachycardia can occur with some non-infectious causes of acute arthritis (e. Polarized light microscopy of material obtained by needle aspiration will be diagnostic for tophi. At larger joints, both are sensitive for the detection of effusion and synovial thickening. Laboratory tests: joint fluid The most important investigation of a patient with monoarticular synovitis is joint aspiration and prompt examination of fluid. Synovial fluid in septic arthritis and acute crystal arthritis is frequently turbid due to the effects of a high number of neutrophils. There is a high probability of infection or gout if the neutrophil differential is >90%. Biopsy may be helpful to diagnose sarcoid arthropathy (see Chapter 18), infectious arthritis, or crystal arthropathy when the usual diagnostic tests are negative. Samples for polarized light microscopy are best fixed in alcohol (urate is dissolved by formalin). In addition, the interpretation and reporting of symptoms varies considerably and can be a source of confusion. This section reviews important aspects of the history, examination, and investigations in the initial evaluation of patients who present with non-localized, multicentric pains. Age, gender, and racial background • What clues can be drawn from the age, sex, and racial background? Taking a history First, establish whether pains arise from joints or tendons/entheses, muscles, bone, or are neurologic. Obtain a detailed history of the pain at different sites • A good history should help narrow the differential diagnosis considerably. A middle-aged woman with ‘hand and neck pain’ could have an arthropathy or radicular pain associated with cervical spondylosis. Bony pain is often unremitting, and changes little with changes in posture and movement. For example, in an older patient, multiple pathologies frequently exist and can be complicated to unravel. The following are all common in the elderly: • osteoarthritis (any/multiple joints). Unlike inflammatory joint pain, mechanical joint pain is worsened by use, and improves with rest.
By C. Karmok. Urbana University.