Anwser,s    Dr :ANAS SAHLE   1. Chest xr cases. 2. Chest clinical case.   3. Chest ct cases.    4. MRCP exam.:http://www.f...
chest xr cases   Dr :anas sahle http://www.facebook.com/dranas224
Cxr-18         Diagnosis is:??
Cxr-18                                                                           Diagnosis is:??S Curve of GoldenWhen ther...
Cxr-19         SIGN NAME IS:…
Cxr-19                                                                              SIGN NAME IS:…                        ...
Cxr-20         Acinar or interstitial nodules?         Name DDX:…….
Cxr-20         Acinar Nodules         DDX:         1. ALVEOLAR CELL CARCINOMA         2. PULMONARY EDEMA         3. ALVEOL...
Cxr-21         DDX:???
Cxr-22this sign name is:….
Cxr-22this sign name is: Inverted Comma                                    This is an example of an azygous lobe
Cxr-23
Cxr-23Mass density is seen in the lateral view, but not in the PA view .This finding suggests a chest wall or external pro...
Cxr-24         DDX:…
Cxr-24           DDX:…         1. Dilated esophagus         2. Paravertebral             nodes         3. Osteophytes     ...
CXR-25Name which anatomic lobe affect when silhoutte sign obscured :                       ABCDEF
CXR-25                                 Silhouette     Adjacent Lobe/Segment                        Right diaphragm       R...
Saturday, December 15, 2012
chest clinical cases A 27-Year-Old With a Non-  Resolving Cavitary Lung           LesionSubmitted byLokesh Venkateshaiah, ...
History•   A 27-year-old man presented to the pulmonary clinic for evaluation of a non-resolving lung    cavity.•   Four m...
Physical Exam• The patient appeared comfortable and was in no acute  distress.• Vital signs were unremarkable.• The cardia...
Lab• White blood cell count was 10,000 per mm3 with  66% Neutrophils, 14% Lymphocytes and 12%  eosinophils• Hematocrit 49%...
Chest computed tomography4 months prior to current presentation                             Saturday, December 15, 2012
at presentation(4 months following initiation of antituberculous therapy)                                              Sat...
Question 1• What is the diagnosis?•   A. Pulmonary tuberculosis•   B. Acute Bronchitis•   C. Paragonimiasis•   D. Schistos...
•   Cysts for Paragonimus were identified on BAL and transbronchial biopsy.•   Paragonimiasis is caused by lung flukes of ...
Question 2•   How do humans acquire Paragonimiasis?•   A. Inhalation•   B. Ingestion•   C. Innoculation•   D. Inconclusive...
life cycle             Saturday, December 15, 2012
Question 3• What is the drug of choice in the treatment  of Paragonimus westermani?• A. Peptobismol• B. Cipro• C. Praziqua...
Treatment• Praziquantel is the drug of choice to treat  paragonimiasis.• The recommended dosage of 75 mg/kg per day  orall...
Saturday, December 15, 2012
chest ct cases-5    Dr :anas sahle  http://www.facebook.com/dranas224
HRCT-1
HRCT-1•   What is the major abnormality in this case?•   a) Linear opacities•   b) Nodules•   c) Consolidation•   d) Groun...
HRCT-1• What is the distribution of the lesions?•   a) Bronchovascular interstitium•   b) Interlobular septa•   c) Centril...
HRCT-1
HRCT-1• Find multiple, connected, thickened  interlobular septa in the right lung.• Find an example of thickened bronchova...
HRCT-1
HRCT-2
HRCT-2• Find the thickened fissural pleura in the right  lung.• Find 2 lobules with thickened interlobular  septa and cent...
HRCT-2
Differential diagnosis• Differential diagnosis of thickened  bronchovascular, interlobular septal, and  pleural interstiti...
Differential diagnosis• Differential diagnosis of thickened  bronchovascular, interlobular septal, and  pleural interstiti...
DiagnosisLymphangitic tumor
SummarySummary of diagnostic features of lymphangitic tumor on  HRCT:• Thickening of      • bronchovascular,      • interl...
Saturday, December 15, 2012
MRCP EXAM  Respiratory                12/15/2012
Q1• Regarding community acquired pneumonia  in infancy:A -Streptococcus pneumoniae is the most  common pathogen.B- It may ...
A1• Regarding community acquired pneumonia  in infancy:A -Streptococcus pneumoniae is the most common  pathogen. (False)B-...
Q2• The following are true of cystic fibrosis:A -Infertility in men is a result of testicular atrophy.B- In children under...
A2• The following are true of cystic fibrosis:A -Infertility in men is a result of testicular atrophy. (False)B- In childr...
Q3• The following are recognised complications  of foreign body inhalation:A- Pulmonary abscessB- AsthmaC- Angioneurotic o...
A3• The following are recognised complications  of foreign body inhalation:A- Pulmonary abscess (True)B- Asthma (False)C- ...
Q4• Which of the following statements are true of  childhood asthma.A- over 90% of patients show exercise-induced  broncho...
A4• Which of the following statements are true of  childhood asthma.A- over 90% of patients show exercise-induced  broncho...
Q5• Regarding inhaler devices:A- Metered dose inhalers can usually be used  from the age of about 7 years.B- The Spinhaler...
A5• Regarding inhaler devices:A- Metered dose inhalers can usually be used from  the age of about 7 years. (False)B- The S...
Q6• Concerning Cystic Fibrosis:A- There is a carrier frequency of 1/220 in the  general population.B- A sibling of an affe...
A6• Concerning Cystic Fibrosis:A- There is a carrier frequency of 1/220 in the  general population. (False)B- A sibling of...
Q7• Hypoxaemic respiratory failure (Type I):A- Can be caused by respiratory muscle  weakness and fatigue.B- Is found in mo...
A7• Hypoxaemic respiratory failure (Type I):A- Can be caused by respiratory muscle  weakness and fatigue. (False)B- Is fou...
Q8• Regarding idiopathic primary pulmonary  haemosiderosis:A- It is inherited as an autosomal recessive.B- The absence of ...
A8• Regarding idiopathic primary pulmonary  haemosiderosis:A- It is inherited as an autosomal recessive. (False)B- The abs...
Q9• Which of the following may cause  pulmonary hypertension?• A- coarctation of the aorta• B- pulmonary stenosis• C- pate...
A9• Which of the following may cause  pulmonary hypertension?• A- coarctation of the aorta (False)• B- pulmonary stenosis ...
Q10• Frequent episodic asthma:• A- Is suffered by 42% of all children with  asthma.• B- Is defined as an attack rate of ev...
A10• Frequent episodic asthma:• A- Is suffered by 42% of all children with asthma.  (False)• B- Is defined as an attack ra...
Comments:•   Types of chronic asthma include:•   Infrequent episodic asthma: affects 75% of asthmatic children, with    ...
Saturday, December 15, 2012
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Anwser,s6

  1. 1. Anwser,s Dr :ANAS SAHLE 1. Chest xr cases. 2. Chest clinical case. 3. Chest ct cases. 4. MRCP exam.:http://www.facebook.com/dranas224 Saturday, December 15, 2012
  2. 2. chest xr cases Dr :anas sahle http://www.facebook.com/dranas224
  3. 3. Cxr-18 Diagnosis is:??
  4. 4. Cxr-18 Diagnosis is:??S Curve of GoldenWhen there is a mass adjacent to a fissure, the fissure takes the shape of an "S".The proximal convexity is due to a mass, and the distal concavity is due to atelectasis.Note the shape of the left oblique fissure in the lateral view below.This example represents a LUL mass with atelectasis.
  5. 5. Cxr-19 SIGN NAME IS:…
  6. 6. Cxr-19 SIGN NAME IS:… Wedge ShapedThis case Densityrepresents apulmonary infarct.Wedge Shaped DensityThe wedges base is pleural and the apex is towards the hilum, giving a triangular shape.You can encounter either of the following:Vascular wedges: Infarct Invasive aspergillosisBronchial wedges: Consolidation Atelectasis
  7. 7. Cxr-20 Acinar or interstitial nodules? Name DDX:…….
  8. 8. Cxr-20 Acinar Nodules DDX: 1. ALVEOLAR CELL CARCINOMA 2. PULMONARY EDEMA 3. ALVEOLAR PROTEINOSIS
  9. 9. Cxr-21 DDX:???
  10. 10. Cxr-22this sign name is:….
  11. 11. Cxr-22this sign name is: Inverted Comma This is an example of an azygous lobe
  12. 12. Cxr-23
  13. 13. Cxr-23Mass density is seen in the lateral view, but not in the PA view .This finding suggests a chest wall or external problem.In the film below, an amputated shoulder is projecting as a mass.
  14. 14. Cxr-24 DDX:…
  15. 15. Cxr-24 DDX:… 1. Dilated esophagus 2. Paravertebral nodes 3. Osteophytes This example is due to paravertebral nodes.
  16. 16. CXR-25Name which anatomic lobe affect when silhoutte sign obscured : ABCDEF
  17. 17. CXR-25 Silhouette Adjacent Lobe/Segment Right diaphragm RLL/Basal segments Right heart margin RML/Medial segment Ascending aorta RUL/Anterior segment Aortic knob LUL/Posterior segment Left heart margin Lingula/Inferior segment LLL/Superior and medialA: Ascending aorta Descending aorta segmentsB: Left heart margin Left diaphragm LLL/Basal segmentsC: Left diaphragmD: Aortic knobE: Right heart marginF: Right diaphragm
  18. 18. Saturday, December 15, 2012
  19. 19. chest clinical cases A 27-Year-Old With a Non- Resolving Cavitary Lung LesionSubmitted byLokesh Venkateshaiah, MDFellowDivision of Pulmonary, Critical Care and Sleep MedicineCase Western Reserve UniversityCleveland, OhioJ. Daryl Thornton, MD MPHAssistant ProfessorDivision of Pulmonary, Critical Care and Sleep MedicineCase Western Reserve UniversityCleveland, Ohio
  20. 20. History• A 27-year-old man presented to the pulmonary clinic for evaluation of a non-resolving lung cavity.• Four months earlier, he had been diagnosed with pulmonary tuberculosis and was started on four-drug anti-tuberculous directly observed therapy.• A PPD placed at that time measured 22 mm of induration.• During the pulmonary clinic visit, the patient stated that over the last year and a half he had a cough occasionally productive of minimal blood-streaked sputum.• He had denied other symptoms including nocturnal diaphoresis, anorexia, weight loss, or fevers.• The patient’s past medical history was remarkable for an abnormal chest radiogram that was noted one and a half years ago and one episode of malaria.• Other than his recent antituberculous therapy he took no regular medications.• He smoked one-half pack daily for the past 12 years.• He occasionally snorted cocaine but did not use alcohol or other recreational drugs.• He emigrated from Malaysia to the United States 8 months ago.• He was originally from Burma but was a refugee in Malaysia.• It was in Malaysia that he was noted to have an abnormal chest radiogram.• He underwent additional investigations while there but was not given a diagnosis nor treatment. Saturday, December 15, 2012
  21. 21. Physical Exam• The patient appeared comfortable and was in no acute distress.• Vital signs were unremarkable.• The cardiac exam demonstrated regular rate and rhythm, a normal S1 and S2, and no murmur, gallop or rub.• Breath sounds were equal bilaterally and absent of adventitious sounds.• The abdomen was soft and without organomegaly.• The patient’s extremities were without clubbing or edema.• There was a scar on the left upper arm from a prior BCG injection.• No other skin lesions were noted. Saturday, December 15, 2012
  22. 22. Lab• White blood cell count was 10,000 per mm3 with 66% Neutrophils, 14% Lymphocytes and 12% eosinophils• Hematocrit 49%• Platelet count was 309,000 per mm3• Urea nitrogen was 12 mg /dl, and serum creatinine was 0.7 mg/dl• Liver function tests were within normal limits• Stools and sputum for ova and parasites were negative• Sputum for AFB times five was negative Saturday, December 15, 2012
  23. 23. Chest computed tomography4 months prior to current presentation Saturday, December 15, 2012
  24. 24. at presentation(4 months following initiation of antituberculous therapy) Saturday, December 15, 2012
  25. 25. Question 1• What is the diagnosis?• A. Pulmonary tuberculosis• B. Acute Bronchitis• C. Paragonimiasis• D. Schistosomiasis Saturday, December 15, 2012
  26. 26. • Cysts for Paragonimus were identified on BAL and transbronchial biopsy.• Paragonimiasis is caused by lung flukes of the genus Paragonimus.• There are 43 species of Paragonimus, 12 of which infect humans.• Paragonimus westermani is the most prevalent, especially in eastern and Southeast Asia.• Infection with these organisms occurs worldwide but predominantly in several parts of Central and South America, West Africa, and Asia (1).• In the United States, the disease is diagnosed most commonly in immigrants from endemic countries (2).• Endogenous infections do occur and usually are caused by Paragonimus kellicot mainly in the midwestern and eastern United States (3-6).• Pulmonary tuberculosis is less likely given several negative sputum AFB stains and cultures.• Alveolar lavage by bronchoscopy elso exhibited negative AFB stain and culture.• In addition, the cavitation worsened on computed tomography despite receiving multidrug direct observed therapy.• Acute bronchitis is not a common cause of pulmonary cavitation.• Pulmonary manifestations of chronic schistosomiasis are generally found in patients with a heavy infectious burden and significant clinical symptoms.• Schistozome eggs may embolize from the liver to the pulmonary circulation where they may lead to granulomatous endarteritis, pulmonary hypertension, and cor pulmonale. Saturday, December 15, 2012
  27. 27. Question 2• How do humans acquire Paragonimiasis?• A. Inhalation• B. Ingestion• C. Innoculation• D. Inconclusive Saturday, December 15, 2012
  28. 28. life cycle Saturday, December 15, 2012
  29. 29. Question 3• What is the drug of choice in the treatment of Paragonimus westermani?• A. Peptobismol• B. Cipro• C. Praziquantel• D. Albendazole Saturday, December 15, 2012
  30. 30. Treatment• Praziquantel is the drug of choice to treat paragonimiasis.• The recommended dosage of 75 mg/kg per day orally, divided into 3 doses over 2 days has proven to eliminate P. westermani in adults and children .• Praziquantel should be taken with liquids during a meal.• Patients with chronic empyema due to paragonimiasis may require decortication in addition to anthelmintic treatment . Saturday, December 15, 2012
  31. 31. Saturday, December 15, 2012
  32. 32. chest ct cases-5 Dr :anas sahle http://www.facebook.com/dranas224
  33. 33. HRCT-1
  34. 34. HRCT-1• What is the major abnormality in this case?• a) Linear opacities• b) Nodules• c) Consolidation• d) Ground-glass opacity• 2. Which lung is involved?• a) Left• b) Right• c) Both
  35. 35. HRCT-1• What is the distribution of the lesions?• a) Bronchovascular interstitium• b) Interlobular septa• c) Centrilobular region• d) Pleura
  36. 36. HRCT-1
  37. 37. HRCT-1• Find multiple, connected, thickened interlobular septa in the right lung.• Find an example of thickened bronchovascular interstitium in the right lung.• Find 2 examples of polygonal lobules with centrilobular nodules in the right lung.
  38. 38. HRCT-1
  39. 39. HRCT-2
  40. 40. HRCT-2• Find the thickened fissural pleura in the right lung.• Find 2 lobules with thickened interlobular septa and centrilobular nodules in the right lung.• Find an example of thickened bronchovascular interstitium in the right lung.
  41. 41. HRCT-2
  42. 42. Differential diagnosis• Differential diagnosis of thickened bronchovascular, interlobular septal, and pleural interstitium on HRCT:……..
  43. 43. Differential diagnosis• Differential diagnosis of thickened bronchovascular, interlobular septal, and pleural interstitium on HRCT: • Lymphangitic tumor, • Lymphoma. • Kaposis sarcoma. • edema.• The uni-laterality would be very unusual for Kaposis sarcoma or edema.
  44. 44. DiagnosisLymphangitic tumor
  45. 45. SummarySummary of diagnostic features of lymphangitic tumor on HRCT:• Thickening of • bronchovascular, • interlobular septal, • centrilobular, and • pleural interstitium• Smooth or nodular thickening• Lack of architectural distortionComment:• Unilateral lymphangitic tumor is most commonly seen in cases of primary pulmonary adenocarcinoma, as in this case.
  46. 46. Saturday, December 15, 2012
  47. 47. MRCP EXAM Respiratory 12/15/2012
  48. 48. Q1• Regarding community acquired pneumonia in infancy:A -Streptococcus pneumoniae is the most common pathogen.B- It may be caused by Staphylococcus aureus.C- Ciprofloxacin is an appropriate treatment if blood cultures are negative.D- Bordatella pertussis infection is usually mild.E- It may be caused by mycoplasma urealiticum. 12/15/2012
  49. 49. A1• Regarding community acquired pneumonia in infancy:A -Streptococcus pneumoniae is the most common pathogen. (False)B- It may be caused by Staphylococcus aureus. (True)C- Ciprofloxacin is an appropriate treatment if blood cultures are negative. (False)D- Bordatella pertussis infection is usually mild. (False)E- It may be caused by mycoplasma urealiticum. (True) 12/15/2012
  50. 50. Q2• The following are true of cystic fibrosis:A -Infertility in men is a result of testicular atrophy.B- In children under one year of age the commonest cause of pneumonia is Staphylococcus.C -10% of patients will not require pancreatic enzyme supplementation.D -In neonates 10 - 10% present with meconium ileus.E -In the school age child, it usually presents with hepatic fibrosis. Saturday, December 15, 2012
  51. 51. A2• The following are true of cystic fibrosis:A -Infertility in men is a result of testicular atrophy. (False)B- In children under one year of age the commonest cause of pneumonia is Staphylococcus. (False)C -10% of patients will not require pancreatic enzyme supplementation. (True)D -In neonates 10 - 10% present with meconium ileus. (True)E -In the school age child, it usually presents with hepatic fibrosis. (False) Saturday, December 15, 2012
  52. 52. Q3• The following are recognised complications of foreign body inhalation:A- Pulmonary abscessB- AsthmaC- Angioneurotic oedemaD- Hyperinflation of the affected lungE- Hyperinflation of the opposite lung Saturday, December 15, 2012
  53. 53. A3• The following are recognised complications of foreign body inhalation:A- Pulmonary abscess (True)B- Asthma (False)C- Angioneurotic oedema (False)D- Hyperinflation of the affected lung (True)E- Hyperinflation of the opposite lung (True) Saturday, December 15, 2012
  54. 54. Q4• Which of the following statements are true of childhood asthma.A- over 90% of patients show exercise-induced bronchoconstrictionB- hypercapnia is the first physiological disturbance in status asthmaticusC- infants are unresponsive to bronchodilatorsD- spontaneous cure occurs before adolescenceE- cough may be the only symptom Saturday, December 15, 2012
  55. 55. A4• Which of the following statements are true of childhood asthma.A- over 90% of patients show exercise-induced bronchoconstriction (True)B- hypercapnia is the first physiological disturbance in status asthmaticus (False)C- infants are unresponsive to bronchodilators (True)D- spontaneous cure occurs before adolescence (False)E- cough may be the only symptom (True) Saturday, December 15, 2012
  56. 56. Q5• Regarding inhaler devices:A- Metered dose inhalers can usually be used from the age of about 7 years.B- The Spinhaler requires co-ordination of device actuation with inhalation.C- The Turbohaler can usually be used from about 3 years of age.D- Salbutamol can be used with the Nebuhaler.E- A face mask can be attached to a spacer, so that it can be used in infants. Saturday, December 15, 2012
  57. 57. A5• Regarding inhaler devices:A- Metered dose inhalers can usually be used from the age of about 7 years. (False)B- The Spinhaler requires co-ordination of device actuation with inhalation. (False)C- The Turbohaler can usually be used from about 3 years of age. (True)D- Salbutamol can be used with the Nebuhaler. (False)E- A face mask can be attached to a spacer, so that it can be used in infants. (True) Saturday, December 15, 2012
  58. 58. Q6• Concerning Cystic Fibrosis:A- There is a carrier frequency of 1/220 in the general population.B- A sibling of an affected individual has a 2/3 chance of being a carrier.C- It can usually be diagnosed antenatally in a family with a surviving affected member.D- Linkage disequilibrium probes may be useful in epidemiological studies.E- In suspected cases, the sweat test is the most appropriate first investigation. Saturday, December 15, 2012
  59. 59. A6• Concerning Cystic Fibrosis:A- There is a carrier frequency of 1/220 in the general population. (False)B- A sibling of an affected individual has a 2/3 chance of being a carrier. (False)C- It can usually be diagnosed antenatally in a family with a surviving affected member. (True)D- Linkage disequilibrium probes may be useful in epidemiological studies. (True)E- In suspected cases, the sweat test is the most appropriate first investigation. (True) Saturday, December 15, 2012
  60. 60. Q7• Hypoxaemic respiratory failure (Type I):A- Can be caused by respiratory muscle weakness and fatigue.B- Is found in mountain sickness.C- Can lead to pulmonary hypertension.D- Can lead to CO retention if treated with 2 100% oxygen.E- Can lead to ventricular failure. Saturday, December 15, 2012
  61. 61. A7• Hypoxaemic respiratory failure (Type I):A- Can be caused by respiratory muscle weakness and fatigue. (False)B- Is found in mountain sickness. (True)C- Can lead to pulmonary hypertension. (True)D- Can lead to CO retention if treated with 2 100% oxygen. (False)E- Can lead to ventricular failure. (True) Saturday, December 15, 2012
  62. 62. Q8• Regarding idiopathic primary pulmonary haemosiderosis:A- It is inherited as an autosomal recessive.B- The absence of digital clubbing is usual.C- Fever is generally absent.D- Patients usually have associated polycythaemia.E- There is often immunoglobulin of complement deposition in the histology of lung biopsies. Saturday, December 15, 2012
  63. 63. A8• Regarding idiopathic primary pulmonary haemosiderosis:A- It is inherited as an autosomal recessive. (False)B- The absence of digital clubbing is usual. (False)C- Fever is generally absent. (False)D- Patients usually have associated polycythaemia. (False)E- There is often immunoglobulin of complement deposition in the histology of lung biopsies. (False) Saturday, December 15, 2012
  64. 64. Q9• Which of the following may cause pulmonary hypertension?• A- coarctation of the aorta• B- pulmonary stenosis• C- patent ductus arteriosus• D- kyphoscoliosis• E- schistosomiasis Saturday, December 15, 2012
  65. 65. A9• Which of the following may cause pulmonary hypertension?• A- coarctation of the aorta (False)• B- pulmonary stenosis (False)• C- patent ductus arteriosus (True)• D- kyphoscoliosis (True)• E- schistosomiasis (True) Saturday, December 15, 2012
  66. 66. Q10• Frequent episodic asthma:• A- Is suffered by 42% of all children with asthma.• B- Is defined as an attack rate of ever 2-4 months.• C- Should be treated with inhaled regular prophylactic therapy, such as inhaled steroids.• D- Is characterised by normal growth rate.• E- Usually requires a burst of oral steroids to bring under control. Saturday, December 15, 2012
  67. 67. A10• Frequent episodic asthma:• A- Is suffered by 42% of all children with asthma. (False)• B- Is defined as an attack rate of ever 2-4 months. (False)• C- Should be treated with inhaled regular prophylactic therapy, such as inhaled steroids. (True)• D- Is characterised by normal growth rate. (True)• E- Usually requires a burst of oral steroids to bring under control. (False) Saturday, December 15, 2012
  68. 68. Comments:• Types of chronic asthma include:• Infrequent episodic asthma: affects 75% of asthmatic children, with fewer than 4 episodes per• year. Intermittent bronchodilators are given.• Frequent episodic asthma: 20%, symptoms 2-4 weekly. Low dose inhaled prophylactic therapy• plus intermittent bronchodilator.• Persistent asthma: 5%, high dose inhaled prophylaxis plus intermittent bronchodilators ± longacting• bronchodilators such as salmeterol. These children need regular monitoring in an asthma• clinic and recording of growth and asthma diary.• Exercise-induced: pre-exercise bronchodilator. The British Asthma Society Guidelines have• recently been updated (1997), and you are strongly advised to familiarise yourself with the step• up and step down approach. Saturday, December 15, 2012
  69. 69. Saturday, December 15, 2012
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