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Drs. Milam and Thomas's CMC X-Ray Mastery Project: July 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:
• Malignant Pneumothorax
• Lung Mass
• Retained Bullet
• Cavitary Lesion
• Pleural Effusion
• Mucus Plug with Atelectasis
• Rib Fracture
• Mediastinal Lymphadenopathy

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

  1. 1. Adult Chest X-Rays Of The Month Alyssa Thomas MD & Claire Milam MD 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™ July 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. 58-Year-Old Female Presents With Shortness of Breath
  8. 8. 58-Year-Old Female Presents With Shortness of Breath Diagnosis: Pleural Effusion
  9. 9. Previous CXRCurrent CXR
  10. 10. Persistent Dyspnea Prompted Ordering of a CT Chest…
  11. 11. CT Chest Revealed Obstruction of Left Lower Lobe (LLL) Bronchus Due to Mucus Plugging Diagnosis: Atelectatic Left Lower Lobe
  12. 12. Let’s Go Back to the CXR… The LLL Collapse is Difficult To Appreciate
  13. 13. Do Not Forget Anatomy! Right Upper Lobe (RUL) Right Middle Lobe (RML) Right Lower Lobe (RLL) Left Upper Lobe (LUL) Left Lower Lobe (LLL) Left Lower Lobe (LLL) Left Upper Lobe (LUL)
  14. 14. Get The Lateral CXR if Possible! Left Lower Lobe Collapse Can Just Appear Like an Effusion, Because So Little of the Lobe is Visible on AP/PA
  15. 15. Mucus Plugging The conditions that are best-known to cause mucus plugging are the following: • Allergic Bronchopulmonary aspergillosis • Plastic Bronchitis • Asthma Mucus can become abnormally thick due to - Pathologic diseases causing stagnation of flow and blockage of tracheobronchial tree - Anticholinergic medications  Resulting in a Mucus Plug Mucus plugs can partially or completely obstruct one or more airways resulting in atelectasis or recurrent infection.
  16. 16. 64-Year-Old Female Presents With Chronic Cough
  17. 17. 64-Year-Old Female Presents With Chronic Cough Diagnosis: Cavitary Lesion
  18. 18. 31-Year-Old Female Presents With Difficulty Breathing
  19. 19. 31-Year-Old Female Presents With Difficulty Breathing Diagnosis: Spontaneous Pneumothorax
  20. 20. 31-Year-Old Female Presents After Pigtail Chest Tube Placement. Notice: The Parenchyma Shows Signs of Chronic Changes – Which Likely Contributed to the Etiology of Her Spontaneous Pneumothorax. i.e. Blebs.
  21. 21. 20-Year-Old Male Presents With Gunshot Wound
  22. 22. 20-Year-Old Male Presents With Gunshot Wound Diagnosis: Retained Bullets Did You Find Both of Them At First? Remember Don’t Stop Looking After Finding One Abnormality!
  23. 23. 20-Year-Old Male Presents With Gunshot Wound Diagnosis: Retained Bullets Assess Position Anteriorly vs Posteriorly: Get a Lateral Film. Scout Films From CT Can Be Helpful, Too!
  24. 24. Difficult to assess position based on one view due to overlapping bones. Always get multiple views! Best view to show retained bullet in scapula.
  25. 25. CT Confirmation of Retained Bullet in Scapula.
  26. 26. Anterior Posterior Cranial Caudal
  27. 27. 81-Year-Old Male Presents With Shortness of Breath
  28. 28. 81-Year-Old Male Presents With Shortness of Breath Diagnosis: Left Sided Mass Lesion and Pneumothorax
  29. 29. Air-Fluid Level
  30. 30. 81-Year-Old Male After Pigtail Chest Tube Placement Don’t Forget the Left Upper Lobe Mass!
  31. 31. 81-Year-Old Male After Pigtail Chest Tube Placement Don’t Forget the Left Upper Lobe Mass! Notice There Is No Longer an Air Fluid Level
  32. 32. CT Imaging
  33. 33. CT Imaging
  34. 34. Partially Necrotic Left Upper Lobe Mass This Mass is Loculated and Has a Large Component of Air, As Can Be Seen on the CT Lung Window, and Helps Explains the Change in the Mass of CXR.
  35. 35. 62-Year-Old Male Presents with Lateral Chest Pain After Coughing
  36. 36. 62-Year-Old Male Presents with Lateral Chest Pain After Coughing Diagnosis: Normal
  37. 37. Diagnosis: Non-Displaced Rib Fracture With Surrounding Hematoma. 62-Year-Old Male Presents with Lateral Chest Pain After Coughing and Normal CXR
  38. 38. Rib Fractures and Chest X-rays Rib Fractures May Be Missed on Chest x-ray. Studies Have Shown That Up to 75% of Rib Fractures Will Be Missed with AP/Lateral Chest x-ray. Citation: Chapman BC, Overbey DM, Tesfalidet F, et al. Clinical Utility of Chest Computed Tomography in Patients with Rib Fractures CT Chest and Rib Fractures. Arch Trauma Res. 2016;5(4):e37070. Published 2016 Sep 13. DOI: 10.5812/atr.37070
  39. 39. Study: What is the clinical significance of chest CT when the chest x-ray result is normal in patients with blunt trauma? Citation: Kea B, Gamarallage R, Vairamuthu H, et al. What is the clinical significance of chest CT when the chest x-ray result is normal in patients with blunt trauma?. Am J Emerg Med. 2013;31(8):1268-1273. DOI:10.1016/j.ajem.2013.04.021 Study design: Retrospective observational study of 589 patients. Methods: Patients over age 14 with blunt trauma who received a chest X-ray were enrolled. Results: Of the 589 patients who had a chest CT after a normal chest X-ray, 66 (11%) had undiagnosed rib fractures, but only 12 (2%) were clinically significant. Conclusions: Chest CT after a normal Chest X-ray in blunt trauma will detect more injuries, but likely not changes in patient management
  40. 40. Summary Of Diagnoses This Month  Pleural Effusion  Cavitary Lesion  Retained Bullet  Malignant Pneumothorax  Lung Mass  Mucus Plug with Atelectasis  Spontaneous Pneumothorax  Rib Fracture with Hematoma  Mediastinal Lymphadenopathy
  41. 41. See You Next Month!

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