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Adult Chest X-Rays Of The Month
Alyssa Thomas MD & Claire Milam MD
Department of Emergency Medicine
Carolinas Medical Cent...
Disclosures
 This ongoing chest X-ray interpretation series is proudly sponsored by the
Emergency Medicine Residency Prog...
Process
 Many are providing cases and these slides are shared with all contributors.
 Contributors from many CMC/LCH dep...
Visit Our Website
www.EMGuidewire.com
For A Complete Archive Of Chest X-Ray Presentations And Much More!
Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum
It’s All About The Anatomy!
Healthy 20-Year-
Old Male Seen At
His PCP’s Office
Where This Chest
X-Ray Was
Obtained.
Healthy 20-Year-
Old Male Seen At
His PCP’s Office
Where This Chest
X-Ray Was
Obtained:
Diagnosed With
RLL Pneumonia.
Rx: ...
The Patient Presents To The ED 24 Hours Later With Cough + Persistent Tachycardia & Hypoxia.
The Patient Presents To The ED 24 Hours Later With Cough + Persistent Tachycardia & Hypoxia.
Worsening Pneumonia Despite T...
ED Rx: Azithromycin + Ceftriaxone & Admitted.
The Patient Presents To The ED 24 Hours Later With Cough + Persistent Tachyc...
Serology [+] For Mycoplasma.
The Patient Was Initially Treated
With Ceftriaxone In The Office And
Prescribed Amoxicillin-Clavulanate.
Is This An Approp...
The Patient Was Initially Treated
With Ceftriaxone In The Office And
Prescribed Amoxicillin-Clavulanate.
Is This An Approp...
This Represents A Change From The 2007 IDSA/ATS Guidelines.
“In a departure from the prior CAP guidelines, the panel did not give a strong
recommendation for routine use of a macroli...
A Complete Summary Of The 2019
IDSA/ATS Guidelines For The
Management of Community Acquired
Pneumonia Are Included At The ...
65-Year-Old Traveling Through Charlotte Presents From The Airport With Dyspnea.65-Year-Old Traveling Through Charlotte Pre...
65-Year-Old Traveling Through Charlotte Presents From The Airport With Dyspnea.65-Year-Old Traveling Through Charlotte Pre...
Thoracic Aortic Aneurysm: 58 x 54 mm Maximal Diameter
65-Year-Old Traveling Through Charlotte
75-Year-Old Has A Routine Pre-Operative Chest X-Ray
Thoracic Endovascular Aortic Repair [TEVAR]
75-Year-Old Has A Routine Pre-Operative Chest X-Ray
62-Year-Old Male With Prostate Cancer
Presents To The ED With Acute Dyspnea.
62-Year-Old Male With Prostate Cancer
Presents To The ED With Acute Dyspnea.
Right Hydropneumothorax
If It Looks Like This… There’s Air In There!
MVC – Struck Chest On The Steering Wheel
MVC – Struck Chest On The Steering Wheel
Sternal Fracture
 Direct impact to the anterior chest.
 Overlying tenderness & ...
What Do You See?
Sometimes The Foreign Body Is No So Easy To See!
Get A 2nd Views If You Suspect It And Your PA or AP Views Are “Negative.”...
What Do You See?
Nail Gun
Injury
Sometimes The Foreign Body Is No So Easy To See!
Get A 2nd Views If You Suspect It And Your PA or AP Views...
Intubated Patient In The ICU Develops Hypoxia & Hypotension.
Left Tension Pneumothorax After Central Line Placement
Left Tension Pneumothorax – After Chest Tube
70-Year-Old With
Presents With
Dyspnea.
Spontaneous Pneumothorax
70-Year-Old With
Presents With
Dyspnea.
70-Year-Old With
Presents With
Dyspnea.
Spontaneous Pneumothorax
69-Year-Old In A
Motor Vehicle
Crash. Complains
Of Left Shoulder
Pain.
69-Year-Old In A
Motor Vehicle
Crash. Complains
Of Left Shoulder
Pain.
RUL Pulmonary Contusion
69-Year-Old In A Motor Vehicle Crash. Complains Of Left Shoulder Pain.
RUL Pulmonary Contusion
EAST Guidelines For The Management Of Pulmonary Contusion & Flail Chest
 The use of optimal analgesia and aggressive ches...
53-Year-Old With
Hypertension
Presents With
Severe Chest And
Abdominal Pain.
53-Year-Old With
Hypertension
Presents With
Severe Chest And
Abdominal Pain.
Read As “Normal.”
The Team Remains
Concerned ...
53-Year-Old With Hypertension Presents With Severe Chest And Abdominal Pain.
Chest X-Rays With The ABSENCE Of:
A Mediastinal Widening 37%
A Mediastinal Widening And Abnormal Contour 21%
N = 464
Chest X-Rays With The ABSENCE Of:
A Mediastinal Widening 37%
A Mediastinal Widening And Abnormal Contour 21%
N = 464
Punch...
45-Year-Old
Presents With
One Week Of
Dyspnea and
Night Sweats.
Diffuse Airspace Opacities.
45-Year-Old
Presents With
One Week Of
Dyspnea and
Night Sweats.
The Patient Has
Recently Been
...
45-Year-Old
Presents With
One Week Of
Dyspnea and
Night Sweats.
The Patient Has
Recently Been
Diagnosed With
HIV.
Pneumocy...
Treatment Of Pneumocystis Pneumonia
Trimethoprim-sulfamethoxazole First Choice
Primaquine + clindamycin Alternative
Atovaq...
Summary Of Diagnoses This Month
 Mycoplasma pneumonia
 Thoracic aortic aneurysm
 Hydropneumothorax
 Sternal fracture
...
APPENDIX
Question #1:
In adults with CAP, should gram stain and cultures of lower respiratory secretions be
obtained at the time of...
Question #2:
In adults with CAP, should blood cultures be obtained at the time of diagnosis?
 Recommend not obtaining blo...
Question #3:
In adults with CAP, should Legionella and Pneumococcal urinary antigen testing be
performed at the time of di...
Questions #4, #5, #6:
In adults with CAP:
 Should a respiratory sample be tested for Influenza virus at the time of diagn...
Question #7:
In adults with CAP, should serum procalcitonin plus clinical judgment versus clinical
judgment alone be used ...
Question #8, 9:
Should a clinical prediction rule for prognosis plus clinical judgment versus clinical
judgment alone be u...
Question #10:
In the outpatient setting, which antibiotics are recommended for empiric treatment of
CAP in adults?
For hea...
Question #11:
In the inpatient setting, which antibiotics are recommended for empiric treatment of CAP
in adults without r...
Question #12:
In the inpatient setting, should patients with suspected aspiration pneumonia receive
additional anaerobic c...
Question #13:
In the inpatient setting, should adults with CAP and risk factors for MRSA or P. aeruginosa
be treated with ...
Question #14:
In outpatient and inpatient adults with CAP who are improving, what is the appropriate
duration of antibioti...
Question #15:
In the inpatient setting, should adults with CAP be treated with corticosteroids?
 Recommend not routinely ...
See You Next Month!
Drs. Milam and Thomas's CMC X-Ray Mastery Project: February Cases
Drs. Milam and Thomas's CMC X-Ray Mastery Project: February Cases
Drs. Milam and Thomas's CMC X-Ray Mastery Project: February Cases
Drs. Milam and Thomas's CMC X-Ray Mastery Project: February Cases
Drs. Milam and Thomas's CMC X-Ray Mastery Project: February Cases
Drs. Milam and Thomas's CMC X-Ray Mastery Project: February Cases
Drs. Milam and Thomas's CMC X-Ray Mastery Project: February Cases
Drs. Milam and Thomas's CMC X-Ray Mastery Project: February Cases
Drs. Milam and Thomas's CMC X-Ray Mastery Project: February Cases
Drs. Milam and Thomas's CMC X-Ray Mastery Project: February Cases
Drs. Milam and Thomas's CMC X-Ray Mastery Project: February Cases
Drs. Milam and Thomas's CMC X-Ray Mastery Project: February Cases
Drs. Milam and Thomas's CMC X-Ray Mastery Project: February Cases
Drs. Milam and Thomas's CMC X-Ray Mastery Project: February Cases
Drs. Milam and Thomas's CMC X-Ray Mastery Project: February Cases
Drs. Milam and Thomas's CMC X-Ray Mastery Project: February Cases
Drs. Milam and Thomas's CMC X-Ray Mastery Project: February Cases
Drs. Milam and Thomas's CMC X-Ray Mastery Project: February Cases
Drs. Milam and Thomas's CMC X-Ray Mastery Project: February Cases
Drs. Milam and Thomas's CMC X-Ray Mastery Project: February Cases
Drs. Milam and Thomas's CMC X-Ray Mastery Project: February Cases
Drs. Milam and Thomas's CMC X-Ray Mastery Project: February Cases
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Drs. Milam and Thomas's CMC X-Ray Mastery Project: February Cases

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Drs. Claire Milam and Alyssa Thomas 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 monthly educational, self-guided radiology slides on:
• Mycoplasma pneumonia
• Thoracic aortic aneurysm
• Hydropneumothorax
• Sternal fracture
• Foreign body
• Iatrogenic pneumothorax
• Pulmonary contusion
• Type A aortic dissection
• Cardiomegaly
• PCP pneumonia
• Pneumothorax

  • Be the first to like this

Drs. Milam and Thomas's CMC X-Ray Mastery Project: February Cases

  1. 1. Adult Chest X-Rays Of The Month Alyssa Thomas MD & Claire Milam MD Department of Emergency Medicine Carolinas Medical Center & Levine Children’s Hospital Michael Gibbs MD, Faculty Editor Chest X-Ray Mastery Project February 2020
  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. Healthy 20-Year- Old Male Seen At His PCP’s Office Where This Chest X-Ray Was Obtained.
  8. 8. Healthy 20-Year- Old Male Seen At His PCP’s Office Where This Chest X-Ray Was Obtained: Diagnosed With RLL Pneumonia. Rx: Ceftriaxone + A Prescription For Amoxicillin/Clavulanate
  9. 9. The Patient Presents To The ED 24 Hours Later With Cough + Persistent Tachycardia & Hypoxia.
  10. 10. The Patient Presents To The ED 24 Hours Later With Cough + Persistent Tachycardia & Hypoxia. Worsening Pneumonia Despite Therapy.
  11. 11. ED Rx: Azithromycin + Ceftriaxone & Admitted. The Patient Presents To The ED 24 Hours Later With Cough + Persistent Tachycardia & Hypoxia.
  12. 12. Serology [+] For Mycoplasma.
  13. 13. The Patient Was Initially Treated With Ceftriaxone In The Office And Prescribed Amoxicillin-Clavulanate. Is This An Appropriate Strategy For The Outpatient Management of Community Acquired Pneumonia?
  14. 14. The Patient Was Initially Treated With Ceftriaxone In The Office And Prescribed Amoxicillin-Clavulanate. Is This An Appropriate Strategy For The Outpatient Management of Community Acquired Pneumonia? According To The Most Recent IDSA/ATS Guidelines: The Answer is Yes.
  15. 15. This Represents A Change From The 2007 IDSA/ATS Guidelines.
  16. 16. “In a departure from the prior CAP guidelines, the panel did not give a strong recommendation for routine use of a macrolide antibiotic as monotherapy for outpatient community acquired pneumonia. This was based on studies of macrolide failures in patients with macrolide-resistant S. pneumonia1,2, in combination with a macrolide resistance rate of >30% among S. pneumonia isolates in the United States, of which is high-level resistance3.” 1Lonks JR. Clin Infect Dis 2002;35:556-564. 2Daneman N. Clin Infect Dis 2006; 43:432-438. 3CDC. Active Bacteria Core Surveillance (ABCs) Report - 2015. Report Accessed 2019. PUNCH LINE?  Macrolide monotherapy is no longer recommended because of Pneumococcal resistance.  Know your local resistance patterns [Charlotte, NC = 30% resistance in 2019].  Choose double therapy if atypical pneumonia is a possibility.
  17. 17. A Complete Summary Of The 2019 IDSA/ATS Guidelines For The Management of Community Acquired Pneumonia Are Included At The End Of This Presentation As An Appendix.
  18. 18. 65-Year-Old Traveling Through Charlotte Presents From The Airport With Dyspnea.65-Year-Old Traveling Through Charlotte Presents From The Airport With Dyspnea.
  19. 19. 65-Year-Old Traveling Through Charlotte Presents From The Airport With Dyspnea.65-Year-Old Traveling Through Charlotte Presents From The Airport With Dyspnea. Calcified Aneurysm Of The Thoracic Aorta
  20. 20. Thoracic Aortic Aneurysm: 58 x 54 mm Maximal Diameter 65-Year-Old Traveling Through Charlotte
  21. 21. 75-Year-Old Has A Routine Pre-Operative Chest X-Ray
  22. 22. Thoracic Endovascular Aortic Repair [TEVAR] 75-Year-Old Has A Routine Pre-Operative Chest X-Ray
  23. 23. 62-Year-Old Male With Prostate Cancer Presents To The ED With Acute Dyspnea.
  24. 24. 62-Year-Old Male With Prostate Cancer Presents To The ED With Acute Dyspnea. Right Hydropneumothorax
  25. 25. If It Looks Like This… There’s Air In There!
  26. 26. MVC – Struck Chest On The Steering Wheel
  27. 27. MVC – Struck Chest On The Steering Wheel Sternal Fracture  Direct impact to the anterior chest.  Overlying tenderness & swelling.  Best seen on the lateral view.
  28. 28. What Do You See?
  29. 29. Sometimes The Foreign Body Is No So Easy To See! Get A 2nd Views If You Suspect It And Your PA or AP Views Are “Negative.” Swallowed Coin
  30. 30. What Do You See?
  31. 31. Nail Gun Injury Sometimes The Foreign Body Is No So Easy To See! Get A 2nd Views If You Suspect It And Your PA or AP Views Are “Negative.”
  32. 32. Intubated Patient In The ICU Develops Hypoxia & Hypotension.
  33. 33. Left Tension Pneumothorax After Central Line Placement
  34. 34. Left Tension Pneumothorax – After Chest Tube
  35. 35. 70-Year-Old With Presents With Dyspnea.
  36. 36. Spontaneous Pneumothorax 70-Year-Old With Presents With Dyspnea.
  37. 37. 70-Year-Old With Presents With Dyspnea. Spontaneous Pneumothorax
  38. 38. 69-Year-Old In A Motor Vehicle Crash. Complains Of Left Shoulder Pain.
  39. 39. 69-Year-Old In A Motor Vehicle Crash. Complains Of Left Shoulder Pain. RUL Pulmonary Contusion
  40. 40. 69-Year-Old In A Motor Vehicle Crash. Complains Of Left Shoulder Pain. RUL Pulmonary Contusion
  41. 41. EAST Guidelines For The Management Of Pulmonary Contusion & Flail Chest  The use of optimal analgesia and aggressive chest physiotherapy should be used to minimize the risk of respiratory failure.  A trial of mask CPAP in combination with optimal regional anesthesia, should be considered in alert, compliant patients with marginal respiratory status.  Epidural catheter is the preferred method of analgesia delivery.  Patients should be adequately resuscitated, and hypovolemia should be avoided. When there are clear signs of hydrostatic fluid overload, diuretics may be used.  Steroids should not be used in patients with pulmonary contusion.  For patients requiring mechanical ventilation, PEEP and CPAP should be part in the ventilatory strategy.
  42. 42. 53-Year-Old With Hypertension Presents With Severe Chest And Abdominal Pain.
  43. 43. 53-Year-Old With Hypertension Presents With Severe Chest And Abdominal Pain. Read As “Normal.” The Team Remains Concerned About Aortic Dissection.
  44. 44. 53-Year-Old With Hypertension Presents With Severe Chest And Abdominal Pain.
  45. 45. Chest X-Rays With The ABSENCE Of: A Mediastinal Widening 37% A Mediastinal Widening And Abnormal Contour 21% N = 464
  46. 46. Chest X-Rays With The ABSENCE Of: A Mediastinal Widening 37% A Mediastinal Widening And Abnormal Contour 21% N = 464 Punch Line? If You Are Worried About Aortic Dissection… Don’t Stop With A ”Normal” Chest X-Ray!
  47. 47. 45-Year-Old Presents With One Week Of Dyspnea and Night Sweats.
  48. 48. Diffuse Airspace Opacities. 45-Year-Old Presents With One Week Of Dyspnea and Night Sweats. The Patient Has Recently Been Diagnosed With HIV.
  49. 49. 45-Year-Old Presents With One Week Of Dyspnea and Night Sweats. The Patient Has Recently Been Diagnosed With HIV. Pneumocystis Jiroveci Pneumonia.
  50. 50. Treatment Of Pneumocystis Pneumonia Trimethoprim-sulfamethoxazole First Choice Primaquine + clindamycin Alternative Atovaquone suspension Alternative Pentamidine1 Alternative Patients with suspected or documented PCP and moderate to severe disease, defined by a room air PO2 <70 mmHg should receive adjunctive corticosteroids as soon as possible and certainly within 72 hours after starting specific PCP therapy. 1IV route only; aerosolized pentamidine should not be used.
  51. 51. Summary Of Diagnoses This Month  Mycoplasma pneumonia  Thoracic aortic aneurysm  Hydropneumothorax  Sternal fracture  Subtle foreign bodies  Iatrogenic pneumothorax  Pulmonary contusion  Type A aortic dissection  Cardiomegaly  Spontaneous pneumothorax  Pneumocystis pneumonia
  52. 52. APPENDIX
  53. 53. Question #1: In adults with CAP, should gram stain and cultures of lower respiratory secretions be obtained at the time of diagnosis?  Recommend not obtaining sputum Gram stain and cultures routinely in adults with CAP managed in the outpatient setting.  Recommend obtaining Gram stain and cultures in adults with CAP who: (1) have severe CAP* [especially if intubated], or (2) are being treated empirically for MRSA or P. aeruginosa. *See next slide for IDSA/ATS definition of “severe community-acquired pneumonia.”
  54. 54. Question #2: In adults with CAP, should blood cultures be obtained at the time of diagnosis?  Recommend not obtaining blood cultures in adults with CAP managed in the outpatient setting.  Recommend obtaining blood cultures in adults with CAP managed in the hospital who: (1) are classified as severe CAP, (2) are being treated empirically for MRSA or P. aeruginosa, (3) were previously infected with MRSA or P. aeruginosa, (4) were hospitalized and received parenteral antibiotics in the last 90 days.
  55. 55. Question #3: In adults with CAP, should Legionella and Pneumococcal urinary antigen testing be performed at the time of diagnosis? Recommend not routinely testing adults with CAP, except in: (1) patients with severe CAP, and/or (2) in cases where this is indicated by epidemiological factors such as exposure to a Legionella outbreak, or recent travel.
  56. 56. Questions #4, #5, #6: In adults with CAP:  Should a respiratory sample be tested for Influenza virus at the time of diagnosis?  Should influenza treatment be initiated for adults with a [+] test?  Should influenza [+] adults being treated with an antiviral also be treated with an antibacterial regimen?  When influenza is circulating in the community, a rapid influenza molecular assay is recommended.  For [+] tests, treatment with oseltamivir is recommended.  For [+] tests, standard antibacterial treatment is recommended.
  57. 57. Question #7: In adults with CAP, should serum procalcitonin plus clinical judgment versus clinical judgment alone be used to withhold initiation of antibiotic treatment? Recommend that empiric antibiotic therapy should be initiated in adults with clinically suspected and radiographically confirmed CAP regardless of initial serum procalcitonin level.
  58. 58. Question #8, 9: Should a clinical prediction rule for prognosis plus clinical judgment versus clinical judgment alone be used to determine: (1) inpatient versus outpatient treatment location for adults with CAP, and (2) the best site of treatment [floor vs. Step-Down vs. ICU]?  In addition to clinical judgement clinicians should use a validated clinical prediction rule for prognosis, preferentially the Pneumonia Severity Index (PSI).  When compared with CURB-65, PSI identifies larger proportions of patients as low risk, and has a higher discriminative power in predicting mortality.  Compared with PSI, there is less evidence that CURB-65 is effective as a decision aid in guiding the initial site of treatment.
  59. 59. Question #10: In the outpatient setting, which antibiotics are recommended for empiric treatment of CAP in adults? For healthy outpatient adults: (1) amoxicillin 1 g TID, or (2) doxycycline 100 mg BID, or (3) azithromycin 500 mg on first day then 250 mg daily, or (4) clarithromycin 500 BID. For outpatient adults with comorbidities (heart failure, liver or renal disease, diabetes, alcoholism, malignancy or asplenia):  Amoxicillin/clavulanate 500mg/125 mg TID, or a cephalosporin, AND a macrolide (azithromycin, clarithromycin, or  Monotherapy with a respiratory fluoroquinolone: levofloxacin 750 mg QD, or moxifloxacin 400 mg QD, or gemifloxacin 320 mg QD.
  60. 60. Question #11: In the inpatient setting, which antibiotics are recommended for empiric treatment of CAP in adults without risk factors for MRSA and P. aeruginosa? In inpatients with non-severe CAP:  A 𝛽-lactam + a macrolide, or  Monotherapy with a respiratory fluoroquinolone, or  A 𝛽-lactam + doxycycline [if macrolides & fluoroquinolones are not tolerated] In patients with severe CAP:  A 𝛽-lactam + a macrolide, or  A 𝛽-lactam + a respiratory fluoroquinolone
  61. 61. Question #12: In the inpatient setting, should patients with suspected aspiration pneumonia receive additional anaerobic coverage beyond standard empiric treatment? Recommend not routinely adding anaerobic coverage for suspected aspiration pneumonia unless lung abscess or empyema is suspected.
  62. 62. Question #13: In the inpatient setting, should adults with CAP and risk factors for MRSA or P. aeruginosa be treated with extended-spectrum antibiotic therapy instead of standard CAP regimens? Recommend that clinicians only cover empirically for MRSA or P. aeruginosa in adults with CAP if locally validated risk factors for either pathogen are present. MRSA Vancomycin (15 mg/kg), or linezolid (600 mg BID) P. aeruginosa Piperacillin-tazobactam (4.5 grams Qº6), or cefepime (2 grams Qº8), or aztreonam (2 grams Qº8), or imipenem 500 mg Qº6)
  63. 63. Question #14: In outpatient and inpatient adults with CAP who are improving, what is the appropriate duration of antibiotic therapy? Recommend that the duration of antibiotic therapy should be guided by a validated measure of clinical stability (resolution of vital sign abnormalities, ability to eat, and normal mentation), and antibiotic therapy should be continued until the patient achieves stability for no less than 5 days.
  64. 64. Question #15: In the inpatient setting, should adults with CAP be treated with corticosteroids?  Recommend not routinely using corticosteroids in adults with non-severe CAP.  Recommend not routinely using corticosteroids in adults with severe CAP.  Recommend not routinely using corticosteroids in adults with severe influenza CAP.  Endorse the Surviving Sepsis Campaign recommendations on the use of corticosteroids in patients with CAP and refractory septic shock.
  65. 65. See You Next Month!

Drs. Claire Milam and Alyssa Thomas 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 monthly educational, self-guided radiology slides on: • Mycoplasma pneumonia • Thoracic aortic aneurysm • Hydropneumothorax • Sternal fracture • Foreign body • Iatrogenic pneumothorax • Pulmonary contusion • Type A aortic dissection • Cardiomegaly • PCP pneumonia • Pneumothorax

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