50 YRS OLD MALE pt admitted with the complaints of fever for 3 days followed by breathlessness. . known case of CAD ..irregular treatment. . RS. .BILATERAL CRACKELES MORE ON LEFT SIDE. . SPO2..78%.. BP.130/90.. PR..104/MNT. . 1..CLINICAL DIAGNOSIS? 2. X RAY FINDINGS? 3.HOW TO PROCEED FURTHER? PLZ SHARE YOUR VIEWS. .THANKS IN ADVANCE.

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Bilateral middle and lower zone lesions.First possibility b/l pneumonia (viral etiology).Second pulmonary edema with superadded infection.Third ARDS. Rule out immunocompromised state, HIV, H1N1 , RSV etc. Start with o2, antibiotics cover and diuretics. Maintain vitals and input and output.

To differentiate these 3 DD's 1) cardiogenic pulm oedema -- The heart is usually enlarged in cardiogenic pulmonary edema, but it may be normal in lung injury and NPE. However, the heart may also be of normal size in cardiogenic edema after acute myocardial infarction. Pulmonary vascular plethora often occurs with upper lobe blood diversion in cardiogenic cases; vessels of the upper lobe are balanced to cephalic in fluid overload but are normal in lung injury. Septal lines indicative of interstitial edema are more frequent with cardiogenic causes than with others. The infiltrates of cardiogenic pulmonary edema are usually diffuse, and air bronchograms are rare. 2) in ARDS shadows are perihilar sparing apex and periphery BAT Wing appearance. Alveolar fluffy shadows are seen. 3) Consolidation - Homogenous opacity with air bronchogram. Septal lines less likely seen.

Thank you so much for your Fantastic approach sir@Dr. Vishal More ....
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dear friends. .. Thank you so much for your wonderful answers. . 3 DDS ... 1. Cardiogenic pulmonary edema 2. ARDS 3 . CONSOLIDATION. . HOW TO DIFFERENTIATE BETWEEN THESE THREE BY ONLY WITH X RAY FINDINGS .. PLZ SHARE YOUR VIEWS

To differentiate these 3 DD's 1) cardiogenic pulm oedema -- The heart is usually enlarged in cardiogenic pulmonary edema, but it may be normal in lung injury and NPE. However, the heart may also be of normal size in cardiogenic edema after acute myocardial infarction. Pulmonary vascular plethora often occurs with upper lobe blood diversion in cardiogenic cases; vessels of the upper lobe are balanced to cephalic in fluid overload but are normal in lung injury. Septal lines indicative of interstitial edema are more frequent with cardiogenic causes than with others. The infiltrates of cardiogenic pulmonary edema are usually diffuse, and air bronchograms are rare. 2) in ARDS shadows are perihilar sparing apex and periphery BAT Wing appearance. Alveolar fluffy shadows are seen. 3) Consolidation - Homogenous opacity with air bronchogram. Septal lines less likely seen
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Right lung: 1. right cardiac border is obliterated suggesting middle lobe pathology whose vertical spread is limited by horizontal fissure 2. Opacity looks relatively homogenous like lobar consoldation compared to left side Left lung : confluent opacity involving lower zone Cardiomegaly present Doubtful left apical bulla (no bronchovascular marking) In view of fever, asymmetric involvement and very rapid progression (3 days) Necrotysing pneumonia or infuenza is definitely upfront diagnosi. Presence of cardiomegaly cant be ignored as the contributing factor. As far as ARDS is concerned, its not a radiological diagnosis rather constellation of typical radiology, non cardiogenic edema and P/F ratio based....

Its pulmonary edema. Immegeatly put on ventilatory support with heigh peep. Do abg, cardic marker, haemogram rfts. Inj. Lasix 40 mg lvly. Inj. Cefeparoxone+ sulbactum 1.5 mg ivly 12 hrly. Inj. Pan 40 mg od inj. Lmwx 0.6 ml scly bd. Tab. Ecosprin 150 mg od ,tab. Resostatin 20 mg hs.after stablise pt. Do 2 D echo.

Bilateral diffuse infiltrates in both mid and lwr zns There was pyogenic inf in body ....may be in chest...but xray chest in the beginning not done ..so can not pin point site of inf .now due to bacteremia pt has gone into. ARDS

? Non cardiogenic pulmonary edema (ARDS) ? Cardiogenic pulmonary edema Are there other features of CCF ? Oxygen, antibiotics, restricted fluid, CPAP/ Lung protective Ventilation I am not in favour of using diuretics or nebulisation......

Bilat lower and middle zone infiltration consolidation and mild cardiomegaly ( in kn CAD... Irregular Rx) with pulmonary oedema . Check and maintain ABCDE and Vitals. ABG with electrolytes, mg, glucose, lactate ,hb. Cbc, clotting, RFT, LFT. Throat swab/ cough expectorant micro c/s. ECG, Echo. Maintain good Oxygenation normal paco2 ( NIV - BIPAP sos, Nebulisation) and urine(lasix and slowly iv fluid with I/O chart). Augmentin, levoflox, Paracetamol and Pantocid, emcet. And cardiac medication .....

1. pulmonary edema 2. B/L mz lz heyerogenous opacity, sparing apex. 3. Only spo2 low, with tachy... o2 via venturi, or BIPAP with desired Fio2... Diuretics, sputum examination, antibiotics, mucolytics

Pulmonary oedema with CCF. Associated superadded infection. ARDS is another possibility. Oxygen inhalation with mask, diuretics, parenteral antibiotics .Maintain input output chart and vitals .

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