POSITION PA AP QUALITY ROTATION PENETRATION INSPIRATION LESIONOPACIT OPACITY Homo Heterogenous Wellill defined Zone Centralperipher Silhouet sign al Y Necrotic PATCHY HILUMMEDIASTINAL NODULE Central deviasionwided MASS COSTO-PHRENIC ANGEL Freeoblitern CAVITARY OTHERINFILTIRATION Bone soft tissuediaphragm
Solitary Pulmonary Nodule(SPN) Appearance Margin Calcification cavitation Comparison with a Size previous x-ray to >8mm <8mm Assess growth over time. Location Upperhillar zone Lowerbasesup-pleural Associated abnormalitiesLymph node enlargement Rib destruction/erosion
Cavitary lesion Air + Air-fluid level Air onlytissue Wall thickness Straight Wavy Thick Thin 1. Fungal ball. 2. Rupture hydatid cyct site 3. Necrotic tumor ruptured 4. Blood glot Hydatid Abscess Irregular Regular Peripheral Central inner wall inner wall cyst Emphesemato Cavitating Chronic us pneumatoc neoplasm abscess ele bulla
LINEAR PATTERN LINEAR PATTERNLEFT VENTRICULAR FAILURE Perihilar and peripheral basal septal lines, changes acutely and resolves with diureticsNormal ageing Coarsening of lung markings in lower zones, no change on review of recent filmsLymphangitis Coarse nodular and linear thickening of markings, known malignancy, often associated with pleural effusion, rapid clinical deterioration of patient
LINEAR PATTERN LINEAR PATTERNAtelectasis Short thin lines, often basal, new on review of previous filmsSubsegmental Longer thicker bands, often perihilar or basal,collapse suggest recent infection or infarctionScarring Any length, persist over time unchangedFibrosis Volume loss is key, persists over time
Causes of fibrosis Mid zone lung Lower zone lung Upper zone lungtuberculosis Drug indused fibrosis sarcoidosis (most common)Chronic extrinsic allergic UIPalveolitisRadio-therapy Asbestose-related fibrosisAnkylosing spondylitisProgressive massivefibrosishistoplasmosis
CASE-1• A 50-year-old male smoker is evaluated for chronic shortness of breath.• On physical examination his vital signs are: – pulse 110 bpm; – Temperature normal; – respirations 30/min with use of accessory muscles and pursed-lip breathing; – blood pressure 110/78 mm Hg.• Other pertinent findings are: – heart exam: apex beat (impulse) is medial to the mid-clavicular line – generalized decreased breath sounds on lung exam;• ABGs (FiO2 0.21): – pH 7.38; PCO2 47 mm Hg; PO2 67 mm Hg.• PFTs/spirometry: – FVC 2.80 L (67% of predicted); – FEV1 1.56 (50% of predicted); – FEV1/FVC% 56%; – TLC 134% of predicted; – RV 170% of predicted; – DLCO 43% of predicted. – There is no reversibility with bronchodilators.
POSITION •PA CXRQUALITY •Good Technical Quality •Bilateral linar (vascular)infitration . •Laminar opacity from right hilum.LESION •Hyper-lucency area at lower right zone.MEDIASTINALHilum •Central trachea and mediasteinal. •Dangle heart.ANGELS •Hazy left angleirregular diaphragm(flat) •NoOTHER
CASE-1• 1. What is the most likely diagnosis?• a. Bronchial asthma with status asthmaticus• b. Emphysema• c. Chronic bronchitis• d. Tuberous sclerosis• 2. Associated with the above condition is• a. Obstructive sleep apnea• b. Increased IgE levels• c. Respiratory failure with increased A-aDO2 gradient• d. Clubbing
CASE-2• A 38-year-old man is admitted with progressive shortness of breath• and cough.• He denies any fever, chills, or purulent sputum production.• He wants to be evaluated to determine the reasons for his symptoms.• On exam, he is afebrile and has decreased breath sounds with hyper- resonant upper lung field more obvious on the right.• ABGs on RA: pH 7.35; PCO2 38mm Hg; PO2 78 mm Hg.• Spirometry: – (FVC) 1.72 (70% of predicted); – (FEV1)1.34 L (60% of predicted); – FEV1/FVC% 76%; – TLC 4.1 L (100% of predicted); – TLC by helium dilution method 3.4 (71%); – DLCO 70% of predicted. – There is no bronchodilator response.
POSITION •PA CXRQUALITY •Poor Technical Quality •Large bulla extend at right upper and middle zone.LESION •Vascular marking crowded at lower zone. •Hyperlucensy area at left upper zone.MEDIASTINALHilum •Central trachea and mediasteinal.ANGELS •Free •NoOTHER
CASE-2• 1. What is the most likely diagnosis?• a. Severe emphysema• b. Bulla• c. Pneumothorax• d. Bronchiectasis• 2. What is the next management option?• a. Place a chest tube urgently• b. Increase bronchodilator dosage and frequency• c. Start chest physical therapy• d. Perform CT scan of chest
CASE-3• A 39-year-old man, a smoker since age 16, is seen in the clinic with complaints of fever, cough, and production of yellowish sputum.• He has been chronically short of breath, but these symptoms have increased over the last week after he developed a flulike illness.• On exam, he is febrile and looks ill.• Lung exam reveals diffuse wheezing with egophony and whispering pectoriloquy on the right side.• ABGs show PO2 of 55 mm Hg on room air,• sputum is negative for TB.
POSITION •PA CXRQUALITY •Poor Technical Quality •Multiple air-fluid level at right middle zone.LESION •Area of hyperlucensy at right and left upper zone.MEDIASTINALHilum •Central trachea and mediasteinal.ANGELS •Free •NoOTHER
CASE-3• 1. The next step in the management of this patient would be• a. Arrange with intervention radiology to do a needle aspiration• b. Consult thoracic surgery for lung reduction surgery• c. Start antibiotic and O2 therapy• d. Admit patient in an isolation room• 2. Appropriate measures at the first follow-up should include• a. Pneumococcal and influenza vaccine• b. Allergy testing• c. Detailed occupational history• d. Genetic counseling
CASE-4• A 31-year-old African American man is admitted with increasing cough, fever, and sputum production.• He gives a history of repeated infections and “pneumonias” since childhood.• Lung exam reveals: – diffuse rhonchi – bilateral crackles, more so in the left lung field.• Routine labs are normal except for a poly- morphonuclear leuko-cytosis.
POSITION •PA CXRQUALITY •Poor Technical Quality •Bilateral nodulo-reticular pattern crowded at lower,middle zone and cyct-LESION like apperance.MEDIASTINALHilum •Central trachea and mediasteinal.ANGELS •Free •NoOTHER
CASE-4• 1. What is the most likely diagnosis?• a. Bronchiectasis• b. Cystic fibrosis• c. Sarcoidosis• d. Allergic bronchopulmonary aspergillosis• 2. What is the next management option?• a. Bronchoscopy• b. Steroid Rx• c. Antibiotics and postural drainage• d. Surgical consult
DISCUSSION• The history is suggestive of bronchiectasis, and the bilateral cystic-appearing lesions on the CXR are consistent with that diagnosis.• Cystic fibrosis is generally predominant in the upper zone.• Sarcoidosis rarely presents with this history, and the fibrotic changes in sarcoidosis are usually in the upper lobes.• Allergic bronchopulmonary aspergillosis is seen with an underlying asthmatic condition.
CASE-5• A 24-year-old male law student presents with a 3-wk history of increasing dyspnea.• He has a history of chronic sputum production of about 100 cc of purulent material each day for many years.• In the past, he was hospitalized for a left pneumothorax.• He is on inhaled bronchodilator as an outpatient.
POSITION •PA CXRQUALITY •Good Technical Quality •Bilateral cyct-like opacity apperance. •At middle zone near hilum and extendLESION to left upper zone (fibrosis).MEDIASTINALHilum •Central trachea and mediasteinal.ANGELS •Freeflated diaphragm. •NoOTHER
CASE-5• 1. Physical exam will most likely show• a. Clubbing• b. Koilonychia• c. Oncholysis• d. Pectus excavatum• 2. Spirometry will most likely show• a. FVC 60%; FEV1 40%; ratio 66%• b. FVC 60%; FEV1 62%; ratio 90%• c. Normal• d. Normal except mild decrease in FEF25–75• 3. The most helpful treatment option would be• a. Increase bronchodilator therapy• b. Start broad-spectrum antibiotic therapy• c. Initiate anti-pseudomonas antibiotic regimen• d. Start oral steroids
DISCUSSION• The history and chest x-ray are consistent with cystic fibrosis with bilateral cystic upper zone predominance.• Physical exam would reveal clubbing; spirometry would show a mixed obstructive with restrictive picture.• The best option would be to initiate anti- pseudomonas antibiotics.
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