Chest XR Cases and Clinical Cases

Anwser,s
Dr :ANAS SAHLE
1. Chest xr cases.
2. Chest clinical case.
3. Chest ct cases.
4. MRCP exam.
:http://www.facebook.com/dranas224

Sunday, December 02, 2012

chest xr cases
Dr :anas sahle
http://www.facebook.com/dranas224

Cxr -7
• Compare between tow viewPALATERAL:
• DIAGNOSIS IS:

DISCUSSION
Mass density is seen in the lateral view, but
not in the PA view.
• This suggests a chest wall or external problem.
• In film below mass in the axilla is projecting as
a mass in the chest.


Non-anatomical Lines
• The linear shadows do not correspond to any
anatomical structure.
• Consider the following:
• Pleural fibrosis
• Extra-thoracic density
• Bleb wall
• Lung fibrosis
• This example represents pleural fibrosis.


Inlet to Outlet Shadow
• In-homogeneous cardiac density: Right half
more dense than left
• Density crossing midline (right black arrow).
• Right sided inlet to outlet shadow
• Right para spinal line (left black arrow).
• This is a case of achalasia cardia.


One Diaphragm (in lateral view)
• You should be able to detect both diaphragms
in the lateral view.
• If one is missing, it indicates that there is a
problem in that hemithorax.
• By identifying which diaphragm is missing, you
can locate the side of the problem.
• Naturally it is easy to identify the problem from
the PA view.
Which lung is resected?
• Note that you can see only one diaphragm in
the film on the left.
• The film below is pre-pneumonectomy, where
you can identify both diaphragms.
• The visible diaphragm has a stomach bubble
underneath, indicating that it is on the left.
• Hence, right lung pneumonectomy has
occurred.

chest clinical cases
Persistent Dyspnea
Despite Maximal Medical
Therapy in COPD
Submitted by
Brian P. Mieczkowski, DO
Fellow
Division of Pulmonary, Allergy, Critical Care and Sleep Medicine
The Ohio State University Medical Center
Columbus, Ohio
Michael E. Ezzie, MD
Assistant Professor of Internal Medicine
Division of Pulmonary, Allergy, Critical Care and Sleep Medicine
The Ohio State University Medical Center
Columbus, Ohio
http://www.thoracic.org/index.php

History
• A 64-year-old woman with a history of smoking presented with progressive shortness of breath
with exertion.
• The patient smoked one to two packs of cigarettes per day for forty-two years and quit smoking
one year ago.
• She had increasing dyspnea on exertion over the past few years that accelerated over the last
year.
• She reported she could now only walk short distances before sitting down to catch her breath.
• Her family doctor started her on bronchodilators a few years ago.
• She had improvement at the time, but now feels very limited.
• She had several episodes of increased dyspnea, wheezing, and productive cough over the past
two years.
• These exacerbations were treated as an outpatient with oral corticosteroids and antibiotics.
• Two years ago, she participated in a four week course of pulmonary rehab which resulted in
improvement in her dyspnea.
• She denied chest pain or palpitations with breathing symptoms.
• She reported no shortness of breath at rest, except when talking for more than a few minutes.
• She had no emergency department visits and had not required mechanical ventilator support for
breathing.
• She had no nocturnal symptoms of wheezing or shortness of breath, but did have occasional
wheezing during the day along with a dry cough.
• The patient was interested in discussing additional therapies for her lung disease.


CONTIN-
• Her past medical history was significant for smoking, depression,
arthritis, hypertension, hyperlipidemia, and squamous cell
carcinoma of the skin on the leg that was removed.
• Her current medications included amlodipine, sertraline, aspirin,
tiotropium, albuterol, salmeterol/fluticasone, and simvastatin.
• The patient reported that her father had chronic obstructive
pulmonary disease (COPD). There was no other family history of
lung disease.
• The patient had been married for forty-five years and had two
children.
• She was a former smoker of one to two packs per day for forty-
two years. She denied alcohol or drug use.
• She reported no significant occupational exposures.
• A review of systems was pertinent for fatigue and occasional
heartburn.


Physical Exam
• On examination, the patient’s weight was 118 pounds with a body
mass index (BMI) of 20.3.
• Her blood pressure was 120/70 mmHg with a pulse of 96 beats
per minute.
• Her oxygen saturation was 91% breathing ambient air.
• Her general appearance was thin, and notable for a pleasant
female who was alert and oriented in no acute distress.
• Her oropharynx was clear without exudate and neck exam
revealed no lymphadenopathy.
• Her lung exam had diminished breath sounds bilaterally with
comfortable respirations and an appreciably long expiratory
phase. No wheezes, rhonchi or rales were noted.
• Cardiac exam was normal rate with a regular rhythm.
• Abdomen was thin, soft and nontender.
• extremities showed no evidence of clubbing or edema.

Diagnostic studies
• Pulmonary Function Tests:
• (FEV1): 0.84 L (34% predicted)
• (FVC): 2.46 L (56% predicted)
• FEV1/FVC: 0.34
• Total lung capacity (TLC): 138% of predicted
• Residual volume (RV): 227% of predicted
• Diffusing Capacity of Carbon Monoxide (DLCO): 31% of predicted
• 6-minute walk distance: She walked 900 feet and desaturated to
91%.
• Cardiopulmonary exercise testing: Her power output was 20
watts.
• Arterial blood gas: Baseline measurement of pCO2 was 37 and pO2
was 72.
• The carboxyhemoglobin level was 0.

CXR


CT


Lung Perfusion Scan

Demonstrating her right upper lobe with 3.6% of total perfusion, her left
upper lobe with 5% of total perfusion, her right middle lobe 13.6% of the
total, her right lower lobe 26.3% of the total, and her left lower lobe 25.8%
with left middle area 25.7%. Sunday, December 02, 2012

Question 1
• Based on our current understanding of gender differences
in COPD, which of the following might be expected in this
female patient compared to a male with an equivalent
degree of airflow obstruction?
A. She has more evidence of emphysema on her chest CT
than her male counterpart.
B. She has a greater bronchodilator response than her male
counterpart.
C. She has a greater number of cigarette pack-years with the
same disease as her male counterpart.
D. She would have greater improvement in her FEV1 one
year after smoking cessation than her male counterpart.
E. She is older than her male counterpart with equivalent
disease.

DISCUSSION
• Chronic Obstructive Pulmonary Disease (COPD) is defined as airflow limitation that is not fully
reversible and is progressive with an associated abnormal inflammatory response of the lung to
noxious stimuli.
• COPD is diagnosed by spirometry, with a forced expiratory volume in one second (FEV1) to forced
vital capacity (FVC) ratio of less than 0.7 and is classified by the degree of loss of FEV1.
• The leading cause of COPD in the United States is cigarette smoking and the number of women
dying from COPD is now equal to or surpassing the number of men.
• There is an increased understanding of gender differences in COPD development and
progression.
• Women tend to develop COPD at an earlier age and generally have less pack-years of smoking
compared to men with similar FEV1 values.
• Chest CT scans of female patients have less evidence of emphysema and histological
examinations demonstrate thicker airways and narrower lumens when compared to men with
equivalent levels of obstruction.
• Even with this phenotypic difference, there has been no data to suggest that women have a
greater response to bronchodilators.
• Given the increased risk of smoking-induced lung impairment, women may
benefit from smoking cessation more than men.
• The Lung Health Study found women had 2.5 times greater percentage improvement in FEV1
compared to men one year after smoking cessation.


Question 2
• Which of the following indices used to
evaluate severity and mortality in COPD
includes the numbers of exacerbations in the
evaluation of the patient?
• A.DOSE
• B.BODE
• C.ADO
• D.Both A and B are correct

DISCUSSION
• Multiple indices have been developed to predict outcomes in COPD.
• The BODE index described additional parameters to improve upon the FEV1-based mortality
prediction in patients with COPD.
• It has also been validated to predict hospitalizations.
• The BODE index includes: BMI, degree of obstruction, symptoms of dyspnea, and exercise
tolerance based on a six minute walk test.
• The DOSE index, in addition to functional status, includes the frequency of exacerbation in its
prediction for hospitalization, respiratory failure and subsequent exacerbations over the next
year.
• The components include dyspnea symptoms, degree of obstruction, smoking status, and
exacerbation frequency.
• The ADO index was designed to simplify and improve the all-cause mortality prediction of the
BODE index and found age to be an important factor.
• It includes age, dyspnea symptoms, and degree of obstruction.
• The COPD prognostic index (CPI) is another index that uses exacerbation history to help
predict future exacerbations, hospitalizations, and mortality.
• The CPI was developed from pooled data of 12 randomized controlled trials.
• The components include age, gender, degree of obstruction, quality of life, BMI, frequency of
exacerbations, and history of cardiovascular disease.


Question 3
• Of the following therapies for COPD, which potential
benefits would you expect to see in our patient?
• A. Supplemental oxygen will improve her life expectancy by
five years.
• B. Tiotropium will decrease her annual exacerbation rate,
but may increase her cardiac mortality.
• C. The combination of salmeterol (long-acting beta agonist)
and fluticasone (inhaled corticosteroid) will improve
mortality related to COPD.
• D. Pulmonary Rehabilitation will improve her quality of life,
but will increase her healthcare utilization.
• E. Lung volume reduction surgery will improve her quality
of life, dead space ventilation and long term mortality.


DISCUSSION
• The patient does have moderately low oxygen levels on her six minute walk test to 91%,
but there is no data to suggest she would have a 5 year mortality benefit from supplement
oxygen.
• Patients with very low oxygen levels at rest (paO2 less than 55 mmHg) had improved
survival in early studies of home oxygen use (10, 11).
• The ongoing Long-term Oxygen Treatment Trial (LOTT) (Clinicaltrials.gov identifier
NCT00692198) is assessing the effect of supplement oxygen in COPD patients with
moderate hypoxemia.
• The TORCH trial evaluated the effectiveness of a long acting beta agonist (LABA) with and
without an inhaled corticosteroid (ICS).
• The combination was most effective at improving lung function and quality of life as well as
decreasing the time to the next exacerbation (12).
• The study did not however, demonstrate a statistically significant mortality benefit in
regard to death from COPD with the use of a LABA with ICS.
• The INSPIRE trial reported that both tiotropium and a LABA with ICS were equally effective
at decreasing the annual exacerbation rate.
• Similar to other trials with inhaled corticosteroids, INSPIRE did show an increased risk of
pneumonia in the ICS treatment group (13).


CONTIN-
• The GOLD guidelines currently suggest adding an ICS in symptomatic
patients with an FEV1 less than 50% who also have frequent
exacerbations (1).
• Based on retrospective data showing ipratropium may increase adverse
cardiac events, there was a concern with a class effect with tiotropium.
• The UPLIFT trial found fewer cardiac events and a decreased cardiac
mortality in the tiotropium treatment group (14).
• Pulmonary rehabilitation has been shown to improve exercise tolerance,
quality of life, and decrease healthcare utilization, but studies have not
been powered to assess the effect on mortality (15).
• Lung volume reduction surgery (LVRS) has been shown to improve
dyspnea scores, dead space ventilation, exercise tolerance, and quality
of life.
• In select patients, including our patient, LVRS may improve long-term
mortality as well (16-18).


Question 4
• What patient population has the greatest
mortality risk from LVRS?
• A. Patients with homogeneous emphysema and a
low exercise capacity
• B. Patients with upper lobe predominate
emphysema and low exercise capacity
• C. Patients with homogenous emphysema and
high exercise capacity
• D. Patients with upper lobe predominant
emphysema and high exercise capacity


DISCUSSION
• Lung Volume Reduction Surgery (LVRS) is done by performing a wedge resection of
emphysematous lung tissue in select patients with COPD that are poorly controlled despite
maximal medical therapy.
• LVRS is thought to improve a patient’s functional status by increasing the elastic recoil and
expiratory airflow by restoring the outward circumferential pull on small airways.
• In addition, it is thought to help improve the strength and efficiency of the diaphragm by
decreasing the radius of its curvature.
• The National Emphysema Treatment Trial (NETT) showed that LVRS improved dyspnea symptom
scoring, minute ventilation with exercise, and maximal exercise capacity (16).
• A group of patients with an FEV1 less than 20% predicted and a diffusion capacity of less than
20% predicted were found to have a 30-day mortality rate of 16%.
• These patients were termed high risk and were eliminated from further analysis (19).
• Among the remaining non-high risk patients, mortality at 30-days was increased (2.2% in the
LVRS group versus 0.2% in the maximal medical therapy group), but long term mortality at two
years was similar.
• A subgroup analysis divided patients into groups based on location of emphysema and high
versus low exercise capacity defined by a cut off of 40 watts in men and 25 watts in women.
• At 24 months, the subgroup of upper lobe predominate emphysema and low exercise capacity
had improved survival, while the subgroup of patients with homogeneous emphysema and a high
exercise tolerance had decreased survival.
• The other two groups did not show survival benefit or an increased risk of death.


Question 5
• Which of the following changes to the patient’s history
would exclude her from Lung Volume Reduction
Surgery (LVRS)?
• A. A post-rehabilitation six-minute walk test of 150
meters
• B. A room air partial pressure of oxygen of 48 mmHg
• C. A diffusing capacity of inhaled carbon monoxide
(DLCO) that is 30% predicted
• D. A total lung capacity of 100% predicted.
• E. A requirement of 30 mg of prednisone a day to
control symptoms


DISCUSSION
• Patients that have COPD with severe obstruction and upper lobe predominate emphysema with
poor control despite maximal medical therapy can be considered for LVRS.
• To better stratify which patients will benefit from LVRS, further evaluation of their physiology and
functional status is needed.
• This evaluation should include a full set of pulmonary function testing, a six minute walk, a
cardiopulmonary exercise test, an ABG, and an echocardiogram.
• The Centers for Medicare and Medicaid Services (CMS) require that a patient have an FEV1 less
than 45% predicted and if over 75 years of age, the FEV1 must be greater than 15% predicted.
• If the FEV1 is less than 20% predicted, the DLCO must be greater than 20% predicted.
• The patient must also be stable on less than 20 mg of prednisone a day.
• A minimal total lung capacity of 100% predicted and a residual volume of 150% predicted are
needed to qualify.
• There is evidence that a higher RV to TLC ratio yields greater improvement in post-operative FVC.
• Participation in a minimal 6-week pre-operative pulmonary rehabilitation program is required
and a post-rehabilitation six minute walk of greater than 140 meters is needed to be considered
for LVRS.
• An arterial partial pressure of oxygen of 45 mmHg or greater and a partial pressure of carbon
dioxide less than 60 mmHg are also requirements from CMS.
• If a patient has an ejection fraction of less than 45% then evaluation and approval by a
cardiologist is required.
• Other factors that may exclude a patient from LVRS include: active smoking, severe cachexia or
obesity, comorbid lung or pulmonary vascular disease, and prior thoracic surgery.


Question 6
• What is the most common complication seven
days out from LVRS?
• A. Persistent chest tube air leak
• B. Pneumonia
• C. Renal failure
• D. Arrhythmias


DISCUSSION
• The most common post-operative complications from LVRS are
persistent air leaks, cardiac arrhythmias, pneumonia, and respiratory
failure requiring sustained mechanical ventilation or re-intubation.
• NETT found that air leaks occurred in 90% of patients with a median
duration of seven days and 12% of patients had an air leak for greater
than thirty days.
• Cardiac arrhythmias were the next most common complication with 23%
of patients developing an arrhythmia within the first thirty days.
• Pneumonia develops in approximately 18% of patients in the post-
operative period.
• Renal failure is not a common complication after LVRS surgery (16).
• A recent review of patients that underwent LVRS based on the NETT
criteria had prolonged air leak (greater than 7 days) as the most common
complication, occurring in 43% of patients (17).
• Persistent air leaks often lead to a protracted time that the patient needs
a chest tube, longer hospitalizations, and may require further surgical
intervention to repair the bronchopleural fistula.

chest ct cases-3
Dr :anas sahle
http://www.facebook.com/dranas224

HRCT-1
• What is the major abnormality in this case?
• a) Linear opacities
• b) Nodules
• c) Consolidation
• d) Ground-glass opacity

Note:
The vessels are very prominent in this case because the computer was set to optimize
visualization of the subtle major abnormality.

HRCT-2
• 2. What is the distribution of the
abnormalities?
• a) Bronchovascular.
• c) Centrilobular.
• d) Pleural.

Note: D = dome of diaphragm

HRCT-3

• Find an area of ground-glass opacity in the
right lung.
• Find 2 pleural nodules in the right lung.
• Find a nodule at the end of a vessel in the
right lung.
• Find 3 centrilobular nodules in the right lung.

HRCT-4

• Find a pleural nodule in the right lung.
• Find 2 nodules along the major fissure of the
right lung.
*Identification of fissure:
Vessels from upper and lower lobes branch and taper toward the fissure and are
absent at the fissure.

• Find two arteries obstructed by a cellular mass
with central hemorrhagic necrosis.
• Find the small subpleural hemorrhagic infarct
caused by the arterial obstruction.

Histologic Features
These two vessels would appear on HRCT as nodules at ends of vessels.

Note that on HRCT, some of the subpleural nodules in these cases may represent infarcts.

• Find and outline the cellular mass within the
vessel.
• What is the nature of the cellular masses in
this picture and in the one above?

• Find and outline the cellular mass within the
vessel.
• What is the nature of the cellular masses in
this picture and in the one above?
• Hematogenous metastatic neoplasm, which
may be confined to the vessel or may spread
into the surrounding lung

Diagnosis:

Hematogenous metastatic tumor

Summary

• diagnostic features of numerous
hematogenous metastatic nodules on HRCT:
– Usually random distribution
– Often smooth, well-defined
– Varying size common

random nodules

• Differential diagnosis of on HRCT:
– hematogenous metastasis (particularly from thyroid,
kidney, and breast) and
– miliary infections.
Langerhans' cell histiocytosis, sarcoidosis, and silicosis are common causes of nodules, but such
nodules are rarely diffuse and haphazard.
• Random nodules occur along the pleura and fissures, in a
centrilobular location, and in the bronchovascular region.
• The bronchovascular nodules in the case of random
nodules are seen at the ends of small arteries and not in
the proximal bronchovascular interstitium.
• Nodules in lymphangitic tumor and sarcoidosis are
frequently seen in the central bronchovascular interstitium.

MRCP EXAM
Respiratory

12/2/2012

Q1
The following are recognised associations •
with pulmonary hypertension:
A- An apgar of 3 at 5 minutes •
B- Meconium aspiration •
C- Hyaline membrane disease •
D- Hypo-glycaemia •
E- Oligo-hydraminos •

12/2/2012

A1
The following are recognised associations •
with pulmonary hypertension:
A- An apgar of 3 at 5 minutes (true) •
B- Meconium aspiration (true) •
C- Hyaline membrane disease (true) •
D- Hypo-glycaemia (true) •
E- Oligo-hydraminos (true) •

12/2/2012

Q2
The following are recognised causes of •
pulmonary eosinophilia:
A- Asthma •
B- Loeffler's Syndrome •
C- Hookworm infestation •
D- Aspergillus fumigatus •
E- Schistosomiasis •


A2
The following are recognised causes of •
pulmonary eosinophilia:
A- Asthma (True) •
B- Loeffler's Syndrome (True) •
C- Hookworm infestation (True) •
D- Aspergillus fumigatus (True) •
E- Schistosomiasis(false) •


Q3
The following are recognised treatments for
complications of cystic fibrosis:
A- DNAase to assist in reinflating collapsed lung
segments.
B- Rectal pull-through and anastamosis for rectal
prolapse.
C- Pancreatic transplant for diabetes mellitus.
D- Nebulised tobramycin for pseudomonas
colonisation of the lower respiratory tract.
E- Hypotonic saline drinks for hypernatraemic
dehydration.


A3
The following are recognised treatments for
complications of cystic fibrosis:
A- DNAase to assist in re-inflating collapsed lung
segments (false) .
B- Rectal pull-through and anastamosis for rectal
prolapse (false).
C- Pancreatic transplant for diabetes mellitus
(false).
D- Nebulised tobramycin for pseudomonas
colonisation of the lower respiratory tract
(true).
E- Hypotonic saline drinks for hypernatraemic
dehydration (false).

Q4
Regarding the sweat test:
A- Sweating is enhanced by application of
atropine.
B- The filter paper is left on for a total of about 4
hours.
C- At least 25mg of sweat is necessary for a
reliable result.
D- More than 60mmol/L of chloride in sweat is
diagnostic of cystic fibrosis.
E- False/positive results may be encountered in
children with nephrotic syndrome.


A4
Regarding the sweat test:
A- Sweating is enhanced by application of
atropine (false) .
B- The filter paper is left on for a total of about 4
hours (false).
C- At least 25mg of sweat is necessary for a
reliable result (false).
D- More than 60mmol/L of chloride in sweat is
diagnostic of cystic fibrosis (true).
E- False/positive results may be encountered in
children with nephrotic syndrome (false).


Q5
Diffusion capacity of carbon monoxide:
A- Is a specific measure of lung perfusion.
B- Depends on the thickness of the alveolar
wall.
C- Depends on the surface area available for
gas exchange.
D- Is increased in cigarette smokers.
E- Is increased in emphysema.


A5
Diffusion capacity of carbon monoxide:
A- Is a specific measure of lung perfusion
(false) .
B- Depends on the thickness of the alveolar
wall (true).
C- Depends on the surface area available for
gas exchange (true).
D- Is increased in cigarette smokers (false).
E- Is increased in emphysema (false).


Q6
The following respiratory symptoms may
be exacerbated by gastro-oesophageal
reflux:
A- Asthma
B- Central apnoea
C- Obstructive apnoea
D- Stridor
E- Wheeze


A6
The following respiratory symptoms may
be exacerbated by gastro-oesophageal
reflux:
A- Asthma (true)
B- Central apnoea (true)
C- Obstructive apnoea (true)
D- Stridor (true)
E- Wheeze (true)


Q7
In lung perfusion scanning:
A- Emphysema and pulmonary embolism
give similar appearances.
B- Iodine sensitivity is a contraindication.
C- Is always abnormal in Scimitar
Syndrome.
D- May show decreased upper lobe
perfusion in mitral stenosis.
E- Shows decreased perfusion in McLeod's
Syndrome.


A7
In lung perfusion scanning:
A- Emphysema and pulmonary embolism give
similar appearances (false) .
B- Iodine sensitivity is a contraindication (false).
C- Is always abnormal in Scimitar Syndrome
(true).
D- May show decreased upper lobe perfusion in
mitral stenosis (false).
E- Shows decreased perfusion in McLeod's
Syndrome (true).


Q8
In cystic fibrosis:
A- The sweat chloride is higher than the sodium.
B- The secretions are viscid because water cannot
be actively transported form the respiratory
epithelial cell.
C- The amino acid at position 508 of the CTRE
gene acts as a regulator of the chloride channel.
D- The DeltaF508 mutation explains most of the inter-
racial differences in the incidence of cystic fibrosis.
E- The CFTR traverses the cell membrane 7 times, and
is arranged in ring formation.


A8
In cystic fibrosis:
A- The sweat chloride is higher than the sodium (true) .
B- The secretions are viscid because water cannot be
actively transported form the respiratory epithelial
cell (false).
C- The amino acid at position 508 of the CTRE gene
acts as a regulator of the chloride channel (true).
D- The DeltaF508 mutation explains most of the inter-racial
differences in the incidence of cystic fibrosis (true).
E- The CFTR traverses the cell membrane 7 times, and is
arranged in ring formation (true).


Q9
Pneumocystis carinii:
A- Predisposes to pneumothorax.
B- Can cause pneumonia with very few
signs on chest x-ray.
C- Is an obligate intracellular organism.
D- May cause extrapulmonary infection.
E- Is usually diagnosed by finding a
rising titre of neutralising antibodies.

A9
Pneumocystis carinii:
A- Predisposes to pneumothorax (true) .
B- Can cause pneumonia with very few
signs on chest x-ray(false).
C- Is an obligate intracellular
organism(false).
D- May cause extra-pulmonary infection
(true).
E- Is usually diagnosed by finding a rising
titre of neutralising antibodies(false).


Q10
Recognised complications of
bronchoscopy include:
A- Haemorrhage
B- Pneumothorax
C- Segmental collapse
D- Hypoxic ischaemic encephalopathy
E- Empyema


A10
Recognised complications of
bronchoscopy include:
A- Haemorrhage (true)
B- Pneumothorax (true)
C- Segmental collapse (true)
D- Hypoxic ischaemic encephalopathy(false)
E- Empyema (true)


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