chest x-ray, bronchiectasis

Routine Mammographic Positioning and Beyond

"USMLE STEP 1 Reality" by Dr Brian Bolante

Anatomy of Neck Muscles

What is the USMLE?

USMLE represents The United States Medical Licensing Examination,it is a three-part licensing examination that is required in order to receive a license to practice medicine within the United States.
This exam is designed by the Federation of State Medical Boards and the National Board of Medical Examiners to determine whether or not an individual understands and can apply the knowledge necessary to practice medicine safely and intelligently. The USMLE is actually comprised of 3 different exams that are referred to as steps, which examine the individual's knowledge of specific topics related to the field of medicine like basic science, medical knowledge, medical skills, clinical science, and the application of all of these skills and areas of knowledge in the medical field.

All three steps of the USMLE include a series of computerized multiple-choice questions (MCQs), but the format of the exam and the information covered in each multiple-choice section is different for each step of the USMLE. The USMLE Step II also has a clinical skills portion that examines an individual's ability to work with real patients and the USMLE Step III has a computerized patient simulation portion in addition to the multiple-choice section of the exam. In order for an individual to receive a license to practice medicine, the individual must pass all three steps of the USMLE.

Automated Breast Ultrasound

U-Systems has developed an Automated Breast Ultrasound System that is FDA 510k approved for diagnostic imaging

Money-Driven Medicine

Money-Driven Medicine provides the essential introduction Americans need to become knowledgeable and vigorous participants in healthcare reform.

Croup (acute laryngotracheobronchitis) on X-ray with steeple sign

Croup, also called acute laryngotracheobronchitis is caused by viral infection of the upper airway usually parainfluenza virus or respiratory syncytial virus (RSV). It is common and has a peak incidence before the age of 1 year (typically between 3 and 6 months of age).

It is presented Clinically by protracted barking cough and inspiratory stridor due to tracheal narrowing that is caused by mucosal oedema .

X-ray finding :
On Plain film
The diagnosis of acute laryngotracheobronchitis or Croup is usually made clinically
and no need for doing x-ray.you may do it just for excluding other causes of same presentation like:
- foreign body aspiration.........tracheal or oesophageal.
- angioneurotic edema
- epiglottitis and epiglottic-cysts
- congenital subglottic stenosis

However there are some typical radiographic findings :


1- steeple sign (the image above): seen on AP radiographs of the neck or chest and neck demonstrates uniform narrowing of the subglottic airway

But What is steeple sign ??
The steeple sign refers to superior tapering of the trachea on a frontal chest radiograph. It is remaniscient of a church steeple and is suggestive of croup.


2- distension of the hypopharynx is also seen due to the patient's attempt at decreasing airway resistance (the image below)

Cornual pregnancy

B mode 2D image :


This UltraSonography image of the uterus can show us a gestation sac of 6 weeks 4 days age, in the right cornu of the uterus. 3-D image of the uterus further confirms the findings. These ultrasound images are diagnostic of cornual pregnancy (Which is a type of ectopic pregnancy).

3D image:

Ultrasound images of Bicornuate uterus with gestation sac

Pregnancy occures in one horn of uterus that has two horns (cornu):




The above ultrasound images show a bicornuate uterus with a gestation sac in the right cornu (1).
The empty left cornu (2) shows typical decidual changes of pregnancy. The 3rd image (bottom) is a sagittal section through each cornu.

C. D. Review of Skeletal Muscle Tissue

This Video is recorded off a cd-room. there may be some background noises, SORRY for that

Brain Anatomy and Functions

Anatomy of Hip Adductors

ultrasound in gallbladder evaluation

Ultrasound elastography may help women avoid breast biopsy.

A group of U.S. researchers has put a new spin on breast ultrasound elasticity imaging, which measures differences in stiffness between malignant and benign tissue. The group believes that its new technique is easier to use than previous attempts at elastography, and could help women avoid biopsy following suspicious mammograms.

How to Get Medical Jobs : How to Become a Radiologist

Radiologists are required to complete medical school, as well as a residency program in radiology during which students learn to read and analyze X-rays, MRI's and CT's. Become a radiologist with tips from a medical administrator in this free video on career information.

Medicare enrollment problems,Medicare payments

A 3-physician, family medicine practice in Lexington, Va., recently found itself with roughly $40,000 in unpaid Medicare claims -- practice revenue that was in limbo because of a cascade of blunders in Medicare's physician enrollment process.

Brenda Harlow, office manager for Lexington Family Practice since 1981 and, thus, no newcomer to the Medicare game, commented she'd never seen anything like the mess in which the practice found itself recently.

The nightmare started with the completion of Medicare enrollment forms in January. A series of events, including Medicare contractor mailroom mishaps and a lack of clarity about what information the contractor needed from the practice, stretched on for nearly two months, according to Harlow.

Then the hammer came down.
"Payments from Medicare were stopped on March 12," said Harlow. Subsequently, the practice was notified that, as of May 25, all three physicians in the practice could be "barred from Medicare for a year."

Robert Pickral, M.D., has been serving Medicare patients at the Lexington practice since 1981. "What is the message to the physicians of America when this kind of disruption happens?" he asked.
"We operate a small practice in a small community. Revenue is way down, and federal quarterly taxes are due," said Pickral, adding that Medicare patients account for nearly 25 percent of the practice's patient panel.

As of June 2, the practice still had no resolution regarding the Medicare enrollment problems, and it still has not received any Medicare payments.

According to Kent Moore, the AAFP's manager of health care financing and delivery systems, there is no way to know for sure how many other Academy members are experiencing similar problems with Medicare. But "I do know that Pickral's practice is not alone," he said.

"I have exchanged e-mails and phone calls with other AAFP members who have run afoul of Medicare's physician enrollment process," said Moore, adding "in some cases, physicians have had their Medicare billing privileges revoked as a consequence."


Avoiding Medicare Mishaps
Medicare's Provider Enrollment, Chain and Ownership System, or PECOS, may be the source of many problems, including those experienced by Pickral's practice, according to Cynthia Hughes, C.P.C., an AAFP coding expert who works with Moore in the AAFP's Practice Support Division.

The Internet-based PECOS was established in 2003, and physicians who have not submitted an enrollment application since it went operational need to re-enroll, said Hughes.

She also cited physician revalidation rules laid out in the Medicare Program Integrity Manual (275-page PDF; About PDFs). According to the manual, Medicare providers and suppliers "must resubmit and recertify the accuracy of their enrollment information every five years in order to maintain Medicare billing privileges."

According to Hughes and Moore, physicians can be proactive to prevent problems with Medicare. For example, physicians should

* log in to PECOS to see if they are registered there and to ensure that their information is complete and accurate;
* respond to Medicare requests for revalidation of enrollment in a timely manner, so if issues crop up, there is ample time to resolve them; and
* report any provider changes, such as a change of address, promptly.

"Physicians may think Medicare is picking on them, but the real issue is that there are lots of new rules that everyone is trying to follow," said Hughes.

She suggested that physicians who are rushing to beat a Medicare enrollment deadline and who are not already established in PECOS should submit a paper application. "Approval for PECOS registration can take some time," said Hughes.

Prosthetic-Valve Dehiscence

A 33-year-old man with rheumatic heart disease presented with an acute onset of chest pain. Five years earlier, the patient had undergone replacement of the mitral and aortic valves (Medtronic Hall and ATS Medical, respectively).

On physical examination, he had diaphoresis with normal vital signs and without evidence of congestive heart failure, acute aortic regurgitation, or abnormal prosthetic heart sounds. Electrocardiography that was performed 4 hours after the onset of pain showed ST elevation in left-sided leads V8 and V9, which was suggestive of inferoposterior myocardial injury. Laboratory evaluation revealed an elevated international normalized ratio (>12; normal range, 2.5 to 3.5), a creatine kinase level of 39 U per liter (normal range, 0 to 150), a creatine kinase MB level of 5.5 U per liter (normal range, 0.6 to 6.3), and a troponin I level of 0.24 ng per milliliter (normal range, 0.01 to 0.03).

Cardiac catheterization showed that the prosthetic aortic valve was significantly displaced with each heartbeat (Panels A and B, arrows); no abnormality of the mitral valve was observed. The patient underwent urgent excision and replacement of the dehisced aortic valve, which was found to be infected with Staphylococcus aureus, with associated vasculitis; the mitral valve was not affected. The patient had postoperative mediastinal bleeding and died from irreversible shock 24 hours later.

What is Periosteal reaction? it`s types? And how it is helpful in diagnosisby it`s X-Ray appearance.

Periosteal reaction:
A periosteal reaction is a non-specific reaction and will occur whenever the periosteum is irritated by a malignant tumor, benign tumor, infection or trauma.
There are two patterns of periosteal reaction: a benign and an aggressive type.
The benign type is seen in benign lesions such as benign tumors and following trauma.
An aggressive type is seen in malignant tumors, but also in benign lesions with aggressive behavior, such as infections and eosinophilic granuloma.

Benign periosteal reaction
Detecting a benign periosteal reaction may be very helpful, since malignant lesions never cause a benign periosteal reaction.
A benign type of periosteal reaction is a thick, wavy and uniform callus formation resulting from chronic irritation.
In the case of benign, slowly growing lesions, the periosteum has time to lay down thick new bone and remodel it into a more normal-appearing cortex.

Aggressive periosteal reaction
This type of periostitis is multilayered, lamellated or demonstrates bone formation perpendicular to the cortical bone.
It may be spiculated and interrupted - sometimes there is a Codman's triangle.
A Codman's triangle refers to an elevation of the periosteum away from the cortex, forming an angle where the elevated periosteum and bone come together.
In aggressive periostitis the periosteum does not have time to consolidate.



In these X-Rays:

* left:
Osteosarcoma with interrupted periosteal rection and Codman's triangle proximally.
There is periosteal bone formation perpendicular to the cortical bone and extensive bony matrix formation by the tumor itself.
* middle:
Ewing sarcoma with lamellated and focally interrupted periosteal reaction. (blue arrows)
* right:
Infection with a multilayered periosteal reaction.
Notice that the periostitis is aggressive, but not as aggressive as in the other two cases.

Note that: Fibrous dysplasia, Enchondroma, NOF and SBC are common bone lesions.
They will not present with a periosteal reaction unless there is a fracture.
If no fracture is present, these bone tumors can be excluded.
So, Periosteal reaction excludes the diagnosis of Fibrous dysplasia, Enchondroma, NOF and SBC unless there is a fracture

Liver tuberculoma on CT

TB is a growing problem worldwide; consequently, it is vital to recognize the more unusual presentations of this disease. Intra-abdominal TB has a high mortality, but it is a difficult diagnosis to make, often requiring laparotomy.

Liver tuberculoma is, in particular, rare, with fewer than 100 cases reported in the literature, most of which are secondary and associated with miliary TB. This is a case of 32 year old female with caviating right upper lobe lesion with miliary mottling and hepatic tuberculomas. Mediastinal lymphnodes are also seen.

Physics of CT Scan

CT Scan Physics - Basics Part1



CT Scan Physics - Basics Part 2

Peritoneal Mesothelioma

View this mesothelioma resource as presented at the International Symposium on Malignant Mesothelioma 2008, hosted by the Mesothelioma Applied Research Foundation. Presentation by Dr. James F. Pingpank, Head of the Surgical Metabolism Section of the Surgery Branch of the NCI, in Bethesda Maryland.

Type I Persistent Truncus Arteriosus

Two days old baby boy had cyanosis. Echocardiography displayed a large,subtruncal ventricular septal defect.Main pulmonary artery arised from truncal root.

Carpal bones mnemonic

Some Lovers Try Positions That They Can't Handle

• S - Scaphoid
• L - Lunate
• T - Triquetral
• P - Pisiform
• T - Trapezium
• T - Trapezoid
• C - Capitate
• H - Hamate

Proximal: A=Scaphoid, B=Lunate, C=Triquetral, D=Pisiform
Distal: E=Trapezium, F=Trapezoid, G=Capitate, H=Hamate

Oil Cyst or Fat necrosis

A 34 years old female Patient that complains of breast lump and a history of breast trauma. Diagnosis was of an oil cyst.
Note............egg-shell calcification.


So,What is oil cyst ?!
Oil cyst that also called Fat necrosis occurs when there is saponification of local fat, usually after a direct trauma. Middle-aged women with pendulous breasts are Most at risk.

At first, they are ill-defined and irregular spiculated dense masses. However, with time, they become more defined and well-circumscribed. The centre of the lesion becomes increasingly with homogenous with fat-density.

Anatomy of the perineum

Brief lesson on anatomy of the perineum.

Lipoma arborescens of Ankle MRI (what`s that !!!)

Lipoma arborescens is a rare benign fat-containing synovial proliferative lesion that is typically known to affect the knee joint in adults. The term “lipoma arborescens” has been used to describe the diffuse infiltration of fat within hypertrophic synovial villi.
We present a rare case of lipoma arborescens of the ankle joint in an adult patient with involvement of the intra-articluar synovium as well as the synovial sheath of the tendons around the ankle.

Note the fat density, this is old lady with past history of trauma, now presented with swelling and pain.

Ultrasound see small radial bone fracture

Cystic Tumors of the Kidney

Cardiac Ultrasound - Subxiphoid View : Case Study

This video details the use of bedside ultrasound imaging to evaluate cardiac structures and health, especially when attempting to identify cardiomyopathy, pericardial effusion, and pericardial tamponade. The subxiphoid view of the heart provides physicians with a great deal of information regarding a patient's condition.

MDCT/CTA Following Nephrectomy for Renal Cell Carcinoma

Part 1:


Part 2:

BP is facing a bill of up to $34bn from the Gulf of Mexico disaster

BP is facing a bill of up to $34bn from the Gulf of Mexico disaster after US senators demanded the oil company deposited $20bn into a ring-fenced account to meet escalating compensation costs.

The sum dwarfs many analysts' previous estimates, shared by BP, that put the cost of the clean-up effort and payment of damages to affected communities, such as fishermen, closer to a total of $5bn.

Shares in BP nose-dived by more than nine per cent today as investors took fright at the demand by the 54 Democratic senators, who represent a majority in the US upper house. The company is now worth almost half what it was before the accident of just under two months ago.

BP already faces up to $14bn in civil penalties, payable under US environmental law, assuming the leak is plugged in August. These punitive damages are directly linked to the size of the spill – already estimated at being up to eight times worse than the Exxon Valdez disaster in 1989 – with BP liable for up to $4,300 for each barrel-worth spilt.

Senate leaders insisted the $20bn ring-fenced account should be exclusively for "payment of economic damages and clean-up costs" and should not be seen as a cap on BP's other legal liabilities. With punitive damages pending too, the theoretical total of $34bn is equivalent to more than half the corporation tax paid by all British companies last year.

Tony Hayward, chief executive of BP, and other directors of the company, will meet Barack Obama at the White House on Wednesday prepared to offer concessions in the hope of taking the sting out of mounting political attacks on the company.

BP will be in "listening mode", willing to cut its next dividend, worth about $2.5bn, possibly paying the cash into the clean-up fund. It will also reiterate its commitment to paying all legitimate claims arising from the disaster. But the company does not believe that the demand by the senators to stump up $20bn is justified.

Executives were also alarmed by the White House's insistence last week that BP must pay the wages of rig workers laid off by other firms because of the six-month moratorium on deepwater drilling in the gulf. If pursued, the company fears it would be exposed to potentially limitless claims from anyone affected by the disaster, which would eventually bankrupt the company. The company hopes that President Obama's statement, following the meeting with BP, will draw back from the demand.
Hayward, who was in Houston today overseeing the spill response, hosted a conference call with his board to discuss BP's next move. The company had indicated that it would wait as usual until close to its next results announcement, on 27 July, to decide whether or not to pay its next quarterly dividend. But it is now set to announce its intentions sooner, perhaps as early as Thursday. It is understood BP could use the dividend as a bargaining chip in its talks with the White House.

Obama today risked the wrath of families of 9/11 victims by comparing the gulf spill to the 2001 terrorist attacks, as pressure intensified on the White House to show greater urgency over the crisis.

Ahead of a trip to Louisiana and a televised address to the nation tomorrow, Obama said the spill, the worst environmental disaster in US history, would, like the 2001 terror plots, continue to influence the country for decades to come. Some people who lost relatives in the 9/11 attacks rejected the comparison. "I think he's off-base," said Jim Riches, a former New York fire department deputy chief, whose son died at the World Trade Centre. "These were 9/11 murders … not something caused by people trying to make money."

Some Occupational Lung Diseases and Their Causes

* Asbestosis, caused by exposure to asbestos particles. Often found among people who worked in shipyards, asbestos mines, and factories that refined or used asbestos to manufacture products.
* Black lung (Coalworker's pneumoconiosis) which affects coal workers
* Chronic Beryllium disease (CBD), which affects workers in a variety of metallurgical occupations
* Byssinosis (brown lung disease), often occurs in cotton and textile workers when bacteria released from cotton or other materials is inhaled and grows with the lungs. This is often associated with poor ventilation systems.
* Hypersensitivity pneumonitis, this can affect people who work in office buildings whose air-conditioning systems are contaminated by certain fungi and bacteria.
* Occupational asthma, can affect people who work with a variety of materials. This includes animals (dander), carbamates (urethanes), dyes, epoxy resins and enzymes used in detergent, leather goods, latex, and automotive paints
* Silicosis often developed by people who worked with clay, sand and stone dust including miners, stone cutters and sandblasters.

Staphylococcal pneumonia: X-ray Finding

Rapid development of extensive alveolar infiltrates, usually involving a whole lobe or even several lobes. Air bronchograms are infrequent because the acute inflammatory exudate fills the airways, leading to segmental collapse and a loss of volume.



Notes:
Most frequently occurs in children, especially during the first year of life. In adults, usually affects hospitalized patients with lowered resistance or as a complication of a viral respiratory infection. A characteristic finding in childhood disease is the development of pneumatoceles, thin-walled cystic spaces in the parenchyma that typically disappear spontaneously within several weeks. Pleural effusion (or empyema) often occurs.

Bad aspects in American health care system

1. Most physicians do not set their own fees. Medicare, Medicaid, and private health plans set these fees, which often have little to do with the costs of doing business.

2. Congress each year sets Medicare fees through a formula called SGR (Sustainable Growth Rate), which this year calls for a 20% reduction in overall physician fees.

3. If SGR were to go through as to proposed, surveys indicate at many at 30% of physicians will not accept new Medicare patients because new Medicare fees will not cover expenses.

4. The next political crisis will be limited access to doctors; this is already occurring in Boston, where waiting times to see doctors are 2 to 3 times the national average for comparable cities.

5. Medicare on average pays 80% of what it costs to provide care: hospitals and doctors make up the difference by negotiating higher payments from the much maligned private plans.

6. An estimated 10% of health costs are due to the practice of “defensive medicine,” whereby doctors order extra tests and procedures in anticipation of defending themselves again future malpractice lawsuits.

7. Passing federal laws permitting patients to enroll in plans and “portability” of plans across state lines would make a public option unnecessary and would render private plans “competitive.”

8. Ending “community ratings,” which force the young to pay the same premiums as older individuals, and reducing “standard benefit plans, “ which often include unnecessary benefits, would reduce premiums for the young and decrease the number of uninsured.

9. The primary care shortage is real and growing because medical students are smart and are not choosing to work twice as long as specialists at 1/2 the pay; doubling Medicare pay for primary office visits would be a good start for relieving the crisis.

10. The surest way to reduce costs is having patients spend more of their own money and making them more responsible for their health, which is the premise of lower-premium health savings accounts and high deductible plans.

Radiological images of Morgagni's Hernia

A 41-year-old woman was evaluated for a 5-month history of dyspnea and cardiac arrhythmia. Chest radiography revealed an enlarged right mediastinum with air content on the right side (Panel A, arrow; and Panel B, lateral view). Thoracic computed tomographic (CT) scans showed a Morgagni's hernia, characterized by an anteromedial diaphragmatic defect, with herniation of the transverse colon and part of the omentum into the thorax (Panels C and D).

CT scans also showed that the bowel contents were compressing the right side of the heart.
Morgagni's hernias are secondary to congenital defects in the anterior diaphragm. The hernia sac frequently contains the transverse colon with the omentum; more rarely, the stomach, small bowel, or liver is involved. The patient's hernia was laparoscopically reduced , and the diaphragmatic defect was repaired with a composite mesh. Postoperatively, the patient's symptoms resolved. Follow-up thoracic CT confirmed the absence of bowel contents in the thorax.

job hazards in Lung Cancer

As we know cigarettes are the most important cause of lung cancer,But chemicals and other on-the-job hazards "play a remarkable role" in lung cancer risk.

5% of lung cancers in men are job-related. Men in the known to be risky occupations were 74% more likely to have been diagnosed with lung cancer.

The strongest associations were seen for ceramic and pottery jobs and brick manufacturing, as well as for those working in manufacturing of non-iron metals.

A Chest X-Ray shows a right upper lobe (RUL) mass due to lung cancer.

MRI on Absence of the Septum Pellucidum?

MRI appearances of septo-optic dysplasia .
(a) Anterior pituitary hypoplasia and absent infundibulum associated with bilateral optic nerve hypoplasia. The posterior pituitary is ectopic. There is an absence of the septum pellucidum.
(b) Ectopic posterior pituitary, anterior pituitary hypoplasia, absence of the infundibulum and partial absence of the septum pellucidum associated with optic nerve hypoplasia.

CC, corpus callosum; AP, anterior pituitary; PP, posterior pituitary; SP, septum pellucidum; OC, optic chiasm.

For More about septo-optic dysplasia :

CLICK HERE