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28-yo man with a 10 day history of mild cough and low fever. No significant PMH and otherwise healthy. No sputum production or hemoptysis. Chest exam is normal. Next best step in management?

Symptomatic management


In which patients should you order f/u imaging in pneumonia?

older, current/former smokers, recurrent pneumonias


Atypical pneumonias on CXR appear with which of the following characteristics?

1) B/L
2) Ground glass appearance
3) Kerley B Lines (septal lines- thickening of interlobular septa)
4) Relative sparing of bases and apices


Which imaging modalities can be used for radiographic diagnosis of pleural effusions?

CXR Right lateral decubitus
CT (for loculated and complex pleural collections)


Which patients need preoperative CXR?

1) Patients with cardiorespiratory signs and symptoms
2) Patients over 65 with stable cardiorespiratory disease and no CXR for six months


Single pulmonary nodules management?

Comparison important to assess stability >2yrs
CT if suspicious for malignancy or many risk factors


Single pulmonary nodule concerning characteristics

size: greater than 1cm or increasing in size
edge: lobulated, spiculated, ill-defined
pattern of calcifications


Single pulmonary nodule patient risk factors

h/o lung disease
>40 yrs
smoking history
granulomatous disease
h/o malignancy


Lung cancer screening?

low dose CT, current/former smokers or other high risk pts
f/u in-determinants with pet before bx


Best choice of imaging to evaluate for a subtle pneumothorax?

erect expiratory CXR (Increased lung density and decreased thoracic volume)
right lateral decubitus CXR


CXR signs of a tension pneumothorax:

-Mediastinal shift AWAY
-Diaphragmatic depression on side of pneumothorax
-Complete lung collapse typical


Clinical signs of tension pneumothorax:

-Pulsus paradox
-Hyper-resonance on side
-Decreased respiratory excursions on side
-Absent breath sounds on side of pneumothorax


Management of tension pneumothorax:

IMMEDIATE temporary relief of by inserting a large-bore needle into the second left interspace in the mid-clavicular line


What pathophysiology correlated to the CXR finding: faint "veil-like" opacification of the middle 2/3 of the left hemithorax?

Atelectic left upper lobe that retracts anteriorly


What pathophysiology correlated to the PA CXR finding: Tracheal shift to the left, diaphragmatic elevation, and loss of the left heart border

Volume loss in the left hemithorax


What pathophysiology correlated to the lateral CXR finding: Sharp edge with opacification over the anterior chest/heart

Left upper lobe collapses against the anterior chest wall


Differential diagnosis of complete opacification of a hemithorax?

complete lobe atelectasis (collapse)
Hemi-pneumonectomy (look for clues: rib resections, clips, volume shift)
large pleural effusion
large mass
large pneumonia


What is a typical x-ray 'trauma series'?

AP supine CXR
Lateral C-spine
AP supine pelvis


Common radiographic findings seen in traumatic aortic injury (TAI)?

Widening mediastinum (>8cm)
Mediastinal deviation to the right
No 'lateral aortic silhouette'
No aortic knob


What is a typical CT 'trauma series'?

CT w/o Head
CT C-spine
CT Chest/Abd/Pelvis with contrast


Appropriate radiologic aorta evaluation?

CT with Contrast
Transesophageal echo (if contrast contraindicated)
MRI (time permitting, if contrast contraindicated)


Recognition of a pneumothorax on supine CXR?

Deep Sulcus Sign- one costophrenic angle appears much 'deeper' and more lucent than the other


Radiographic evaluation of chest tube placement?

anterior and apical for a pneumothorax
posterior and basal for a pleural effusion


Radiographic evaluation of endotracheal tube placement?

3-5 cm above the carina


Radiographic evaluation of enteric (NG) tube placement?

Feeding tube: third portion of the duodenum or duodenal-jejunal junction
Regular NG/OG: Stomach (confirmed by auscultation)


Considerations for obtaining baseline CXR for patients with chronic dyspnea of suspected pulmonary origin?

age, lung cancer risk, suspicion for- pulmonary fibrosis, COPD, pneumonia, pleural effusion, pneumothorax.


CXR signs of COPD?

CXR NOT sensitive or specific for COPD...but
-mediastinal narrowing
-enlarging central pulmonary arteries
-increase lucency (darkness)


Confirmatory test for CXR suspicious for COPD?

Pulmonary function tests
FEV1/FVC 45% predicted (c/w severe obstruction)


Imaging options for suspected aortic dissection?

#1 Contrast enhanced CT angiogram of the entire aorta
#2 MRI (if stable)
#3 Transesophageal echo


BEST imaging test to confirm the diagnosis of pulmonary emboli?

#1 CT angiography EXCEPT in patients with contraindications to intravenous contrast (allergy/renal)
#2 Nuclear medicine V/Q scanning