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Flashcards in Amir Sam Lectures Deck (50):
1

3 causes of sudden onset breathlessness. (Seconds)

Pneumothorax Pulmonary Embolism (any risk factors?) Foreign Body obstruction (anything in history to suggest?)

2

60 yr old man SOB Sudden onset PMH: COPD On symbicort & tiotropium PR: 110 bpm JVP: raised , Decreased BS, Scattered wheeze & creps (R) Peripheral oedema Sats: 80% (air) FBC: Hb 8.5, WCC 12, plt: 300

Most likely diagnosis?

1. Pneumothorax

2. Pulmonary embolism

3. Airway disease

4. Pneumonia

5. Pulmonary oedema

6. Interstitial lung disease

7. Pleural effusion

8. Anaemia

9. Thyrotoxicosis

10. Nerve/muscle disease

Sudden onset SOB!!! Signs of COPD 1. Pneumothorax No risk factors for PE, nothing in history suggestive of foreign body. PC is most important thing. Sudden onset breathlessness. Chronic lung disease can predispose to pneumothorax (bullae bursting).

3

Framwork for breathlessness. 3 things from HPC/History

Example for pneumothorax. Symptom characteristic (eg- sudden onset) Associated symptoms (eg- no cough, sputum, haemoptysis) DDx and Risk factors: (eg- PE or pneumothorax- ?signs of DVT, previous DVT/PE, ?immobility, surgery, malignancy.

4

Causes of acute onset SOB (Mins/Hours)

Airways (inflammation/obstruction) Chest infection in alveoli/interstitium (pus- pneumonia) Acute heart failure (fluid- pulmonary oedema)

5

Major risk factors for PE

Previous DVT/PE Signs of DVT Family history of PE Immobility Surgery Malignancy

6

Causes of slower onset SOB (Days/Weeks)

Go back through more acute causes- recurrent or not resolving. Eg- recurrent small PEs, Asthma/COPD, persistent pneumonia etc. Interstitial lung disease (PF) Malignancy/large pleural effusion Neuromuscular problem Anaemia/Thyrotoxicosis

7

60 yr old man SOB Sudden onset PMH: COPD On symbicort & tiotropium PR: 110 bpm JVP:  ,  BS, Scattered wheeze & creps (R) Peripheral oedema Sats: 80% (air) FBC: Hb 8.5, WCC 12, plt: 300 Started on Oxygen and CXR.(CXR showing large RS pneumothorax) What is the most appropriate next step? A. Chest drain insertion B. Chest ultrasound C. CPAP D. Observation E. Pleural aspiration

Primary pneumothorax or Secondary? (Secondary- underlying lung disease: COPD) Is it small or large? Is it more than 2cm or less than 2cm from chest wall? (Large) A. Chest drain insertion (Secondary pneumothorax >2cm)

8

Signs of primary pneumothorax

Tall, thin man with no underlying lung disease. Could be asymptomatic if small or: Sudden onset SOB, pleuritic chest pain especially on inspiration, respiratory distress, reduced expansion and breath sounds, hyper-resonant percussion.

9

Signs of secondary pneumothorax.

Pre-existing lung disease (COPD, asthma, TB, pneumonia, lung carcinoma, cystic fibrosis, diffuse lung disease). Could be asymptomatic if small or: Sudden onset SOB, pleuritic chest pain especially on inspiration, respiratory distress, reduced expansion and breath sounds, hyper-resonant percussion.

10

Management of primary pneumothorax. 2cm

2cm/SOB- Aspiration. If unsuccessful- chest drain.

11

Management of secondary pneuomothorax. 2cm

2cm- chest drain insertion

12

4 types of shadowing on CXR

Homogeneous white: haemothorax, pleural effusion

Coin lesions: masses/cavitations

Reticulo-nodular (lines and dots): pulmonary fibrosis or interstitial lung disease 

Fluffy airspace shadowing: fluid (Heart failure- pulmonary oedema), pus (pneumonia), blood (pulmonary haemorrhage- rare). (Interstitial/alveolar shadowing)

(Hard to differentiate between fluffy and reticular nodular)

13

Differential of fluffy airspace shadowing.

Fluid- heart failure and pulmonary oedema- usually bilateral Pus- pneumonia- usually unilateral Blood- pulmonary haemorrhage in someone with vasculitis- v. rare)

14

Pneumothorax- what 2 questions do you ask?

Primary or Secondary Large or Small (2cm away from chest wall)

15

47 year old woman Acute SOB Pleuritic chest pain PMHx: DVT O2 Saturation: 78% OA PR: 110 bpm BP: 120/80 mmHg Raised JVP Vesicular BS Most likely diagnosis? 1. Pneumothorax 2. Pulmonary embolism 3. Airway disease 4. Pneumonia 5. Pulmonary oedema 6. Interstitial lung disease 7. Pleural effusion 8. Anaemia 9. Thyrotoxicosis 10. Nerve/muscle disease

5 P's of pleuritic chest pain Previous DVT Raised JVP (pulmonary hypertension) Vesicular BS (not pneumonia) 2. Pulmonary Embolism is cause

16

5 causes of pleuritic chest pain

5 P's PE Pneumothorax Pericarditis Pneumonia Pleural pathology

17

3 causes of raised JVP

Right sided failure or strain finish this card

18

Quick way of determining Axis. 2 questions. 3 leads.

I, II and avL

 

1. Look at I and II. Is either of them overall negative? Yes?--> axis deviation

2. Look at avL: is it overall positive? Yes?-->Left axis deviation. No?-->Righ axis deviation

19

47 year old woman
Acute SOB
Pleuritic chest pain
PMHx: DVT

O2 Saturation: 78% OA

PR: 110 bpm
BP: 120/80 mmHg
Raised JVP
Vesicular BS

CXR showed now pneumothorax. Wat does the ECG show?


A.Atrial fibrillation
B.Normal axis & RBBB
C.Right Axis deviation & RBBB
D.Right Axis deviation & LBBB
E.S1, Q3, T3 
 

Q image thumb

C. Right axis deviation and RBBB

Not atrial fibrillation

P waves present before QRS- sinus rhythm

Right axis deviation (I or II overall negative. avL overall negative)

Bundle branch block (M is V1, W in V6. MaRRoW- V1 mostly above line, V6 mostly below line)

PE- right heart strain expected.

 

20

47 year old woman
Acute SOB
Pleuritic chest pain
PMHx: DVT

O2 Saturation: 78% OA

PR: 110 bpm
BP: 120/80 mmHg
Raised JVP
Vesicular BS

Given Oxygen. CXR showed now pneumothorax. ECG showed RAD and RBBB.

 

What is the next most appropriate step in her management?


A.LMWH
B.BiPAP
C.Warfarin
D.Thrombolysis
E.Furosemide

A. LMWH 

Low molecular weight heparin.

Anticoagulation needed. LMWH gives immediate anticoagulation- upon suspicion of PE (before CTPA).

Thrombolysis (rarely done- do it in PE when haemodynaically compromised)

Warfarin will be long term treatment after diagnosis by CTPA- but intially procoagulant until INR within theraeutic range (2-3) (about 5 days)- then you can stop LMWH.

21

Possible changes on ECG in a person with PE. (4)

1. sinus tachycardia (commonest)

2. AF (common)

3. RAD and/or RBBB

4. S1, Q3, T3 (large S wave in I, Q wave in III and T inversion in III)

 

Strain on right side of heart.

(Best signs to look at is the R wave in V1- big R wave in V1 suggests a big right ventricle (strain))

22

Indication for BiPAP

Respiratory acidosis for a patient who is retaining CO2 (COPD).

23

Indication for thrombolysis in PE.

If person has PE and is haemodynamically compromised (eg- SBP of 60 and is about to arrest) and if no contraindications (eg- recent haemorrhagic condition- haemorrhagic stroke, bleeding)

24

Management plan for suspected PE if haemodynamically stable.

Oxygen

Upon suspicion of PE.

Interim LMWH (tinzaparin)

Request CTPA

Upon diagnosis- start warfarin and continue LMWH

When INR (2-3) or 5 days (whichever is longer)- stop LMWH and continue warfarin for at least 3 months (6 months). If recurrent PEs then life-long warfarin.

25

What does this CXR show? Diagnosis?

Q image thumb

Arrow pointing to area of slightly darker. Area of oligaemia (Westamark's sign)- vessels distal to the clot have collapsed. V. rare to see on CXR (2% of PEs). So PE is the diagnosis- seen on CTPA- sudden cut off where no more contrast is going beyond- big clot).

26

Management plan for a patient with a primary pneumothorax >2cm. And what drug would you prescribe?

Put them on oxygen.

Aspirate (repeat CXR to see if resolved)- to avoid chest drain.

If unsuccessful then put in a chest drain (local anaesthetic)

Prescribe regular analagesics (paracetemol 1g, QDS or PRN)- local anaesthetic will wear off. (also codeine, ibuprofen, morphine if severe).

Repeat CXR.

27

Management plan for a patient with a secondary pneumothorax >2cm. What drug will you prescribe?

Give oxygen.

Insert a chest drain. (Aspiration is futile in Secondary >2cm) 

Repeat CXR to see if resolved.

Give regular analgesics (Paracetemol 1g, QDS)- also codeine, ibuprofen. (Local anaesthetic will wear off).

28

A 41-year-old man with a smoking history of 30 pack-years presented with chronic chest pain, dyspnea, and cough. His vital signs were normal, and laboratory studies were unremarkable, including his level of α1-antitrypsin, which was normal. Physical examination revealed cachexia, with decreased apical breath sounds and hyperresonance to percussion in both lungs.

What does the CXR and CT show?

Q image thumb

History suggests pneumothorax, but CXR and CT does not look like pneumothorax. Air fluid level and can't see lung border. Very large bullous (destruction of alveolar). Called vanishing lung syndrome. Do not put a needle in this- will be catastrophic- not pneumo.

Chest radiography showed extensive bullous lung disease in the apex and upper lobes of both lungs (Panel A, arrows; Panel B), which was suggestive of vanishing lung syndrome; air–liquid levels were seen in the left lung (Panels A, B, and C, asterisk). Computed tomography of the chest confirmed these findings (Panels C and D). Vanishing lung syndrome, otherwise known as idiopathic giant bullous emphysema, typically occurs in young, thin male smokers. The radiographic criteria for vanishing lung syndrome were proposed in 1987, and they include giant bullae in one or both upper lobes occupying at least one third of the hemithorax and compressing surrounding parenchyma. Air–liquid levels within bullae are uncommon and raise the question of bacterial superinfection. Lung-volume–reduction surgery is considered for selected patients with vanishing lung syndrome after assessment of exercise capacity, pulmonary-function testing, and smoking cessation. This patient underwent successful lung-volume–reduction surgery and is currently without residual symptoms.

29

•50-year-old female
•progressive SOB
•dry cough
•clubbing
•FEV1/FVC ratio > 70%. 
 

What does this CXR show?

1. Pneumothorax 

2. Pulmonary embolism 

3. Airway disease 

4. Pneumonia 

5. Pulmonary oedema 

6. Interstitial lung disease 

7. Pleural effusion 

8. Anaemia 

9. Thyrotoxicosis 

10. Nerve/muscle disease

Q image thumb

6. Interstitial lung disease (or pulmonary fibrosis.)

Progressive breathlessness

No sputum (dry cough)

CXR shows reticular nodular shadowing

Clubbing- sign of ILD

FEV1/FVC ratio >70% (not obstructive- COPD/asthma)- restructive lung disease

 

(everything you need to know for interstitial lung disease)

DDx: idiopathic fibrosing alveolitis; CTDs (RA), drugs, asbestosis (?ship builder).

30

What is asbestosis?

Pulmonary fibrosis (chronic SOB, dry cough, FEV1/FVC >70%) clubbing caused by asbestos. Asbestos can aslo cause pulmonary plaques- this is not asbestosis.

31

50-year-old female

Chronic SOB

Sputum

No clubbing

FEV1/FVC ratio < 70% 

 

What does this CXR show? Diagnosis?

Q image thumb

Sputum/productive cough. (not PF)

FEV1/FVC <70% (obstructive ling disease)

CXR shows hyperinflated/hyperexpanded lungs (COPD) with diaphragm flattening.

No clubbing (COPD does not cause clubbing- sign of cancer or PF- so clubbing in COPD patient suggests cancer from smoking history)

32

•Cough
•sputum
•wt loss
•Night sweats
 

Diagnosis and management?

Q image thumb

Pulmonary TB

productive cough (?haemoptysis), weight loss, night sweats

CXR shows fluffy airspace shadowing in upper lobe (TB affects upper lobes)

 

Isolate this patient and send a sputum sample (acid-fast bacilii etc)

 

33

•A 70-year-old man
•SOB
•Keeps pigeons
 

What is the diagnosis?

Q image thumb

Extrinsinc allergic alveolitis.

SOB

Bilateral reticular nodular shadowing (pulmonary fibrosis/ ILD)

Keeps pigeons (extrinsic allergic alveolitis EAA)

 

Can be caused by fungi, protazoa, animal/insect proteins
or LMW chemical compounds. Can be acute, subacute or chronic.

Acute EAA (most common): fever, chills, chest tightness, breathlessness, cough.

Fine insiratory crepitations. Finger clubbing is rare.

Full occupational history and enquiry into hobbies and pets is important.

 

 

Farmer’s lung: Mouldy hay containing thermophilic actinomycetes.
Pigeon/budgerigar fancier’s lung: Bloom on bird feathers and excreta.
Mushroom worker’s lung: Compost containing thermophilic actinomycetes.
Humidifier lung: Water-containing bacteria and Naegleria (amoeba).
Maltworker’s lung: Barley or maltings containing Aspergillus clavatus.

 

 

34

Classical picture of interstitial lung disease / pulmonary fibrosis.

Progressive SOB (so present with dyspneoa on exertion)

Dry cough

Cyanosis

Clubbing (50%)

FEV1/FVC >70%

Full occupational and drug history is important.

Auscultation: Bibasal fine late inspiratory crepitations. No wheeze.

CXR: reticular nodular shadowing

35

Differential Diagnosis of interstitial lung disease or pulmonary fibrosis

Idiopathic fibrosing alvelolitis (cryptogenic fibrosis alveolitis)

Connetive tissue disease (RA)

Drugs

Asbestosis (?ship builder/exposure)

 

36

Commenting on the Quality of the chest radiograph.

With regards to the quality of the film...

 

RIP

Rotation (distance between spinous process and medial ends of clavicles and they should be equidistant on either side)

Inspiration (can see 7 ribs anteriorly)

Penetration (look at vertbrae- lines between. Too white= under penetrated; Too black= over penetrated).

37

What does this X-ray show?

1. COPD

2. Pneumothorax

3. Pneumonia

4. Left lower lobe consolidation

5. Pulmonary oedema

6. Fibrosing alveolitis

7. Pleural effusion

8. Lung collapse

9. Cavitating lesion

10. Pericardial effusion

11. Bilateral hilar lymphadenopathy

12. Pleural plaques

13. Mastectomy

14. Pacemaker or ICD

Q image thumb

1. COPD

Hyperinflated lungs with flattened diaphragm

38

What does this X-ray show?

1. COPD

2. Pneumothorax

3. Pneumonia

4. Left lower lobe consolidation

5. Pulmonary oedema

6. Fibrosing alveolitis

7. Pleural effusion

8. Lung collapse

9. Cavitating lesion

10. Pericardial effusion

11. Bilateral hilar lymphadenopathy

12. Pleural plaques

13. Mastectomy

14. Pacemaker or ICD

Q image thumb

2. Pneumothorax (left sided)

compare left and right sides

39

What does this X-ray show?

1. COPD

2. Pneumothorax

3. Pneumonia

4. Left lower lobe consolidation

5. Pulmonary oedema

6. Fibrosing alveolitis

7. Pleural effusion

8. Lung collapse

9. Cavitating lesion

10. Pericardial effusion

11. Bilateral hilar lymphadenopathy

12. Pleural plaques

13. Mastectomy

14. Pacemaker or ICD

Q image thumb

3. Pneumonia (right middle zone)

Fluffy, airspace shadowing, unilateral. Cannot see right heart border. Consolidation in right middle lobe.

40

What does this X-ray show?

1. COPD

2. Pneumothorax

3. Pneumonia

4. Left lower lobe consolidation

5. Pulmonary oedema

6. Fibrosing alveolitis

7. Pleural effusion

8. Lung collapse

9. Cavitating lesion

10. Pericardial effusion

11. Bilateral hilar lymphadenopathy

12. Pleural plaques

13. Mastectomy

14. Pacemaker or ICD

Q image thumb

4. Left lower lobe consolidation

loss of left hemidiaphragm. loss of cardiophrenic border. loss of costophrenic angles.

41

What does this X-ray show?

1. COPD

2. Pneumothorax

3. Pneumonia

4. Left lower lobe consolidation

5. Pulmonary oedema

6. Fibrosing alveolitis

7. Pleural effusion

8. Lung collapse

9. Cavitating lesion

10. Pericardial effusion

11. Bilateral hilar lymphadenopathy

12. Pleural plaques

13. Mastectomy

14. Pacemaker or ICD

Q image thumb

5. Pulmonary oedema

Bilateral fluffy airspace shadowing (bat wings)- could be bilateral pneumonia

Pulmonary oedema most likely (could be pneumonia)- depend on history (fever and green sputum- pneumonia; breathless when lie flat, elevated BNP, abnormal echo- heart failure and pulmonary oedema)

42

What does this X-ray show?

 

1. COPD

2. Pneumothorax

3. Pneumonia

4. Left lower lobe consolidation

5. Pulmonary oedema

6. Fibrosing alveolitis

7. Pleural effusion

8. Lung collapse

9. Cavitating lesion

10. Pericardial effusion

11. Bilateral hilar lymphadenopathy

12. Pleural plaques

13. Mastectomy

14. Pacemaker or ICD

Q image thumb

6. Fibrosing alveolitis (Pulmonary fibrosis)

Reticulo-nodular shadowing

Idiopathic, CTDs, drugs (amiodarone, phenytoin), asbestosis, EAA

43

What does this X-ray show?

1. COPD

2. Pneumothorax

3. Pneumonia

4. Left lower lobe consolidation

5. Pulmonary oedema

6. Fibrosing alveolitis

7. Pleural effusion

8. Lung collapse

9. Cavitating lesion

10. Pericardial effusion

11. Bilateral hilar lymphadenopathy

12. Pleural plaques

13. Mastectomy

14. Pacemaker or ICD

Q image thumb

7. Pleural effusion (left sided)

Homogeneous shadow, unilateral, meniscus

44

What does this X-ray show?

1. COPD

2. Pneumothorax

3. Pneumonia

4. Left lower lobe consolidation

5. Pulmonary oedema

6. Fibrosing alveolitis

7. Pleural effusion

8. Lung collapse

9. Cavitating lesion

10. Pericardial effusion

11. Bilateral hilar lymphadenopathy

12. Pleural plaques

13. Mastectomy

14. Pacemaker or ICD

Q image thumb

8. Collapsed lung (right sided)

Homogeneous white (pleural effusion or pneumonectomy). Pneumonectomy as trachea is deviated towards white space (pleural effusion would push it away) (collapsed lung or pneumonectomy- look for scars).

45

What does this X-ray show?

1. COPD

2. Pneumothorax

3. Pneumonia

4. Left lower lobe consolidation

5. Pulmonary oedema

6. Fibrosing alveolitis

7. Pleural effusion

8. Lung collapse

9. Cavitating lesion

10. Pericardial effusion

11. Bilateral hilar lymphadenopathy

12. Pleural plaques

13. Mastectomy

14. Pacemaker or ICD

Q image thumb

9. Cavitating lesion

left sided

Lesion (coin lesion) with an air fluid level (in which a cavity has formed)

either a tumour (squamous cell carcinoma) or TB or inflammatory nodule. (want to make sure it's not malignant)

46

What does this X-ray show?

1. COPD

2. Pneumothorax

3. Pneumonia

4. Left lower lobe consolidation

5. Pulmonary oedema

6. Fibrosing alveolitis

7. Pleural effusion

8. Lung collapse

9. Cavitating lesion

10. Pericardial effusion

11. Bilateral hilar lymphadenopathy

12. Pleural plaques

13. Mastectomy

14. Pacemaker or ICD

Q image thumb

10. Pericadial effusion

Lungs are normal

Heart is large and globular big pericardial effusion- fluid inside the pericardium

Causes: infection (TB), inflammation (CTDs- rheumatoid nodule or Wegener's granulomatosis), malignancy (squamous cell carcinoma)

47

What does this X-ray show?

1. COPD

2. Pneumothorax

3. Pneumonia

4. Left lower lobe consolidation

5. Pulmonary oedema

6. Fibrosing alveolitis

7. Pleural effusion

8. Lung collapse

9. Cavitating lesion

10. Pericardial effusion

11. Bilateral hilar lymphadenopathy

12. Pleural plaques

13. Mastectomy

14. Pacemaker or ICD

Q image thumb

11. Bilateral hilar lymphadenopathy (Sarcoidosis)

Large hilar on both sides

Infection (TB), inflammation (Sarcoidosis), malignancy (lymphoma)

48

What does this X-ray show?

1. COPD

2. Pneumothorax

3. Pneumonia

4. Left lower lobe consolidation

5. Pulmonary oedema

6. Fibrosing alveolitis

7. Pleural effusion

8. Lung collapse

9. Cavitating lesion

10. Pericardial effusion

11. Bilateral hilar lymphadenopathy

12. Pleural plaques

13. Mastectomy

14. Pacemaker or ICD

Q image thumb

12. Pleural plaques

Well-defined plaques- pleural plaques. Exposure to asbestos (not asbestosis)

49

What does this X-ray show?

1. COPD

2. Pneumothorax

3. Pneumonia

4. Left lower lobe consolidation

5. Pulmonary oedema

6. Fibrosing alveolitis

7. Pleural effusion

8. Lung collapse

9. Cavitating lesion

10. Pericardial effusion

11. Bilateral hilar lymphadenopathy

12. Pleural plaques

13. Mastectomy

14. Pacemaker or ICD

Q image thumb

13. Mastectomy (right)

Missing

50

What does this X-ray show?

1. COPD

2. Pneumothorax

3. Pneumonia

4. Left lower lobe consolidation

5. Pulmonary oedema

6. Fibrosing alveolitis

7. Pleural effusion

8. Lung collapse

9. Cavitating lesion

10. Pericardial effusion

11. Bilateral hilar lymphadenopathy

12. Pleural plaques

13. Mastectomy

14. Pacemaker or ICD

Q image thumb

13. Pacemaker or ICD

 

look where leads go- atrial lead and ventricular lead so dual chamber cardiac pacer