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Chest and vascular > Practice viva > Flashcards

Practice viva Flashcards

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1
Q

Pulmonary hypertension, plain film

A

Elevated apex - RVH
Enlarged right atrium
Prominent pulmonary outflow tract, enlarged pulmonary arteries
Pruning of peripheral pulmonary vessels

Mural calcification of pulmonary vessels highly specific - seen in Eisenmengers

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2
Q

Pulmonary HTN 2008 world sympsosium

A

PA pressure >25, wedge pressure >15

1 - idiopathic, drug toxin induced, connective tissue disease
2 - left sided heart disease
3 - lung disease or hypoxia - COPD, interstitial lung disease
4 - thromboembolism
5 - multifactorial

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3
Q

Mediastinal mass localisation

A

Mediastinal masses create obtuse angles with lung, and disrupt mediastinal lines

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4
Q

Anterior mediastinal mass

A

Obliterated retrosternal clear space
Loss of sharp ascending aorta or anterior junctional line (lower of the two lines, doesn’t go above 1st rib / clavicle)
Hilum overlay (most will be anterior)
Loss of cardiophrenic angle

Lymphoma most common child (actually thymic hyperplasia 1), thymic adult

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5
Q

Middle mediastinal mass

A

To 1cm posterior to anterior vertebral line
AP window, paratracheal stripes
Azygooesophageal recess displacement (Right - new intervace, looks like a paravertebral line) (Can be displaced by posterior mass)
Left pseudoparavertebral line
Mass on posterior trachea on lateral
Doughnut sign - mass surrounds bronchus on lateral

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6
Q

Lateral chest x-ray (add stuff from the MCQ file)

A

.

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7
Q

Cervicothoracic sign

A

Superior border of mass descernible, above the clavicels

Must be in Apical upper lobe, pleural, or posterior medastinum

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8
Q

Foregut duplication cyst

A

Generic term
Encompasses neurenteric cysts and bronchogenic cysts., oephageal
Bronchogenic tend to be middle mediastinum, neurenteric posterior.

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9
Q

Paeds mediastinal masses

A

Lymphoma most common anterior
Duplication cyst most common middle
Neurogenic tumour most common posterior

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10
Q

ECMO

A

Venoarterial or venovenous
Venoarterial - out via right atrium (via femoral or IJV), in via femoral, subclavian artery line, aorta.
Venovenous - In and out via central venous lines. Can have double lumen catheter.
Anticoagulated (consider if need to put chest drain)

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11
Q

Mitral stenosis

A

Often secondary to rheumatic fever
Left atrial enlargement - splayed carina, elevation left main bronchus, convex left atrial appendage, double right heart border,
Upper lobe venous engorgement from venous hypertension

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12
Q

Other valvular diseases?

A

.

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13
Q

Chest wall soft tissues

A

Alway evaluate for mastectomy

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14
Q

Secondary findings

A

E.g. right sided arch, but also lymphoma

Or additional aberrant subclavian

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15
Q

Primary TB

A

Patchy or lobar consolidation, any lobe, preference for middle and lower lobes
Lymphadenopathy (especially in children - 90%, only 10-30% adults. Low density with rim enhancement)
May be miliary (immunocompromised more)
Pleural effusions (30-40% adults, 10% children)
May resolve without any radiological abnormality, or Ghon focus scar may remain (calcified granuloma)
Symptoms only in 5%
Cavitation uncommon
May have massive haemoptysis from erosion into a bronchial artery

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16
Q

Secondary TB

A 
Upper zone predominant
Far more likely to cavitate
Lymphadenopathy less common
Effusion less common
Usually patchy
Can have lobar consolidation, miliary, tuberculoma
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17
Q

Massive haemoptysis

A 
Cancer
Bronchiectasis, bronchitis
TB
Aspergilloma
Pneumococcal
Contusion
PE
Other

Bronchiectasis is most common cause of bronchial artery hypertrophy leading to massive haemoptysis

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18
Q

Left atrium, congenital

A

Enlarged in VSD, PDA. Normal size in ASD

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19
Q

Left atrial enlargement

A

Congenital (VSD, PDA)

Or acquired - mitral valve disease, most commonly Rheumatic

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20
Q

Tetralogy of fallot

A

VSD
Overarching aorta
Pulmonary stenosis
RVH

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21
Q

Dilated ascending aorta

A 
Aneurysm
HTN
Dissection
Coarctation
Valvular disease including bicuspid valve
Congenital heart disease
Connective tissue disorders.
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22
Q

Bicuspid aortic valve

A 
Major cause of aortic valve disease in young adults
2% incidence, more common in males
Dilated ascending aorta
70% of coarctations have bicuspid valve
10% of Turners have it
Associated with ADPKD
Associated with berry aneurysms
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23
Q

Pacemaker

A

Single chamber
Dual chamber
Biventricular (additional lead through coronary sinus to left ventricular vein)

Coronary sinus drains to RA, drains cardiac veins, courses along posterior LA.
Unroofed coronary sinus has opening to LA also, a rare ASD
Hiccups?

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24
Q

Ribbon ribs

A

Thinned ribs
Commonly due to neurofibromas in NF1
Also seen in OI, Edwards (18), Gorham disease (progressive massive osteolysis)

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25
Left to right shunt
ASD, VSD, PDA, AVSD
26
Sarcoid, biochemical markersm, imaging stage
ACE - 40% false negative, 10% false positive 30-50% hypercalcuric, 10-20% hypercalcaemic May be stage 1-3 at presentation, unlikely 4 (fibrosis)
27
Common cavitating lesions
Malignancy most common Then infection Cancer, autoimmune, vascular, infection, trauma, young Sarcoid can cavitatae
28
Transposition
L - congenitally corrected D - egg-on-a-string - narrowed superior mediastinum due to stress thymic atrophy and pulmonary hyperexpansion, parallel great vessels, globular heart from LA enlargement and convex RA L - AV discordance and VA discordance Plain film appearance?
29
Scleroderma
Dilated oesopagus Soft tissue calcification - subcutaneous and periarticular Acroosteolysis Finger contractures Atrophic finger tips Resorption UIP, NSIP, PAH Egg-shell calcification of mediastinal nodes (seen in other conditions e.g. silicosis (more pathognomonic of this), treated lymphoma rarely sarcoid)
30
TIP
Be wary of recommending CT on chest viva. Get most out of the plain film
31
Cystic lung disease
LIP (Sjogrens, women), LAM, LCH (smokers) LIP lower zone (and ground glass), LCH upper (nodules which cavitate), LAM uniform (prone to chylothoraces and pneumothoraces) UIP, Cystic bronchiectasis, pneumocystis, pulmonary lac Burt-Hogg-Dube - Lower zone lung cysts, chromophobe RCC and oncocytomas, cutaneous manifestations, chromosome 17, AD, rare
32
Pneumomediastinum
``` Asthma Barotrauma Interstitial lung disease Infection Booerhaves Oesophageal cancer ```
33
Supine pneumothorax
Deep sulcus
34
Cannonball mets
RCC, choriocarcinoma Less commonly, prostate, synovial, endometrial. bladder TCC
35
Chest wall mass
Soft tissue, benign, malignant Ribs, benign, malignant ST B - haemangioma, lymphangioma, lipoma, nerve sheath ST M - rhabomyosarc, Askin Ewings sarc, malignant fibrous histiocytoma (/PUS), neuroblastoma, malignant peripheral nerve sheath tumour Ribs B - Fibrous dysplasia, ABC, GCT Ribs M - myeloma, mets, osteosarcoma, chondrosarcoma
36
TNM staging of lung cancer
.8th edition staging 2016 T1 <3, 2 2-5 or main bronchial involvement or atelectatic, 3 5-7 or tumour nodule same lobe, 4 >7 or tumour nodule different lobe or invasive N1 ipsilateral hilar, N2 ispilateral mediastinal or subcarinal, N3, contraleteral mediastinal or hilar, or supraclavicular M1a - pleural or pericardial, b single extrathoracic, c multiple extrathoracic Once N3 or T3/4 N2, can't operate, stage 3b
37
Posterior medastinal mass
Neurogenic tumour - benign and malignant (most common. Includes neurofibroma, schwannoma, MPNST, neuroblastoma, ganglioneuroblastoma, ganglioneuroma - ganglioneuroma most common, with both the ganglios in older patients than neuroblastoma) Neurenteric duplication cyst Paravertebral mass - include abscess, haematoma, mets Descending thoracic aneurysm Lymphadenopathy / extramedullary haematopoiesis Oesophageal neoplasm Also pancreatic pseudocyst, dermoid, sarcoid
38
Double aortic arch
Narrowed trachea Most common symptomatic aortic arch variant 50-60% of vascular rings
39
Thoracic nodal stations
``` 1 - supraclavicular 2-4 - superior medastinal 5-6 - aortic 7-9 - Inferior mediastinal 10-14 - N1 nodes, hilar, then through lungs ``` 2 upper paratracheal 3 prevascular and retrotracheal 4 lower paratracheal 5 AP window 6 para-aortic 7 subcarinal 8 paraoesophageal (below carina) 9 pulmonary ligament ``` 10 hilar 11 interlobar 12 lobar 13 segmental 14 subsegmental ```
40
Dense bones and no splenic flexure visible
Myelofibrosis with splenomegaly
41
Hampton hump
Dome-shapled pleural based opacification from embolism and infarction The apex of the wedge may be spared due to collateral supply causing the rounding. If infarcts, linear scar. Otherwise melting sign.
42
Diffuse alveolar haemorrhage
Vasculitis (Wegeners, Churg-strauss, Goodpastures), SLE, coagulation disorder, PE, mitral stenosis and regurg, diffuse alveolar damage
43
PCP
``` CD4 <200 Lavage to confirm diagnosis Perihilar distribution Pneumatoceles and subpleural blebs Effusions rare Adenopathy uncommon (10%) ```
44
PCP
``` CD4 <200 Lavage to confirm diagnosis Perihilar distribution Pneumatoceles and subpleural blebs Effusions rare Adenopathy uncommon (10%) ``` Atypical findings more common in those receiving aerosolised prophylaxis - upper lobe predominant, adenopathy, effusions
45
Malplaced PICC line
Going into neck
46
Malplaced intercostal drain
Straight course, in a fissure
47
Miliary metastases
Breast, ovarian, thyroid, renal, melanoma, pancreatic, trophoblasic
48
Metastatic calcification
Centrilobular ground glass nodules, may appear calcified Upper zone predominant Renal failure most common But also primary HPT, sarcoid, osteolysis e.g. mets, vit D intoxication
49
Right sided aortic arch
Mirror image branching associated with cyanotic heart disease - TOF, truncus, tricuspid, transposition Aberrant left no association
50
Pericardial effusion, mm
Must be at least 3mm on CT
51
Bronchial carcinoid
``` Bronchial obstruction, wheeze Carcinoid syndrome rare (diarrhoea, flushing, RHF, bronchospasm, pain, from excess serotonin) May produce Cushings Association with MEN1 Marked homogeneous contrast enhancement Endobronchial Can have peripheral calc but not common ```
52
Cystic adventitial disease
Young to middle age without evidence of vasculitis or atherosclerosis Male predominant Peripheral arteries Striking prediliction for popliteal region See cysts in the wall, which may displace the artery Main differential in popliteal region is popliteal artery entrapment syndrome (medial head of gastroc, or popliteus or fibrous band) (not same as cystic medial necrosis or degeneration, seen in aorta in Marfans)
53
Upper lobe predominant
Beryllosis, radiation, EAA (HSP), ank spond, sarcoid, TB (secondary), histiocytosis X (metastatic calc and PCP in patients receiving prophylaxis)
54
Hypersensitivity pneumonitis
Upper lobe predominant Bird fanciers, hot-tub Ground glass, centrilobular nodules, air trapping, Small airways inflammation, interstitial lymphocytic infiltrates, granuloma formation Fibrosis in latter stages
55
CAVITY
Cancer (SCC), autoimmune (Wegeners, RA), vascular (PE), infection (abscess, TB), trauma, young (CPAM, sequestration, cyst)
56
VOTE SSSX
.
57
Pulmonary hamartoma
6% of solitary pulmonary nodules Fat pathognomonic Popcorn calc Other benign option is chondroma, but has ossified segments, form part of Carneys triad
58
Carneys triad
Pulmonary chondroma, GIST, spinal paraganglioma
59
Grid cutoff
Can stimulate assymetric lucency / opacity
60
NF1 MSK manifestations
``` Rib notching Ribbon ribs Vertebral body scalloping Limb bowing Limb pseudoarthroses - tibial, ulnar Scoliosis Multiple non-ossifying fibromas ```
61
Chronic airspace opacity
Organising pneumonia (peripheral), chronic eosinophilic pneumonia (upper lobe predominant usually) Atypical infection - TB, fungal Neoplasia esp adenocarcinoma, also consider lymphoma
62
Other lung patterns e.g. crazy paving
.
63
Don't forget to look at neck
Don't forget
64
Perilymphatic nodules
Sarcoid, lymphangitis, silicosis | Coal pneumoconiosis, amyloidosis, LIP
65
Centrilobular nodules
``` Infection Neoplasia with airway spread HSP RB-ILD (becomes DIP) (lower zone predominant) Vasculitides e.g. Churg-Strauss ```
66
Random nodules
Haematogenous mets, septic emboli
67
Lateral radiograph
.
68
Plombage
Extrapleural pneumonolysis Historical treatment of upper lobe cavitatory TB Surgical cavity created under upper ribs, filled with inert material e.g. ping pong balls, parrafin wax, gauze, acrylic / lucite balls
69
Oleothorax
.
70
Thoracoplasty
.
71
Thoracic lymph node levels
``` 10 hilar 11-14 Interlobar through subsegmental 7 subcarinal 1-6 higher than carina 8-9 lower than carina ```

Chest and vascular (9 decks)

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