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Drs. Milam and Thomas's CMC X-Ray Mastery Project: March 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:
• Esophageal Impaction
• Obstructive Lung Mass
• Descending Aortic Aneursym
• Pleural Effusion
• Dextrocardia and Situs Inversus
• Thyroid Mass
• Pulmonary Tuberculosis
• Malignant Pleural Effusion
• Hiatal Hernia
• Subcutaneous Emphysema
• Pseudoaneurysm
• Asbestosis

Published in: Education
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Drs. Milam and Thomas's CMC X-Ray Mastery Project: March 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 March 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. 75-Year-Old Female Presents With Vomiting. What Do You See?
  8. 8. Here Is Her Prior CXR For Comparison. Prior CXR Today’s CXR
  9. 9. Here Is Her Prior CXR For Comparison. Prior CXR Today’s CXR
  10. 10. Diagnosis: Esophageal Impaction
  11. 11. Diagnosis: Esophageal Impaction
  12. 12. 75-Year-Old with Esophageal Impaction. Can You See Any Other Evidence of The Impaction?
  13. 13. 75-Year-Old with Esophageal Impaction.
  14. 14. Density over the heart corresponds with lower food bolus 75-Year-Old with Esophageal Impaction.
  15. 15. 58-Year-Old Presents With Shortness of Breath.
  16. 16. 58-Year-Old Presents With Shortness of Breath. Diagnosis: Right Pleural Effusion
  17. 17. 58-Year-Old Presents With Shortness of Breath. Diagnosed With Right Pleural Effusion. Treatment With Ultrasound Guided Thoracentesis.
  18. 18. Post Thoracentesis  Much ImprovedDiagnosis: Right Pleural Effusion
  19. 19. Light’s Criteria Transudate Versus Exudate1,2 Pleural Fluid Protein/Plasma Protein >0.5 Pleural Fluid LDH/Plasma LDH >0.6 Pleural Fluid LDH >200 IU 1In patients with heart failure on diuretics, Light’s Criteria may misclassify a transudate as an exudate up to 25% of the time. 2In heart failure patients, a serum protein 3.1 g/dl higher than the pleural fluid, or a serum albumen 1.2 g/dl higher than the pleural fluid will help correctly identify a transudate.
  20. 20. Parapneumonic Effusions • The most common exudative effusions are those associated with underlying pneumonia • Mortality is higher among pneumonia patients who have a parapneumonic effusion, compared with those with pneumonia and no effusion • With the aging of the population, the incidence and mortality due to parapneumonic effusion and empyema continues to rise
  21. 21. Right Parapneumonic Effusion
  22. 22. Malignant Effusions • The second most common exudative effusions are those associated with underlying malignancy • The majority of malignant pleural effusions arise from lung cancer, breast cancer, and lymphoma • The presence of a malignant pleural effusion is associated with higher mortality and significantly shorter survival
  23. 23. Lung Mass With Malignant Effusion
  24. 24. Lung Mass After Effusion Drainage
  25. 25. 65-Year-Old With A History Of Smoking.
  26. 26. 65-Year-Old With History of Smoking. Complete Opacification Of The Left Lung. Can You See Any Hints To The Cause?
  27. 27. 65-Year-Old With History of Smoking. Complete Opacification Of The Left Lung. Can You See Any Hints To The Cause?
  28. 28. 65-Year-Old With A History of Smoking. Atelectasis and Collapse of Left Lung Secondary To Obstructive, Mass on the Bronchus. Heterogeneity Concerning For Malignancy.
  29. 29. 65-Year-Old With History of Smoking. Diagnosis: Obstructive Lung Mass With Associated Atelectasis And Lung Collapse Remember: Not Only Fluid Causes Complete Opacification!
  30. 30. 36-Year-Old Presents for Routine Pre-operative CXR.
  31. 31. 36-Year-Old Presents for Routine Pre-operative CXR. Not An Inverted Image!
  32. 32. 36-Year-Old Presents for Routine Pre-operative CXR. Not An Inverted Image! Diagnosis: Dextrocardia What Associated Diagnosis Do You Think This Patient May Have?
  33. 33. 36-Year-Old With Dextrocardia Associated Diagnosis: Situs Inversus
  34. 34. 36-Year-Old With Dextrocardia And Situs Inversus. RIGHT LEFT
  35. 35. 76-Year-Old Presents with Chest Pain
  36. 36. 76-Year-Old Presents with Chest Pain Density in the cardiac silhouette
  37. 37. Diagnosis: Descending Aortic Aneurysm
  38. 38. Density Behind The Cardiac Silhouette Is The Dilated Aorta.
  39. 39. 41-Year-Old Presents with Difficulty Breathing.
  40. 40. 41-Year-Old Presents with Difficulty Breathing. Diagnosis: Thyroid Mass
  41. 41. 41-Year-Old Presents with Difficulty Breathing. Do Not Forget to Take Note of Mass Effect  Notice Here the Tracheal Deviation Diagnosis: Thyroid Mass
  42. 42. 50-Year-Old Male Presents with Chronic Dry Cough.
  43. 43. 50-Year-Old Male Presents with Chronic Dry Cough.
  44. 44. Apical Opacity With Central Cavitation Diagnosis: Pulmonary Tuberculosis 50-Year-Old Male Presents with Chronic Dry Cough.
  45. 45. 80-Year-Old Male With A History of Tobacco Use Presents With Dyspnea.
  46. 46. Diagnosis: Malignant Pleural Effusion 80-Year-Old Male With A History of Tobacco Use Presents With Dyspnea.
  47. 47. Diagnosis: Malignant Pleural Effusion
  48. 48. 79-Year-Old Female Has A Chest X-Ray After A Car Crash.
  49. 49. 79-Year-Old Female Has A Chest X-Ray After A Car Crash. Diagnosis: Hiatal Hernia
  50. 50. Notice the Gastric Bubble Diagnosis: Hiatal Hernia
  51. 51. What Else Can You Diagnose? 79-Year-Old Female Has A Chest X-Ray After A Car Crash.
  52. 52. Don’t Forget About the Bones! 79-Year-Old Female Has A Chest X-Ray After A Car Crash. Diagnose: Osteoporosis
  53. 53. 23-Year-Old Female Presents After Multiple Episodes of Coughing.
  54. 54. Diagnosis: Subcutaneous Emphysema 23-Year-Old Female Presents After Multiple Episodes of Coughing.
  55. 55. Diagnosis: Subcutaneous Emphysema
  56. 56. Pneumomediastinum 2° Iatrogenic 2° Medical & Traumatic Spontaneous  Endoscopic procedures  Intubation  Pleural instrumentation  Central vascular procedure  Chest/abdominal surgery  Blunt chest injury  Penetrating chest injury  Asthma/COPD  Bronchiectasis  Interstitial lung disease  Thoracic malignancy  Tobacco use  Recreational drugs  Breath holding  Weight lifting Vasileios K. Journal of Thoracic Disease 2015; 7:S44-S49. Management Essentials  Manage the underlying cause  Pain management & cough suppression as indicated  Oxygen may increase gas absorption in severe cases  Brief period of observation vs. close outpatient follow-up
  57. 57. 68 Year Old Male Presents with Hemoptysis
  58. 58. 68-Year-Old Male Presents with Hemoptysis Diagnosis: Pseudoaneurysm
  59. 59. Diagnosis: Pseudoaneurysm
  60. 60. 48-Year-Old Male Presents with Chest Pain and Dry Cough
  61. 61. 48-Year-Old Male Presents with Chest Pain and Dry Cough Diagnosed with Costochondritis and Discharged Home
  62. 62. 48-Year-Old Male Presents with Chest Pain and Dry Cough What Abnormality Do You Notice?
  63. 63. 48-Year-Old Male Presents with Chest Pain and Dry Cough Bilateral Rounded Opacities What Abnormality Do You Notice?
  64. 64. Diagnosis: Asbestosis Calcified Nodular Pleural Plaques
  65. 65. Summary Of Diagnoses This Month  Esophageal Impaction  Obstructive Lung Mass  Descending Aortic Aneurysm  Pleural Effusion  Dextrocardia and Situs Inversus  Thyroid Mass  Pulmonary Tuberculosis  Malignant Pleural Effusion  Hiatal Hernia  Subcutaneous Emphysema  Pseudoaneurysm  Asbestosis
  66. 66. See You Next Month!

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