B wayang kulit


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  • Pectus excavatum (funnel chest) is a congenital chest wall deformity characterised by concave depression of the sternum. Compression of the heart causes characteristic findings on frontal CXR of an indistinct right heart border, decreased heart density and displacement of the heart to the left. The anterior ribs have an accentuated downward slope so that the ribs appear heart-shaped. The indistinct right heart border can mimic right middle lobe pathology but a lateral CXR confirms the sternal deformity. Surgical repair is performed in severe cases. Pectus excavatum is usually an isolated anomaly but can be associated with Marfan’s syndrome, Noonan’s syndrome, fetal alcohol syndrome and homocystinuria
  • B wayang kulit

    1. 1. CHEST RADIOGRAPHS, NORMAL VARIANTS IN THE CHESTA WAYANG KULIT RADIOGRAPHPart Two Dr Ng Kian Seng MBBS (Singapore) MCGP (Malaysia)Second Edition Master Of Medicine (Internal Medicine, Singapore)February 2012 FAFP (Malaysia) Cert In Occupational Medicine Ph D (Theology, USA)
    2. 2. An Album On The Normal Variants In The Chest RadiographYou need to know the normal well enoughso that you will not mistake a normalvariant for some pathological condition.Practise looking at the normal ChestRadiograph…do not disdain it because ithas no bizarre or frightful shadows you canbe excited about! The “practice of looking”at the normal Chest radiograph is what I calla “trifle of medicine” & in Medicine “TriflesMakes Perfection & Perfection Is No Trifle”.
    3. 3. ACESSORY FISSURE, THE AZYGOS FISSURE The azygos lobe appears starting in a teardrop shape at around the level of T5 to the right of the midline as a pale line curving outward . and upward and then back in to meet the root of the neck, the line is the infolding of the pleura. Also described as a “curvilinear opacity, Inverted comma, tadpole.”
    5. 5. NIPPLE SHADOWS RIGHT NIPPLE LEFT NIPPLE Confirm these are indeed nipple shadows by using metal markers!
    6. 6. ASYMMETRY OF THE BREASTS Breast asymmetry is very common, even to the extent that no breast tissue is visible on one side. It should not be assumed that the patient has had a mastectomy, unless this is known from the history.
    9. 9. “Ripley’s Believe It Or Not” The See Saw DiaphragmThese two Chest Radiographs belong to the same Nepalese Worker who presented for a Fomema ME on27 Dec 2011. The first “shocked” me. It showed a high right dome shaped diaphragm with a medialdromedary hump. It is 8 cm higher than the left. He was asymptomatic and a clinical examination wasunremarkable, specifically there was no Hepatomegaly . I asked for a repeat CXR. The second was takenminutes later. Imagine my second “shock”. The second CXR is reproduced here on the right. Now theLeft Hemidiaphragm appears to be slightly higher than the right, and it appeared to have been pushed upby the Splenic flexure of the colon. A very mobile see saw diaphragm.
    10. 10. Tenting In The Diaphragm Note the triangular opacity at mid part of right hemi-diaphragm (arrow). Diaphragmatic tenting is a localized Diaphragmatic tenting is due to fibrosis accentuation of the normal convexityand may not have any clinical significance. of the hemidiaphragm as if "pulled upwards by a string." This finding is minor, may be due to any inflammatory condition and not suggestive of TB. Source : Nexradiology
    11. 11. Diaphragmatic HumpScalloping In The DiaphragmNote multiple arcuate elevations of the right This is due to incomplete muscularization of thehemi-diaphragm. Scalloping is seen in about diaphragm. Instead of the normal diaphragmatic 10% of normal CXR. muscle, the diaphragm is now consists of a thin membranous sheet. This is a very common abnormality. Most of the time, the abnormality is partial, involving one half to one third of the hemidiaphragm. Usually the anteromedial portion is affected. Source : Nexradiology
    12. 12. Normal Variants in the Rib Cage 1.Discontinuity of the first rib 2. Bridge formation posteriorly, forked rib anteriorly 3. Costal bridge 4. Bridge-shaped fusion 5. Fusion dorsally 6. Suggestion of costal bridging 7. Bifurcation suggested 8. Luschkas bifurcated rib
    13. 13. EXAMINE THE FIRST & SECOND RIBS ON BOTH SIDESSee Next Two Slides For The Answers
    14. 14. FUSION OF FIRST & SECOND RIB ON THE RIGHTA bicipital rib is seen in relation to the first thoracic rib. It appears to bethe result of the fusion of two ribs, either of a cervical and first thoracicor of the first two thoracic ribs. Fusion of the first two ribs is common.
    16. 16. BIFURCATED RIBRibs bifurcated at their sternal ends are occasionally observed, with the two extremities joined to a bifid costal cartilage.
    17. 17. What is the bony abnormality in this patient? Chest radiograph is showing well developed bilateral cervical ribs.
    18. 18. The Cervical Rib is an extra rib that arises from the7th Cervical Vertebrae. How do you know these areCervical Ribs and not the 1st Thoracic Ribs? Cervical Transverse Processes Points Downwards= CD Thoracic Transverse Processes Points Upwards = TU Look at the transverse processes that articulate with these ribs. Cervical transverse processes points down while thoracic transverse processes points up.
    19. 19. At first sight there appears to be an oval opacity the Left apical region which could be a coin lesion or something ominous…click to see! What do you think this is?Ossification at the anterior end of the first rib, which is a common finding!
    20. 20. Look at the ossified costal cartilages of these two individuals, a female, aged 78 on the left & a male, aged 79 on the right. What is the difference? There is a Sexual Dimorphism Of Ossified Costal Cartilage… Female, Aged 78 Male, Aged 79
    21. 21. Male, the peace sign The first is the “Peripheral Ossification Pattern”, the male pattern, in which there is subperichondral deposits which contour the upper and lower margin of cartilage. Some radiologists described this appearance as that of 2 fingers making a “peace sign”.Male, Aged 79 Another Image of The peace sign
    22. 22. Female, A solitary Finger The second is the “Central Lingual Ossification Pattern”, the female pattern which is characterized by the pyramidal (lingual) shape of ossifications with a peak towards the sternum. The ossification involves the central portion of the cartilage and is described by Radiologists as a solitary finger.Female, Aged 78
    23. 23. What is the abnormalityIn this Indonesian man ? A “Charm Needle” inserted into the chest wall, a common practice among Indonesian men
    24. 24. Fat Tissue Soft tissue fat This close-up demonstrates a normal fat plane between layers of muscle. Fat is less dense than muscle and so appears blacker. Note that the edge of fat is smooth. Irregular areas of black within the soft tissues may represent air tracking in the subcutaneous layers. This is known as surgical emphesyma
    25. 25. Pectus Excavatum, Funnel Chest Pectus excavatum is usually an isolated anomaly but can be associated with Marfan’s Syndrome, Noonan’s Syndrome, Fetal Alcohol syndrome and Homocystinuria
    26. 26. Pectus Excavatum, Funnel Chest (1)Indistinct R heart border, sometimes mimic R Middle Lobe Pathology (2)Decreased Heart density (3)Displacement of heart to Left (4)Anterior ribs have an accentuated downward slope so that the ribs appear heart shaped
    27. 27. Dextrocardia with Situs Inversus If you did not look at the side markeryou would have missed the diagnosis of Dextrocardia
    28. 28. Collage, Shanghai Girl Series, By Ng Kian SengCopyright : Please Do Not Post This PowerPoint On The Net