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Drs. Lorenzen and Barlock’s CMC X-Ray Mastery Project: May Cases

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Drs. Breeanna Lorenzen and Travis Barlock are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides. This set will cover:
Pneumonia
Lung Masses
Pulmonary Nodules
Hilar Lymphadenopathy
Aorto-enteric Fistula
Diaphragmatic Hernia
Intra-aortic Balloon Pump
Pacemaker
Impella

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Drs. Lorenzen and Barlock’s CMC X-Ray Mastery Project: May Cases

  1. 1. Adult Chest X-Rays Of The Month Travis Barlock, MD & Breeanna Lorenzen, MD Department of Emergency Medicine Carolinas Medical Center & Levine Children’s Hospital Michael Gibbs, MD - Faculty Editor Chest X-Ray Mastery Project May 2021
  2. 2. Disclosures  This ongoing chest X-ray interpretation series is proudly sponsored by the Emergency Medicine Residency Program at Carolinas Medical Center.  The goal is to promote widespread mastery of CXR interpretation.  There is no personal health information [PHI] within, and ages have been changed to protect patient confidentiality.
  3. 3. Process  Many are providing cases and these slides are shared with all contributors.  Contributors from many CMC/LCH departments, and now from EM colleagues in Brazil, Chile and Tanzania.  Cases submitted this month will be distributed next month.  When reviewing the presentation, the 1st image will show a chest X-ray without identifiers and the 2nd image will reveal the diagnosis.
  4. 4. Visit Our Website www.EMGuidewire.com For A Complete Archive Of Chest X-Ray Presentations And Much More!
  5. 5. Airway Bones Cardiac Diaphragm Effusion Foreign body Gastric Hilum
  6. 6. It’s All About The Anatomy!
  7. 7. 65-year-old male with a history of right-sided lung cancer presents with dyspnea.
  8. 8. Diagnosis: Right lower lobe pneumonia 65-year-old male with a history of right-sided lung cancer presents with dyspnea. Consolidation Infusion Port
  9. 9. 71-Year-Old Female With Several Weeks Of Back Pain And Fatigue Presents To The ED For An MRI After An Outpatient Lumbar CT Reveals An Abnormality. Diagnosis: Pathologic Fracture Of L4 With Involvement Of Adjacent Soft Tissue & The Spinal Canal.
  10. 10. 71-Year-Old Female Presents With Back Pain And Fatigue. After Reviewing The MRI, The ED Team Orders A CXR As Part Of The Carcer Work-Up.
  11. 11. 71-Year-Old Female Presents With Back Pain And Fatigue. After Reviewing The MRI, The ED Team Orders A CXR As Part Of The Carcer Work-Up. Diagnosis: Right lung mass Rounded Opacity Rounded Opacity
  12. 12. 71-Year-Old Female Presents With Back Pain And Fatigue. Histopathology: Squamous Cell Lung Cancer * * *
  13. 13. 70-year-old female presents with fatigue and diarrhea.
  14. 14. 70-year-old female presents with fatigue and diarrhea. Official Read: “Mild Bilateral Interstitial Changes.”
  15. 15. 70-year-old female presents with fatigue and diarrhea. Fluid In The Fissure Interstitial Edema What Else To You Notice?
  16. 16. 70-year-old female presents with fatigue and diarrhea. What Else To You Notice? Widened Mediastinum Markedly Enlarged Right Hilum
  17. 17. Diagnosis: Malignant Mediastinal & Hilar Adenopathy 71-Year-Old Female Presents Fatigue & Diarrhea.
  18. 18. Our Patient’s Lesion Is In The Middle Mediastinum
  19. 19. Our Patient’s Lesion Is In The Middle Mediastinum
  20. 20. 20-year-old male with testicular cancer presents with shortness of breath.
  21. 21. 20-year-old male with testicular cancer presents with shortness of breath. Diagnosis: Right Pleural Effusion (*) + Scattered Metastatic Pulmonary Nodules (Arrows). * * *
  22. 22. 57-year-old male with prior repaired aortic dissection presents with nausea and hematemesis.
  23. 23. 57-year-old male with prior repaired aortic dissection presents with nausea and hematemesis. Clinical Diagnosis: Aorto-Esophageal Fistula. Properly Positioned Aortic Endograph
  24. 24. Our patient after esophageal stenting. Properly Positioned Aortic Endograph Properly Positioned Esophageal Stent
  25. 25. Ima g es In emer g enc y medIc Ine Aortoesophageal Fistula Ryan Roten, DO Ryan Peterfy, DO Section Editor: Rick A. McPheeters, DO Submission history: Submitted; Submitted November 16, 2016; Revision received February 10, 2017; Accepted February 22, 2017 Electronically published July 6, 2017 Full text available through open access at http://escholarship.org/uc/uciem_cpcem DOI: 10.5811/cpcem.2017.2.33141 [Clin Pract Cases Emerg Med. 2017;1(3):260–261.] Desert Regional Medical Center, Department of Emergency Medicine, Palm Springs, California CASE PRESENTATION A 90-year-old female presented after sudden collapse with a Glasgow Coma Score of 3, and profound hypotension. Shortly after endotracheal intubation, the patient developed subsequently instituted. Computed tomography angiogram of the chest revealed active bleeding from an aortoesophageal blood were collected via oral gastric tube and manual suctioning by nursing staff before the resuscitation was terminated at the family’s request. DISCUSSION thoracic aortic aneurysm, foreign body ingestion, postoperative complications, and esophageal malignancy. The classic presentation of mid-thoracic chest pain and sentinel arterial hemorrhage followed by exsanguination is known as Chiari’s triad.1 asymptomatic period using endoscopy or computed tomography angiogram of the chest, survival is possible with immediate surgical intervention or endovascular stenting.2 Medical providers must be familiar with the presentation, diagnostics, rapid interruption of diagnostics and treatment of typically fatal pathology possible. Ima g es In emer g enc y medIc Ine Aortoesophageal Fistula Ryan Roten, DO Ryan Peterfy, DO Section Editor: Rick A. McPheeters, DO Submission history: Submitted; Submitted November 16, 2016; Revision received February 10, 2017; Accepted February 22, 2017 Electronically published July 6, 2017 Full text available through open access at http://escholarship.org/uc/uciem_cpcem DOI: 10.5811/cpcem.2017.2.33141 [Clin Pract Cases Emerg Med. 2017;1(3):260–261.] Desert Regional Medical Center, Department of Emergency Medicine, Palm Springs, Calif CASE PRESENTATION A 90-year-old female presented after sudden collapse with a Glasgow Coma Score of 3, and profound hypotension. Shortly after endotracheal intubation, the patient developed subsequently instituted. Computed tomography angiogram of the chest revealed active bleeding from an aortoesophageal blood were collected via oral gastric tube and manual suctioning by nursing staff before the resuscitation was terminated at the family’s request. DISCUSSION thoracic aortic aneurysm, foreign body ingestion, postoper complications, and esophageal malignancy. The classic presentation of mid-thoracic chest pain and sentinel arteria hemorrhage followed by exsanguination is known as Chia triad.1 asymptomatic period using endoscopy or computed tomog angiogram of the chest, survival is possible with immediat surgical intervention or endovascular stenting.2 Medical providers must be familiar with the presentation, diagnosti rapid interruption of diagnostics and treatment of typically fatal pathology possible. Clinical Practice and Cases in Emergency Medicine 260 Volume I, no. 3: August 2017 CASE PRESENTATION A 90-year-old female presented after sudden collapse with a Glasgow Coma Score of 3, and profound hypotension. Shortly after endotracheal intubation, the patient developed subsequently instituted. Computed tomography angiogram of the chest revealed active bleeding from an aortoesophageal blood were collected via oral gastric tube and manual suctioning by nursing staff before the resuscitation was terminated at the family’s request. DISCUSSION thoracic aortic aneurysm, foreign body ingestion, postoperative complications, and esophageal malignancy. The classic presentation of mid-thoracic chest pain and sentinel arterial hemorrhage followed by exsanguination is known as Chiari’s triad.1 asymptomatic period using endoscopy or computed tomography angiogram of the chest, survival is possible with immediate surgical intervention or endovascular stenting.2 Medical providers must be familiar with the presentation, diagnostics, rapid interruption of diagnostics and treatment of typically fatal pathology possible. Image 1. Clinical Practice and Cases in Emergency Medicine 260 Volume I, no. 3: August 2017 subsequently instituted. Computed tomography angiogram of the chest revealed active bleeding from an aortoesophageal blood were collected via oral gastric tube and manual suctioning by nursing staff before the resuscitation was terminated at the family’s request. DISCUSSION hemorrhage followed by exsanguination is known as Chiari’s triad.1 asymptomatic period using endoscopy or computed tomography angiogram of the chest, survival is possible with immediate surgical intervention or endovascular stenting.2 Medical providers must be familiar with the presentation, diagnostics, rapid interruption of diagnostics and treatment of typically fatal pathology possible. Image 1. Clinical Practice and Cases in Emergency Medicine 260 Volume I, no. 3: August 2017 blood were collected via oral gastric tube and manual suctioning by nursing staff before the resuscitation was terminated at the family’s request. DISCUSSION surgical intervention or endovascular stenting.2 Medical providers must be familiar with the presentation, diagnostics, rapid interruption of diagnostics and treatment of typically fatal pathology possible. Image 1. 1º Causes: • Thoracic aortic aneurysms • Foreign body ingestion • Esophageal malignancy • Mediastinal infections 2º Causes: • Prior aortic surgery and/or stenting Chiari’s Triad: • Mid-thoracic chest pain • Sentinel bleed followed by… • Brisk exsanguination Outcomes: • 77% mortality • 100% mortality without intervention (surgery or stenting).
  26. 26. Notice Scattered Free Air Within The Mediastinum. Our Patient Subsequently Develops Signs Of Sepsis.
  27. 27. Diagnosis: Aorto-Esophageal Fistula & Graft Infection
  28. 28. 57-year-old male with prior heart transplant presents with nausea and vomiting.
  29. 29. 57-year-old male with prior heart transplant presents with nausea and vomiting. Diagnosis: Diaphragmatic Hernia. Loops Of Bowel In The Left Chest
  30. 30. 52-Year-Old With With A History Of Cardiac Sarcoid. CXR Just Before Heart Transplant.
  31. 31. 52-Year-Old With With A History Of Cardiac Sarcoid. CXR Just Before Heart Transplant. Arrows Point To The Proximal (Red) And Distal (White) Radiopaque Markers Of The IABP
  32. 32. Intra Aortic Balloon Pump Femoral Subclavian
  33. 33. Intra Aortic Balloon Pump
  34. 34. Marker Tip Seen On CXR
  35. 35. 38-Year-Old With With Non- Ischemic Cardiomyopathy. CXR Before Heart Transplant.
  36. 36. 38-Year-Old With With Non- Ischemic Cardiomyopathy. CXR Before Heart Transplant. Arrows Points To The Radiopaque Markers Of The intra-aortic balloon pump
  37. 37. 62-Year-Old With Ischemic Cardiomyopathy. CXR Just Prior To Orthotopic Heart Transplant.
  38. 38. 62-Year-Old With Ischemic Cardiomyopathy. CXR Just Prior To Orthotopic Heart Transplant. Defibrillator Defibrillator coil Impella™
  39. 39. Impella™  Percutaneous femoral artery access – device advanced into the left ventricle (LV)  LV blood drawn into the pump and released across the valve in the proximal aorta  Aortic flow rates up to 5.0 liters/minute  Increases cardiac output & coronary perfusion and decreases myocardial O2 consumption
  40. 40. Impella™
  41. 41. 62-Year-Old With Ischemic Cardiomyopathy. CXR Just Prior To Orthotopic Heart Transplant. Impella™ Inflow Impella™ Outflow
  42. 42. 62-Year-Old With Ischemic Cardiomyopathy. CXR Just Prior To Orthotopic Heart Transplant. Impella™ Blood Flow Directed Up The Aorta
  43. 43. 62-Year-Old With Ischemic Cardiomyopathy. CXR One Week After Transplant!
  44. 44. Summary Of Diagnoses This Month  Pneumonia  Lung masses  Pulmonary nodules  Hilar lymphadenopathy  Aorto-enteric fistula and graft infection  Diaphragmatic hernia  Intra-aortic balloon pumps  Pacemaker and ICD  Impella™ Assist Devices
  45. 45. See You Next Month!

Drs. Breeanna Lorenzen and Travis Barlock are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides. This set will cover: Pneumonia Lung Masses Pulmonary Nodules Hilar Lymphadenopathy Aorto-enteric Fistula Diaphragmatic Hernia Intra-aortic Balloon Pump Pacemaker Impella

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