Moreover it is also a part of MBBS / Medical course curriculum for Students around the Globe both in Basic science and Clinical Sciences.

On all X-rays check the following:

1. Patient details-  Name , age and Complaints in Brief ( If available)
2. Orientation, position and side description- Left, right, erect, AP -anterioposterior , PA- poserioanterior, supine, prone
3. Additional information- inspiratory, expiratory film
4. Rotation-  Rotated or not , Measure the distance from the medial end of each clavicle to the spinous process of  the vertebra at the same level, which should be equal in Good Xray.
5. Adequacy of inspiration- Nine pairs of ribs should be seen posteriorly in order to consider a chest x-ray adequate in terms of inspiration
6. Penetration- Good/Inadequate- one should barely see the thoracic vertebrae behind the heart
7. Exposure- Adequate /Inadequate- One needs to be able to identify both costophrenic angles and lung apices.

Read the X ray in Order Either Outside to Inside or Vice-versa. Most Prefer Out to in.

8. Soft tissue

• Look  for subcutaneous air, foreign bodies and surgical clips
• Caution with nipple shadows, which may mimic intrapulmonary nodules
• Compare side to side, if on both sides the “nodules” in question are in the same
• position, then they are likely to be due to nipple shadows

 9. Bony Cage and structures

• Check for fractures, dislocation, subluxation, osteoblastic or osteolytic lesions in clavicles, ribs, thoracic spine and humerus.

10. Trachea and Bronchi-

• Ensure trachea is visible and in midline
•  Trachea gets deviated away from abnormality- eg pleural effusion or tension pneumothorax
•  Trachea gets deviated towards abnormality- eg atelectasis
•  Trachea normally narrows at the vocal cords
•  View the carina, angle should be between 60 –100 degrees
•  Check for tubes, pacemaker, wires, lines foreign bodies
•  If an endotracheal tube is in place, check the positioning, the distal tip of the tube should be 3-4cm above the carina

11.Diaphragm and Angles

• See Costophrenic angles and Cardiophrenic angles- Normally should be sharp. Bluting denotes effussions.
• Right hemidiaphragm- Should be higher than the left. If much higher, think of effusion, lobar collapse, diaphragmatic paralysis. If you cannot see parts of the diaphragm, consider infiltrate or effusion
• If film is taken in erect or upright position you may see free air under the diaphragm if intraabdominal perforation is present

12.Lung Fields-

• Normal or Hyperinflated- Count Ribs- Anterior Ribs if 7 or more visible -Hyperinflated, Posterior ribs more than 9 than hyperinflated.
• Check for infiltrates-Identify the location of infiltrates by use of known radiological phenomena, eg loss of heart borders or of the contour of the diaphragm,Remember that right middle lobe abuts the heart, but the right lower lobe does not
• Identify the pattern of infiltration-
• o Interstitial pattern (reticular) versus alveolar (patchy or nodular) pattern
• o Lobar collapse
• o Look for air bronchograms, tram tracking, nodules, Kerley B lines
• o Pay attention to the apices
• Check for granulomas, tumour and pneumothorax

13.Cardia sillouhete and Mediastinum-

• Heart size and heart borders-Appropriate or blunted, Thin rim of air around the heart, think of pneumomediastinum, Cardiomegaly – Calculate Cardiothoracic Ratio
• Aorta- Widening, tortuosity, calcification
• Heart valves- Calcification, valve replacements
• SVC, IVC, azygos vein- Widening, tortuosity
• Check for a widened mediastinum-  Mass lesions (eg tumour, lymph nodes), Inflammation (eg mediastinitis, granulomatous inflammation), Trauma and dissection (eg haematoma, aneurysm of the major mediastinal vessels)

1. Anemia -Persistent or severe nonmocytic anemia (in the absence of hemolysis or blood loss) -Macrocytic anemia without obvious etiology .
2. Thrombocytopenia -ITP (some cases) -Unexplained thrombocytopenia
3. Leukemia
4. Leukopenia -Some undiagnosed cases of prolonged leukopenia
5. Pancytopenia -Leukemia -Aplastic anemia -Neuroblastoma -Lymphohistiocytic disorders -Myelodysplastic syndromes
6. Malignant Solid Tumors -Diagnostic and metastatic evaluation of some solid tumors

Disorders in WhichMarrow ExaminationUsually Is Not Necessary

1. Microcytic anemias
2. Normocytic anemias dueto hemolysis or blood loss
3. Mild normocytic anemiasassociated with acute illnesses
4. Most macrocytic anemias
5. Reactive lymphocytosis
6. Storage diseases
7. Leukocytosis in the absenceof blasts or neutropenia
8. Thrombocytosis

Standarized Procedure for Bone Marrow Aspiration and cytology-

Materials required:

• 1. Lidocaine cream with occlusive dressing
• 2. 16-gauge 2-1/2 or V bone marrow needle
• 3. (3) 10ml syringes
• 4. 25-gauge needles
• 5. 20-gauge needles
• 6. 4 x 4 and 2 x 2 gauze pads
• 7. Povidone-iodine swabs
• 8. Sterile drapes
• 9. Lidocaine 1% multidose vial
• 10. Alcohol swabs
• 11. Elastoplast adhesive, or other pressure dressing
• 12. Sterile gloves

Procedure:
1. Prior to the procedure
• Obtain consent for procedure.
• Notify hematology to schedule BM tech.
• Determine and obtain appropriate type and dose of sedation and pain medications.

Schedule child for anesthesia if elective and child/adolescent have no contraindications for anesthesia.

Instruct patient/family in NPO requirements.

• Prepare the patient for the procedure:

2. Apply Lidocaine cream 1-2 hours prior to the procedure: either the staff RN
or the NP should apply the cream on the right or left iliac crest, covering an
area of approximately 3-4 cm in diameter. A transparent occlusive dressing is
then applied.

3. At the time of the procedure:
• Wash hands.
• Assemble supplies and medications, checking expiration date on BMA tray.
• Complete a time out with all elements of the preprocedure process.
• Administer sedation medications, monitoring vital signs, pulse oximetry,level of sedation.
• Remove outer wrapping from bone marrow tray using clean technique.
• Position patient in prone or side-lying position.
• Expose area for aspiration and locate posterior superior iliac crest.Remove Lidocaine from aspirate site. A towel roll or small pillow placed under the hips may allow easier location of the iliac crest.
• If necessary, a member of the nursing staff will help secure the patient’s position.
• Position the parent near the child’s head in order to more easily comfort the child during the procedure.
• Expose contents of bone marrow tray using aseptic technique.
• Put on sterile gloves.
• Swab bone marrow site with povidone-iodine swab stick, applying some friction and working in a circular motion beginning in the center and moving outward. Repeat x 2 with new swabs.
• Allow povidone-iodine to dry.
• Remove povidone-iodine with alcohol swab using concentric motion beginning in the center. Repeat with new swab x 2 (optional).
• Allow area to dry.
• Apply sterile drape.
• Draw up 2-3ml lidocaine 1% from a vial held by an assistant into a 3 ml syringe with a 22 gauge 1 ” needle.
• Location exact point for aspiration and outline area between thumb and index finger.
• Perpendicularly inject lidocaine subcutaneously and into periosteum. Avoid injecting too much and obscuring landmarks.

4. While allowing 2-3 minutes for lidocaine to take effect:
• Prepare bone marrow needle, assuring stylet moves freely.
• Prepare (2) 10ml syringes, assuring plungers move freely. Remove top from one syringe and set aside. Prepare second syringe (if needed for special studies) using 0.2ml heparin and rinsing inside of syringe. Set aside.
• Stretch skin taunt over puncture site, keeping crest between thumb and index finger of one hand.
• Holding bone marrow needle with stylet in place, puncture skin and advance through subcutaneous tissue, periosteum and into marrow cavity using a steady, controlled pressure with a twisting motion. When the needle is firmly in place and a slight give in pressure is felt, the cavity has been entered.
• Remove the stylet and quickly attach the plain syringe to the needle hub.
• Apply strong, quick suction and obtain approximately 0.5ml marrow.
• Hand syringe to the lab technician.
• Obtain other samples with heparinized syringe as needed.
• Remove needle with syringe attached with slight twisting motion.
• Maintain pressure over site approximately 2 minutes until bleeding has stopped.
• Meanwhile, remove sterile drape and cleanse povidone-iodine from skin with alcohol swab to avoid burn.
• Apply dry 2×2 gauze folded into quarters and secured with tightly stretched Elastoplast.
• Praise the patient’s cooperation.
• Inform patients / parents and child of marrow result when obtained.

5. Patient conditions requiring consultation:
• Unusual bleeding, pain or signs/symptoms of concern to the practitioner will be brought to the attention of the responsible fellow or attending physician.
• After two unsuccessful attempts by the NP, a fellow, attending or another NP will complete the procedure.

6. Patient education:
• The parents and/or patient are instructed to remove the dressing after 24 hours, observing for signs of infection, unusual bleeding, or any other drainage on the dressing. If either is noted, the practitioner should be informed. The site should be checked daily thereafter until healed for signs of infection.

• It is not unusual to feel an aching or bruised feeling for several days after the procedure. This may be relieved with a warm pack. The nurse practitioner should be notified if pain persists beyond several days or worsening pain.

V. Documentation
A. Inpatient documentation is in the UCARE procedure note and outpatient will be in the event note.
1. Documentation of the pretreatment evaluation
2. Record the time out, procedure, the outcome, patient tolerance, medications given, and the plan in the progress note.

References-

American Academy of Pediatrics Journal.

http://www.ucsfmedicalcenter.org/medstaffoffice/Standardized_Procedures/Bone%20Marrow%20Aspiration.pdf

• BodyMaps – A Human Atlas
• 3D Human Anatomy – Visible Body
• Anatomy Atlases – Atlas of Human Anatomy
• Anatomy Atlases – Atlas of Human Anatomy in Cross Section
• Anatomy Atlases – Illustrated Encyclopedia of Human Anatomic Variation
• Anatomy Atlases – Anatomy of First Aid – A Case Study Approach
• Anatomy Atlases – Lessons From a Bone Box
• Bartleby – Gray’s Anatomy
• Loyola University – Structure of the Human Body
• Mascagni – Images from Anatomia Universa | NLM – AnatLine
• State University of New York – Human Anatomy
• Temple University – Neuroanatomy Lab Resource
• Tufts University – Anatomy of the Head and Neck
• University of Michigan – Medical Gross Anatomy
• University of Michigan – Visible Human Project
• University of Utah – Neuroanatomy Atlas
• University of Utah – Visible Human
• University of Washington – Digital Anatomist
• University of Washington – Musculoskeletal Atlas
• Whitaker – Instant Anatomy
• Bridgeport Hospital – Anatomy Wiz
• Campus Medica – e-Anatomy – Interactive Atlas of Whole Body Cross-Sectional Anatomy
• Chest X-ray – Thoracic Anatomy
• Davidoff – The Common Vein
• Emory University – Radiologic Anatomy
• Harvard University – Whole Brain Atlas
• Lee – Musculoskeletal MRI Movie Atlas
• Loyola University – Cross Section Tutorial
• McGill University – Radiological Anatomy
• Society for Cardiovascular Magnetic Resonance – Cardiac MRI Anatomical Atlas
• University of Erlangen – Compare
• University of Utah – Atlases of the Brain
• University of Warsaw – Atlas of Radiological Anatomy
• University of Washington – Musculoskeletal Radiologic Anatomy Modules
• University of Washington – Radiology Anatomy Teaching Modules
• University of Washington – Muscle Atlas
• University of Wisconsin – Neuroradiology Tutor
• USUHS – Radiologic Anatomy Browser
• Wayne State University – Radiologic Anatomy
• Inner Body – Your Guide To Human Anatomy Online
• Human Anatomy – Enchanted Learning
• Department of Anatomy – University of Wisconsin Medical School
• The Anatomy Lesson
• vAnatomy – Explore the entire Human Body
• Web Anatomy – University Of Minnesota
• Instant Anatomy – Aiding Learning in Human Anatomy
• Get Body Smart – An Online Texbook for Human Anatomy and Physiology

1. Things that are hard to understand can be learned watching animations. These provide an excellent way to remember. Videos can even include mnemonics.
2. Things that cannot be imagined from text can be seen in the videos.
3. One can take online lessons via medical lectures available in the web.
4. Funny and entertaining clips also make learning a lot more enjoyable.

Completing medical education requires acquisition of vast knowledge in Basic medical sciences (Anatomy, Physiology, Biochemistry, Microbiology, Pathology, Pharmacology) and Clinical medical sciences (Medicine, Surgery, Dermatology, Psychiatry, Pediatrics, Orthopedics, etc) which is a chore unless you learn with interest, building concepts and by understanding. Educational videos aids in making such learning process effective and easier.

Medchrome Online Medical Magazine presents a new medical video blog “MedchromeTube“. Founded in 2011, MedchromeTube allows people to discover and watch medical and health videos from YouTube. MedchromeTube provides a simple platform for medical students, doctors and others related to the medical profession across the globe that makes learning process of medical science more fun and interactive.

List of Medical Videos Available:

June 2011

• [09] How to Remember the branches of External Carotid Artery (ECA)?

May 2011

• [14] Draw to Know it – Branches of Celiac Artery and Blood Supply of Stomach
• [10] Pathogenesis of Atherosclerosis : Video Animation
• [06] Baroreceptor Reflex Animation Video
• [05] Lipoprotein Metabolism : Animation video
• [03] Lecture Video: Cell Adaptation, Cell Injury and Cell Death
• [03] Tracheotomy Procedure : Animation

April 2011

• [29] Examination of Cranial Nerves III, IV, V, VI, VII, VIII, IX, X, XI and XII
• [29] 12 Lead ECG Placement Video
• [28] Fetal Circulation Explained with Video
• [26] Coronary Circulation : Anatomy Demonstration Video
• [26] Development of Heart : Embryology Video
• [25] How to draw brachial plexus : Video
• [24] Transcription and Translation : Best Animation
• [24] Hemostasis Animation Video
• [17] Mechanism of cough reflex

November 2010

• [06] Pathogenesis of AIDS and Replication of HIV
• [05] Nasal Myiasis Removal Video

October 2010

• [31] Tumorman and Pathology of Neurofibromatosis
• [20] Fate of RBC / Hemoglobin Video
• [18] Shock and its types
• [18] Gastrulation Animation Video
• [17] Muscles of Mastication Video
• [17] Muscles of the facial expression : Demonstration Video
• [17] Cranial Nerves Mnemonic Song
• [14] Biosynthesis of Protein : Translation Process Video