Radiology Block 2 Flashcards
1
Q
What are the 5 factors for determining a chest x-rays adequacy?
A
Penetration Angulation Inspiration Rotation Magnification
2
Q
How are frontal radiographs determined to have adequate penetration?
A
Visualization of thoracic spine through heart shadow
3
Q
What is a pitfall of an under penetrated/inadequate x-ray?
A
Can not visualize thoracic spine through cardiac shadow
4
Q
Underpenetrated x-ray= ?
Over penetrated x-ray= ?
A
Under= too light, hides L lung base, accentuates lung markings Over= too dark, may mimic emphysema/pnemothorax
5
Q
What are two errors that can occur from underpenetrated x-rays?
A
L hemidiaphragm no visible on frontal image which mimics/hides diseases in L lower lung
Inc prominence of pulmonary markings leading to incorrect CHF/pulmonary fibrosis diagnosis
6
Q
What is a pitfall of an over penetrated x-ray?
A
Too dark/absent
Incorrect diagnosis of emphysema/pneumothorax
7
Q
How is the degree of inspiration assessed in chest x-rays?
A
Counting number of posterior ribs visible above the diaphragm on a frontal x-ray
8
Q
What are the characteristic appearances of posterior/anterior ribs and an x-ray?
A
Post: inc appearance on frontal x-ray
More/less horizontal
Attach to thoracic vertebrae
Ant: more difficult to ID on frontal image
Angle downward
Attach to sternal cartilage
9
Q
What are the pitfalls of a x-ray taken with poor inspiration?
A
Crowded lung markings Mistaken for pneumonia/basilar lung disease
Heart appears larger
10
Q
PT rotation on a chest x-ray affects the appearance of what four structures?
A
Heart contour
Hila
Hemidiaphragm
Great vessels
11
Q
Virtually all of the lung markings on the chest radiographs are composed of what?
A
Pulmonary blood vessels
Bronchi are too thing to be visible
12
Q
How does normal pulmonary vasculature appear on radiographs?
A
Tapers gradually from center to peripheral with larger vessel area near base than apex in an upright x-ray
13
Q
The retrosternal clear space can be filled in with what type of abnormalities?
A
Anterior mediastinal mass
Adenopathy- lymphoma is most common
14
Q
Pulmonary arteries are normally seen in what region and on what view of an x-ray?
A
Hila on lateral view
Possible tumor or adenopathy
15
Q
Minor fissure is normally visible on a ____ view
A
Frontal
Major and minor can be seen on a lateral view
16
Q
Define Spine Sign
A
Increased density that highlights the thoracic spine instead of making it darker
17
Q
How are the hemidiaphragms seen on lateral views?
A
Left will be silhouetted anteriorly by the heart
Right is higher and can be seen from front to back
18
Q
What are two examples that would blunt the costophrenic angles?
A
Pleural effusions
Scarring
19
Q
How are quick assessments of heart size made for adults?
A
Cardiothoracic ratio
Widest transverse diameter compared to widest internal diameter of rib cage
20
Q
What is the first response to obstructions in the ventricles?
A
Hypertrophy
21
Q
On plain films, how is cardiomegaly primarily produces?
A
Ventricular enlargement
22
Q
The most marked chamber enlargement of the heart will be caused by what?
A
Volume overload, not pressure
23
Q
What are the six levels of the chest for a normal CT anatomy scan of the heart?
A
Five vessel view Aortic arch Aortapulmonary window Main pulmonary window Upper cardiac level Lower cardiac level
24
Q
What two additional adjuncts are used with cardiac CTs?
A
IV iodine contrast
ECG gated acquisition
25
Cardiac CT scanning is used to evaluate what structures?
Coronary arteries
Cardiac masses
Aorta abnormalities/dissection
Pericardial diseases
26
How is coronary artery dominance established?
The artery that supplies the posterior descending artery
| Majority of population- R coronary dominant
27
PTs presenting with acute chest pain can have an emergent CT scan to search for what abnormalities?
Coronary artery disease
Aortic dissection
Pulmonary thromboembolic disease
AKA- Triple Rule out scan
28
MRIs of the heart can shows what types of damage?
MI scarring
Heart perfusion
Anatomic defects/masses
Function of valves/chambers
29
What are the specific views used on an MRI of the heart to gather data?
Horizontal long axis- 4 chamber view
Vertical long axis
Short axis
Three chamber view
30
Cardiac function is usually evaluated with ?
| Cardiac morphology is evaluated with ?
MRIs
Function- white blood images
Morphology- black blood
31
Parenchymal lung disease can be divided into what two categories?
Airspace- aveolar
| Interstitial- infiltrative
32
What are the characteristics of airspace diseases?
Fluffy
Indistinct margins
Possible air bronchograms/silhouette sign
33
Air bronchogram is usually a _______ disease
Airspace
34
Define Silhoutette sign
| What causes this?
Two objects with same radiographic densities contact each other, normal edges disappear
35
A silhouette sign can be used throughout radiology for what two purposes?
Abnormality location
| Abnormality density
36
Give 3 examples of airspace diseases
Pulmonary aveolar edema
Pneumonia
Aspiration
37
What are the seven types of interstitial lung diseases?
```
Interstitial edema/pneumonia
Bronchogenic carcinoma
Metastases
Pulmonary fibrosis
Sarcoidosis
```
38
What is an examples of a disease that demonstrates both airspace and interstitial lung patterns?
TB
39
What are the four differential possibilities for an opacified hemithorax?
Altelactasis of entire lung
Large pleural effusion
Entire lung pneumonia
Postpneumonectomy
40
What are the 3 mobile strctures that can be pulled or pushed in the chest?
Trachea
Heart
Hemidiaphragm
41
What is the direction of shift during atelectasis, pleural effusions, and pneumonia?
Atel- toward (vol loss)
Eff- away (acts like mass)
Pneumo- none (bronchogasms may be present)
42
Shift of malignant effusion may be masked by what other counter-disorder?
Balanced from underlying/obstructive bronchogenic carcinoma
43
What are the four common types of atelectasis?
Subsegmental (disc/plate-like)- splinting PT due to deactivation of surfactant
Compressive/passive- collapsed from effusion/pneumo
Obstructive
Round- atelectasis recedes, lung remains uninflated
44
When is subsegmental atelectasis usually seen?
PTs not taking deep breath (splinting)
| Produces linear density at lung base
45
What are the signs of the obstructive atelectasis?
Displaced fissures
Inc density of affected lung
Shift of structures to atelectasis
Compensatory over inflation of unaffected lung
46
Pleural effusions collect in what area and are usually what type?
Potential space
| Transudate / exudate- depending on LDH and protein content
47
How much fluid is required to blunt the posterior costophrenic angles?
How much is needed to blunt the lateral angles?
How much opacifies the hemithorax?
75mL
200-300mL
2L
48
Most pleural effusion begin by collecting in what area?
Hemidiaphragm/base of lung
| Called subpulmonic effusion
49
Define Loculated
Adhesion where fluid assumes abnormal appearance in abnormal location
50
Define Pseudotumor
Type of effusion, transudate, occurs in minor fissure
| Frequently secondary to CHF
51
How are Laminar Effusions best recognized?
| What causes them?
At lung base above costophrenic angles on frontal xray.
CHF or lymphangitic spread of malignancy
Density on lateral chest wall near angle, wont move with PT shifts
52
How are Hydrophneumothorax ID'd on xray?
Upright view xray with straight air fluid interface instead of meniscus shape of pleural fluid
53
How does pneumonia present on a chest xray?
More opaque
Fluffy and indistinct margins
Homogenous density
Possible air bronchograms and atelectasis
54
How does segmental pneumonia appear on x-rays?
Multi-focal
No bronchograms
Volume loss may be present
55
Interstitial pneumonia involves what structures and has what type of appearance?
Involves airway walls and alveolar septae
Reticular pattern
May produce airway Dz
56
Round pneumonia effects what PT population and occupies what area?
Effects children
| Lower, posterior lobes
57
Cavitary pneumonia is usually caused by ? and occupies what area
TB- causes Lucent cavities/necrosis
| Postprimary TB- affects upper lobes
58
Aspiration usually occurs in what areas of the lung?
Upright PT- lower lobe
| Recumbent PT- superior lower lobes, posterior of upper lobes
59
How can pneumonia be localized on an x-ray?
Silhouette sign
| Spine side
60
Define Vacuolization
Pneumonia resolve by breaking up so patchy areas of aerated lung appears in previous pneumonia locations
61
What types of masses can be seen in the anterior mediastinum
Thyroid
Lymphoma
Thymoma
Tertoma
62
What types of masses can be seen in the middle mediastinum
Lymphadenopathy from lymphoma or metastatic disease
63
What types of masses can be seen in the posterior mediastinum
Neurogenic tumors originating from nerve sheaths
64
Incidental solitary pulmonary nodule less than what size are rarely malignant?
What does this change?
4mm
| 50% over 50 y/o are malignant
65
What are four pieces of info that can be used for criteria to evaluate a mass's benignity?
Size
Calcification
Margin
Change
66
Bronchiogenic carcinomas can present in what three ways?
Visualize tumor
Effects of obstruction (pneumonia/atelectasis)
ID of direct/metastatic spread to distal organs
67
Small cell carinoma is what type of cell that is usually associated with what two types of paraneoplastic syndromes?
Neurosecretory
Cushing's
Inappropriate ADH secretion
68
Multiple nodules in the lung are usually caused by ?
Metastatic lesion from hematogenous spread, cannonball appearance
69
Lymphangitic carcinomas produce patterns that radiologically similar to ?
Pulmonary interstitial edema from CHF
| EXCEPT, only involves a single segment/lung
70
Why do conventional radiograph's have a high false-negative rate in pulmonary thromboembolitic diseases?
Inability to demonstrate Hampton's Hump, Westermark sign, Knuckle sign
71
What is used to diagnose pulmonary embolsim
CT pulmonary angiography
72
COPD consists of what two disorders?
Emphysema- pathologically defined, seen on CT and x-ray
| Chronic bronchitis- clinical diagnosis
73
Bullae and cysts are filled with ?
Air filled lesions in lungs
74
What is the study of choice for evaluating bronchiectasis?
What are the classical findings?
CT study of choice
| Demonstrates Signet Ring Sign, Tram-Tracks, cystic lesion and tubular densities
75
PA radiographs have what 4 blind spots
Retro sternal
Retro cardiac
Hilar region
Posterior hemi diaphragm
76
What are the criterias for cardiomegaly on AP/Lat films?
PA- 50% of width
| Lat- cardiac shadow overlaps spine
77
What are 3 causes of apparent heart enlargement?
Pericardial effusions
Extra cardiac factors
Cardiomegaly
78
What are the causes of apparent heart enlargement from pericardial effusions?
```
CHF
Infections
Metastatic malignancy
Uremic pericarditis
Lupus
Trauma
Postpericardiotomy Syndrome
```
79
What are the causes of apparent heart enlargement from extra-cardiac factors?
```
AP projection
Suboptimal inspiration
Chest wall abnormalities
Rotation
Fluid collction
```
80
What are causes of apparent heart enlargements from CHF factors?
Pulmonary interstitial edema
| Pulmonary alveolar edema
81
Appearance of pulmonary interstitial edema
Thickened interlobar septa
Peribronchial cuffing
Fluid in fissure
Pleural effusions
82
Appearance of alveolar edema
```
Fluffy/indistinct densities
Batwing/butterfly
Pleural effusions
No bronchograms
Cardiac origin= effusions causing thickened major and minor fissures
```
83
5 areas to inspect on lateral images for any general image?
```
The Fastest Hot Rods Drive Straight
Thoracic
Fissures
Hilum
Retrosternal
Diaphragms
Sulci
```
84
Minor fissure is aka
| Major fissure is aka
Transverse- visible on frontal
| Oblique- not on frontal image
85
Hypertensive cardiovascular disease will causes what structural change that can be seen on x-rays?
Straightened aorta
86
What are the 3 types of Cardiomyopathy
Dilated- most common
Hypertrophic
Restrictive
87
Dilated cardiomyopathy effects what structures of theheart?
Biventricular
88
Define Parenchymal
Effecting the functional tissue of an organ
89
Mediastinal mass that affects younger PTs
Teratomas
| Thymomas- middle aged adults, benign
90
What are the characteristics of Panicenar pattern of COPD?
Destruction in distal lobes
| PTs w/ A1-Anti-trypsin dysfunction
91
What structures are hidden in the right lung by what disease location/issue
Ascending aorta- R upper lobe
R heart border- R middle lobe
R hemidiaphragm- R lower lobe
92
What structures are hidden in the left lung by what disease location/issue
Descending aorta- L upper/lower lobe
L heart border- Lingula of L lobe
Left hemidiaphragm- L lower lobe
93
What are the signs of an atelectasis?
```
Displaced fissure
Inc density of affected lung
Shift of mobile structures
Over inflation
Points towards hilum
```
94
What are the 4 types of atelectasis
Subsegmental
Compressive
Round
Obstructive
95
What are the indications to seek further imaging modalities for atelectasis?
```
Entire lung
Lobular more than 2 days
Segmental more than 2 wks
Round
Mass/tumor findings
```
96
What are the causes of pleural effusions?
Inc rate of formation:
Inc hydrostatic press
Inc capillary permeability
Dec colloid osmotic press
Dec rate of reabsorption:
Lymph blockage
Dec pressure in pleural space
97
What are the causes of transudate pleural effusions?
```
Inc hydrostatic press/dec osmostic press
CHF
Hypoalbuminemia
Cirrhosis
Nephrotic Syndrome
```
98
What are the causes of exudative pleural effusions?
Malignancy
Empyema
Hemothorax
Chylothorax
99
What are the visual appearances of pleural effusions?
```
Subpulmonic effusion
Blunting of angles
Meniscus sign
Opacified hemithorax
Loculated effusions
Laminar effusions
Hydropneumothroax
```
100
How do loculated effusions appear on x-rays?
Adhesions between pleura trapping fluid in unusual patterns
| curves inward into lung space
101
Fissural pseudotumors are usually associated with ?
CHF
102
What is the most common sign/cause of fissural pseudotumors?
Fluid trapped between layers of minor fissure
103
What are the visual appearances of pneumonia on an x-ray?
```
More opaque than normal lung
Fluffy/indistinct margins
Interstitial pneumonia= interstitial tissue prominences
Homogenous density
Lobular pneumonia= air bronchograms
```
104
What are the patterns of pneumonia?
```
Lobular
Segmental
Interstitial
Round
Cavitary
Consolidation
```
105
What is the pattern of Lobar pneumonia
Homogenous consolidation of affected lobe w/ air bronchogram and silhouette sign
106
What is the pattern of Segmental pneumonia
Patch airspace of several segments
107
What is the pattern of Interstitial pneumonia
Diffusely spread early in process
| Frequently progresses to airspace Dz
108
What is the pattern of Round pneumonia
Spherical shapes in lower lobes of kids
109
What is the pattern of Cavitary pneumonia
Post-Primary TB
110
How does aspiration pneumonia differ?
Upright- lower lobes
| Recumbent- superior lower lobes/posterior upper lobes
111
What are the differences between Primary and Secondary pneumothorax?
Primary- occurs in normal lung
| Secondary- diseased lung
112
What is the difference between Simple and Tesnion pneumothorax?
Simple- no shift of structures
| Tension- shifted structures
113
What is the difference between spontaneous and traumatic and diseased pneumothorax?
Spontaneous- rupture of apical, subpleural bleb or bulla (tall, thin males)
Trauma- most common cause (accidental/latrogenic)
114
What is the most important determinant in deciding whether PTs need a chest tubes or not?
Assessing clinical status
Greater than 2cm- chest tube
Less than- no tube
115
What issue presents with a comb-like, striated appearance?
Subcutaneous Emphysema- air along muscle bundles
116
Difference between Nodule and Mass?
Nodule- less than 3cm
| Mass- greater than 3cm
117
What are the benign causes of solitary nodules/masses?
Granuloma
| Hamartomas
118
Categories of nodules less than 4mm
Low- no f/u
| High- 12mon f/u
119
Categories of nodules 4-6mm
Low- 12mon f/u
| High- CT at 6-12mon and 18-24mon
120
Categories of nodules 6-8mm
Low- CT at 6-12 and 18-24mon
| High- CT at 3-6mon and 9-12mon
121
Categories of nodules greater than 8mm?
CT at 3 9 and 24mon
122
What does calcification of a nodule/mass mean?
Benign= central, laminar, diffuse calcification
123
What do changes in a nodule/mass over a week, mid-range or year mean?
Week- inflammatory
Mid- malignant
Year+= benign
124
What are the characteristics of Squamous Cell Carcinoma?
Upper/central location
Segmental/lobar
Cause obstructive pneumonitis/atelectasis
Rapid growth
125
What are the characteristics of Adenocarcinoma?
Small, peripheral growth
Solitary
Slowest grower
126
What are the characteristics of Small Cell, Oat Cell Carcinomas?
Central location, bilateral
| Inappropriate secretion of ADH
127
What are the characteristics of Large Cell Carcinoma
Diagnosis of exclusion for lesions that are nonsmall cell and not squamout or adenocarcinoma
Larger peripheral lesion
Extremely rapid grower
128
Most PTs presenting with air way nodule/mass will have ?
| Those presenting with bronchial obstructions usually have?
Adenocarcinoma
| Squamous cell carcinoma
129
PTs presenting with direct extension or metastatic lesions will have what identifiers?
```
Rib destruction
Hilar adenopathy
Mediastinal adenopathy
Pleural effusion
Metastases to bone
```
130
Define a Pancoast Tumor
Rib destruction from apical lung tumor
131
Metastatic neoplasms have what characteristics depending on if it was hematogenous or lymph spread
Hema- vary in size, sharp margins
| Lymph- Kerley B lines, thickened fissures, most common in breast, lung, pancreas
132
Thromboembolic diseases usually occur in what PT populations?
+60y/o
From DVT
Immobilized/post-surgery
133
Thromboembolic diseases are historically assessed with what modality of imaging?
CT
| VQ scan
134
75% of PTs with pulmonary embolism present with what 4 S/Sx?
Elevated hemi-diaphragm
Unilateral pleural effusion
Enlarged pulmonary artery
Infiltrate
135
What are the 2 uncommon findings in PTs with PEs?
Westermark's Sign- region of oligemia
| Hamptons Hump
136
Define Westermark's Sign
Focused decrease blood flow leading to collapse of vessel distal to PE
137
Define Hapton's Hump
Shallow wedge shaped opacity in peripheral lung tissue with base against pleural surface that represents hemorrhage and necrotic lung tissue
138
What are the 3 pathological patterns of emphysema
Centriacinar
Panacinar
Paraseptal
139
Define COPD
Disease of airflow obstruction caused by chronic bronchitis or emphysema
140
Define Chronic Bronchitis
Productive cough
141
Define Emphysema
Permanent and abnormal destruction of air spaces distal to terminal bronchioles
142
What are the classic x-ray findings of COPD
```
Hyperinflation
Flattened Diaphragm
Increased retrosternal clear space
Hyperfluency of lungs
Prominences of pulmonary arteries
```
143
Define Centriacinar emphysema
Most common, strong association with smoking
| Focal destruction to bronchioles and central acinus
144
Define Panlobular emphysema
Entire alveolus distal to terminal bronchiole
| Most severe in lower lung zones and develops in PTs with A-1antitrypsin deficiency
145
Define Paraseptal Emphysema
Distal airway structures, alveolar ducts, and sacs
| Develops around septae or subpleural surfaces
146
Centriacinar emphysema usually occurs where in the lung?
Upper lobes
| Smokers w/ chronic bronchitis
147
Paraseptal emphysema tends to occur more often in what PT population
Young adult w/ history of spontaneous pneumos from formation of bullae
NOT associated with airflow obstruction
148
Obstructive atelectasis produces what changes to a chest x-ray?
Blocked side will be more radiopaque and pulled to that side
149
Difference between Bullae and Blebs
Bullae- central air containing lesions
| Bleb- peripheral
150
Bullae more than 1cm are associated with ?
Emphysema
| Occur in lung parenchyma
151
Blebs are small bullae that usually form where?
| What are the thought to be associated with?
Visceral pleura at lung apex
Seen on CT, not x-ray
Associated with spot pneumos
152
What are the 3 most common causes of cavities?
Carcinoma
Pyogenic abscess
TB
153
Define Bronchiectasis
Localized irreversible dilation of bronchial tree with thickened walls best eval'd by CT
154
What x-ray sign may be identified with bronchiectasis
Tram-tracks
155
What is the hallmark lesion on CT for bronchiectasis
Signet Ring Sign
| Bronchus is larger than pulmonary artery
156
Progressive, bilateral upper love bronchiectasis in children is highly suggestive of what issue?
CF
157
Hollow lung space that is less than 1mm? 1-3mm? Greater than 3mm?
Less than 1= bullae/bleb
1-3= cyst
3+= cavity
158
What are the extracardiac causes that make the heart appear larger than actual size?
AP portable
Preventative deep inhalation
Bony thorax abnormalities
Pericardial effusion
159
What are the 4 key findings in pulmonary interstitial edema?
Thickened interlobar septa
Peribronchial cuffing
Fluid in fissures
Pleural effusions
160
What are the four findings of pulmonary alveolar edema?
Fluffy/indistinct patches
Bat wing
Pleural effusions
Bilateral, peripheral
161
What is more likely to be found with Cardiogenic Pulmonary Edema?
Pleural effusion
Kerly B lines
Cardiomegaly
Inc wedge pressures
162
What are the Noncardiogenic causes of pulmonary edema?
```
Uremia
Intravascular coagulopathy
Smoke inhalation
Near drowning
Volume overload
Lymph spread of malignancy
```
163
ARDS is classified as what type of pulmonary edema?
Noncardiogenic
164
Pulmonary arterial HTN produces what key sign?
Pruning of pulmonary vasculature
165
Aortic stenosis in elderly PTs are most often secondary to what issue?
Tricuspid aortic valve degeneration
166
What are the 3 types of cardiomyopathys?
Dilated
Hypertrophic
Restricted
167
What are the 3 types of aortic aneurysms?
Saccular
Fusiform
Dissection
168
Most thoracic aortic dissections are what type?
Stanford type A- surgical treatment
169
What is the leading cause of death worldwide?
Coronary artery disease
170
Evaluation of the abdomen should focus on what 4 main areas?
Gas pattern
Extralumenal
Abnormal calcification
Soft tissue masses
171
Air is normally present in what are of the colon?
Retrosigmoid- highest point of large bowel when PT is prone
172
What does an acute abdominal series consist of?
| Which view does not have an optional substitute?
```
Supine abdomen- no substitute
Prone abdomen (substituted with lateral rectum view)
Upright abdomen (substituted with lateral decubitus)
Upright chest (substituted with supine chest)
```
173
The supine view of the abdomen is generally a ____ view and is used to look for ? 2 things
Scout- looking at gas patterns
| Calcifications/masses
174
The prone view is used to identify/rule out ?
Air in retrosigmoid- identification of mechanical obstruction of the bowel
175
Upright abdomen film is used to visualize ?
Air-fluid levels in bowel
| Free intraperitoneal air
176
Upright chest film is used to visualize ?
Air beneath diaphragm
Pleural effusion
Pneumonia
177
What information is essential to help determine which imaging study will provide the best info in diagnosing the PT
History
178
Abnormal gas patterns can be divided into what two groups?
Functional ileus- localized, generalized
| Mechanical obstruction- small bowel, large bowel
179
How does the guy respond to amechanical obstruction?
Distal area dilates as peristalsis increases
180
What are the key findings of localized ileus?
2-3 dilated loops of sentinel loops w/ air in retrosigmoid
| Underlying irritative process adjacent to dilated loops
181
What are causes of sentinel loops?
Pancreatitis
Cholecystitis
Diverticuliits
Appendicitis
182
What are the key findings in a generalized adynamic ileus?
Dilated loops of large/small bowel with gas in retrosigmoid
| Long air-fluid levels
183
Generalized adynamic ileus is frequently seen in what typ of PTs?
Post-op
184
What are the key image findings in mechanical small bowel obstructions?
Disproportionate dilations
| Fluid filled loops of small bowel with no gas in retrosigmoid
185
Mechanical small bowel obstructions are best imaged with ?
CT
186
What is the most common cause of a small bowel obstruction?
Adhesion
| Post-surgical adhesion- most common
187
Define Closed Loop Obstruction
Two points of bowel are obstructed in the same location
188
Define Volvulus
Closed loop obstruction of the large bowel
189
What are the key imaging findings of a mechanical large bowel obstruction?
Dilation of colon up to the obstruction
| No gas in rectum and no dilation of small bowel
190
What are the causes of a lower bowel obstruction?
Malignancy
Hernia
Diverticulitis
Intussusception
191
Define Ogilvie Syndrome
Loss of peristalsis causing massive dilation of entire colon that resembles a large bowel obstruction
192
What are the four most common sites of extraluminal air?
Intraperitoneal
Retroperitoneal
Air in bowel wall
Biliary system
193
What are the three key signs of free air in the abdomen?
Air beneath diaphragm
Rigler Sign- visualization on both sides of bowel wall
Visualization of falciform ligament
194
What are the most common causes of free air in the abdomen?
Perforated peptic ulcer
Trauma
Perforated diverticulitis
Perforated carcinoma
195
What are the key signs of extraperitoneal air?
Streaky linear appearance outlining extraperitoneal structures (kidneys, psoas muscles, aorta, Inf Vena Cava_)
196
What are the key signs of air in the bowel wall?
Linear radioluscencies parallel to air in adjacent bowel lumen
197
What are causes of air in the bowel wall
Pneumatosis cystoides intestinalis
Necrotic bowel
Ischemic bowel
Obstructing lesions
198
What are the causes of pneumobilia
Incompetence of Sphincter of Oddi
Spincterotomy
Gallstone ileus
199
What is the triad of findings in gallstone ileus?
Air in biliary system
Small bowel obstruction
ALJ:ALKJLK:
200
Define Barret Esophagus
Reflux causes stimulation of metaplasia of squamous to columnar cells
201
Esophageal carcinomas can appear in what forms?
Annular constrictions
Polypoid mass
Superficial infiltration
202
What are the radiological signs of a gastric ulcer?
Barium that extends along lesser curvature/posterior wall of region
203
What are the key findings in a gastric carcinoma
Mass that protrudes into lumen causing defect
| Causes rigidity/nondistensibility
204
What are the radiological signs of duodenal ulcers?
Collection of contrast seen more on en face view
| Healing causes scarring and deformity of duodenal bulb
205
Any image evaluation of the bowel should be done after what actions are taken on the bowel?
Filled with air
| Filled with contrast
206
What are key abnormal findings of bowel disease on CT?
Thickening of bowel wall
Submucosal edema/hemorrhage
Hazy infiltration
Extraluminal air
207
What part of the intestine does Crohn's Disease effect the most?
Terminal ileum
208
What region of the bowel is affected by colonic diverticulitis the most?
Sigmoid colon
| Almost always asymptomatic
209
What is the imaging modality of choice for diverticulitis?
CT
210
What are the imaging signs of colonic polyps?
Filling defect of colon w/ or w/out stalks
211
What are the imaging findings of Colonic Carcinoma?
Persistent annular filling defect
Microperforation
Metastases- liver and lungs
212
Define Colitis
Thickened bowel wall
Narrowed lumen
Infiltration into surrounding fat
213
What are the imaging modalities of choice for diagnosing appendicitis?
CT or US
214
Lower GI bleeding is usually caused by ?
Diverticulitis
215
What are the two most common causes of pancreatitis?
Gallstone
| Alcoholism
216
Where does pancreatic adenocarcinoma grow most often?
Head of pancreas as hypodense mass
217
Evaluation of liver masses if often done with what imaging modality?
Triple phase CT
218
What are the most common hepatic masses?
| What is the most common primary malignancy?
Malignancy
| Hepatocellular carcinoma
219
How do cavernous hemangiomas appear on imaging?
More common in females
Asymptomatic
"outside-in" pattern
220
What is a non-invasive way of imaging the biliary tree?
MRCP
| Demonstrates biliary structures, gallstones and congenital abnormalities
221
How do renal cysts appear on imaging?
Multiple bilateral
Do not enhance
Sharp margins
On US- simple cysts are well define anechoic masses
222
What is the most common primary renal malignancy
Renal cell carcinoma
| US= echogenic masses
223
What is the imaging study of first choice for evaluating the famle pelvis
US
224
Creation of a sonographic image depends on what 3 components?
High frequency sound wave
Reception of reflected wave/echo
Conversion of echo to image
225
Echogenic appears what color on US?
| Hypoechogenic appears what color?
White
| Black
226
Doppler US is used to determine what 2 things?
Direction
| Velocity
227
How do gallstones appear on US?
| How does biliary sludge appear?
Echogenic with an acoustic shadow
Echogenic without an acoustic shadow
228
How does obstructive uropathy appear on US?
Dilated calyceal system
| Fluid filled, dilated hypoechoic system
229
What happens in medical renal disease during an US?
Renal parenchyma become more echogenic than the liver and spleen
Normal is reverse
230
What is the image study of choice for AAAs?
US
231
What are the most common tumors of the uterus?
Leiomyomas- fibroids
232
Define Adenomyosis
Ectopic endometrial tissue in myometrium
| Presents as small cystic space in myometrium of enlarged uterus
233
What is the most common ovarian mass?
Functional cyst
Thin wall anechoic structure
Echogenic= hemorrhage
234
Nonfunctional ovarian cysts include what two things?
Dermoid cysts
| Endometriomas
235
Ovarian tumors most often arise from the _____ and are either ___ or _____
Surface epithelium
| Serous or mucinous
236
Define PID
Infectious diseases of uterus, tubes and ovaries
| Begins as transient endometritis
237
How are molar pregnancies suggested?
Uterus size is large for date of gestation
| Elevated HCG levels +100K
238
How are abdominal hernia diagnosed by US?
Intraabdominal contents visualized through abdominal wall
| Detection increases if PT stands and performs valsalva maneuver
239
Vascular US uses what two modes to display what two pieces of info?
Gray scale and Doppler US
Direction and velocity
240
US can be used to detect arterial narrowing in what two circumstances?
Carotid stenosis
| Peripheral vascular disease
241
When/why is a pseudoaneurysm formed?
Rupture/injury to arterial wall allowing blood to collect under intact outer vessel wall
242
Define Germinal Matrix
Microscopic vessels that are at risk of bleeding in premature infant
Appear echogenic in caudothalamic groove
243
How far into development can US be used to detect developmental dysplasia of hips?
4-6wks
244
Define Necrotizing Enterocolitis
Life threatening GI in neonates that can cause bowel perforations
245
What causes a gastric outlet obstruction and leads to nonbilious projectile vomiting?
Hypertrophic pyloric stenosis
| Abnormal thick pyloric muscles and elongated pyloric channel
246
Define FAST and its purpose
Focused Assessment with Sonography in Trauma
| Detects intraperitoneal bleeding, especially in hemodynamically unstable PTs unable to undergo CT/US
247
Where do pneumothoraces travel to in a supine PT?
Most superior part of chest
248
How does a pericardial effusion appear on a US?
Hypoechoic/anechoic
249
Cardiac tamponade occurs when fluid accumulates around what chambers of the heart?
R atrium and ventricle
250
How is an elevated/decreased central venous pressure depicted on a US?
Caliber of Inf Vena Cava during inhale/exhale
251
PT presents with facial trauma and periorbital swelling preventing direct examination of the eye, what can be used?
US
252
What does the anterior mediastinum encompass?
Back of sternum to anterior border of heart/great vessels
253
What does the Middle Mediastinum encompass?
Anterior border of heart/aorta to posterior heart border
| Contains heart, origins of great vessels, trachea, main bronchi, lymph nodes
254
What does the Posterior Mediastinum encompass?
Posterior border of heart to anterior border of the vertebral column
255
What imaging modality has increased accuracy in determining location/nature of mediastinal masses
CT
256
How to remember masses that occupy the anterior mediastinum
Terrible Lymphoma
Thyroid
Thymoma
Teratoma
257
Substernal goiter characteristically displace ? and the study of choice is ?
Trachea but don't extend past top of aortic arch
| Thyroid scans
258
What are the most frequently encountered anterior mediastinal masses?
Substernal thyroids
259
What is the most common causes of mediastinal masses overall and how does it appear on imaging?
Lymphadenopathy- present w/ border that is lobulated or polycyclic in contour
260
Thymomas occur most often in what PT population?
Middle aged adults, mostly benign
261
What mediastinum mass occurs earlier than thymomas?
Teratomas
262
What is the most common variety of teratomas?
Cystic- well marginated mass near origin of great vessels
263
What are the most common types of masses in the posterior mediastinum?
Nerve sheath tumors- Schwannoma- benign
| Ganglioneuromas/neuroblastomas- neoplasms that arise from nerve elements other than the sheath
264
What issue causes Ribbon Ribs?
Plexiform neurofibromas- erodes inferior border of ribs
265
Define Continuous Diaphragm Sign and what causes it
Air enters mediastinum causing entire diaphragm under hear to become visible
266
What are the common indications for a FAST exam?
```
Blunt/penetrating trauma
Trauma in pregnancy
Pediatric trauma
Torso Trauma
Undifferentiated HOTN
```
267
What are four pathology's found on FAST
Hemopericardium
Hemoperitoneum
Hemothorax
Pneumothorax
268
What are the 5 views of a FAST exam?
```
RUQ
LUQ
Subxyphoid
Suprapubic- transverse/sagittal
Lungs
```
269
Define Valvulae Conniventes
Muscular folds of small intestine starting at duodenum
270
Define Diverticula
Abnormal sac at weak point of wall in the alimentary tract
271
Sefine Sessile
Fixed in one place, immobile
272
Define Pedunculated
Elongated stalk of tissue
273
What are two types of normal calcifications
Phleboliths
| Rib cartilage
274
What are the 4 patterns of abnormal calcifications
Rimlike- wall of hollow area
Linear/tracklike- wall of tubular structure
Lamellar- around nidus of hollow lumen
Cloud/popcorn like- inside of organ/tumor
275
What are the three rim-like abnormal calcifications?
Cysts- renal/splenic
Aneurysm- aorta, splenic, renal
Saccular- gallbladder, bladder
276
What are three examples of structures that can experience linear/tracklike calcifications?
Fallopian tube
Vas deferens
Ureter
277
What are three examples of lamellar abnormal calcificatioins
Renal calculi
Gallstone
Bladder stone
278
What are four locations that cloud/popcorn like abnormal calcifications can occur?
```
Pancreas body
Leiomyomas of uterus
Lymph nodes
Kidneys
Mucin-producing adenocarcinomas
```
279
Define Riedel Lobe
Normal variant when tongue-like projection of R lobe of liver reaches down to iliac crest
280
What is the normal location of the spleen on an x-ray?
12cm length not projecting below 12th rib
281
What is the normal size of kidneys on an x-ray?
Hieght of four lumbar vertebraes
| 10-14cm
282
How big is the bladder when distended and contracted?
Cantaloupe
| Lemon
283
What are the normal dimensions of a uterus?
8cm x 4cm x 6cm
| If enlarged, US
284
What are the risks of injecting iodinated agents?
| What PTs are at risk?
Contrast induced nephropathy
SrCr inc x 25% or >0.5mg 2-7days later
Diabetes, dehydrated, multiple myelomas
285
What are the four common locations of extraluminal gas?
Intraperitoneal
Retroperitoneal
Pneumatosis
Pneumobilia
286
What causes esophagus dilation?
Lower sphincter doesn't relax causing swallowed material to back up and stretch the wall
287
Esophagus constrictions can be caused by what two things?
Cancer
| Hiatal hernia
288
How does small intestine ulceration appear on imaging?
Collar button ulcer- air and barium
| Cobblestone appearanc
289
What disease will demonstrate a "String Sign" on imaging?
Crohn Disease
290
What pediatric issue will be seen on imaging as a "football" sign?
Neonatal pneumoperitoneum
291
What is an "apple core" lesion associated with?
Large intestine narrowing from colon cancer
292
A short cervix measurement on US is indicative of what?
Intrauterine pregnancy
293
What is cephalization a sign of?
Mitral valve stenosis
294
What is the classical triad of symptoms that presents with Aortic Stenosis?
Angina
HF
Syncope
295
Aortic stenosis can be 2* to what three issues?
Congenital aortic valve
Degenerative tricuspid valve
RHD
296
What is the hallmark of a stenoic lesion on any major artery?
What causes this change?
Poststenoic dilation
| Eddie Currents and Turbulent Flow
297
What can be used to predict the likelihood of aortic stenosis or mortality from CVD?
Aortic valve calcification
298
What are the two hallmarks of Dilated Cardiomyopathy
Decreased contractility
| Ventricular dilation
299
What type of cardiomegaly is linked to sudden deaths in high profiled athletes?
Hypertrophic
300
How can Constrictive and Restrictive cardiomyopathy different?
Why is this differentiation important
Restrictive- pericardium is normal (thickened in constrictive) and heart is not enlarged
Constrictive is surgically curable
301
What is the most common caused of aortic aneurysm?
| What are Kevin's Hallmark's for aortic aneurysm?
Atherosclerosis
Loss of aortic knob
Widened mediastinum
302
How does an aortic aneurysm change the vessels location depending on the location?
Ascending- anterior/right extension
Arch- middle mediastinal mass
Descending- posterior/left extension
303
What is the modality of choice for diagnosing aortic aneurysms?
CT w/ contrast
304
How does a aortic dissection present on radiographs?
```
Widened mediastinum
L pleural effusion
L apical cap
Loss of aortic knob
Deviation of structures to Right
```
305
Diagnosis of an aortic dissection rests with what feature?
Identification of the intimal flap
306
A normal lateral chest x-ray is called what type of exam?
Two-View- upright, frontal and upright, left lateral
307
Most hilar densities are what structures?
Pulmonary arteries
308
How do the Major and Minor fissures run along the chest?
Major- T5 vertebrae to sternum
| Minor- Fourth anterior rib of R side w/ horizontal orientation
309
Compression Fx are most often from ? and usually first involve what structure?
Osteoporosis
| Depression of superior end-plate of vertebral body
310
Evaluating the thoracic spine on a lateral view can provide great detail/info on what type of issues?
Systemic disorders
311
What is the lowest point of the pleural space with an upright PT?
Hemidiaphragm indents into base of lungs, creating sulcus- the lowest point
312
On CT, what is smaller: bronchioles or pulmonary artery?
Bronchioles
313
What is a favorite window/location for enlarged lymph nodes to appear and grow?
Aortopulmonary window- beneath aortic arch but above pulmonary artery
314
What does the Major Fissure separate?
| What does the Minor Fissure mark?
Upper/lower on left side
Lower/middle on right side
Minor- right middle
315
What are the acute airspace diseases?
```
PHEAN
Pneumonia
Hemorrhage
Edema
Aspiration
Near-drowning
```
316
What are the chronic airspace diseases?
```
APLS
Adenocarcinoma
Proteinosis
Lymphoma
Sarcoidosis
```
317
What are the Reticular interstitial diseases?
```
PESS
Pneumonia
Edema
Scleroderma
Sarcoid
```
318
What are the Nodular Interstitial diseases?
```
MS BMS
Metastases
Silicosis
Bronchogenic carcinoma
Miliary TB
Sarcoid
```
319
What are the four components of lung interstitium?
CT
Lymph
Vessels
Bronchi
320
What are the characteristics of Interstitial Lung diseases?
Inhomogenous
Sharp margins
Focal or diffuse
No bronchograms
321
What are 3 examples of primarily reticular interstitial lung diseases?
Pulmonary interstitial edema
Interstitial pneumonia
Non-Specific Interstitial Fibrosis
322
What type of Pt is likely to have Interstitial Pneumonia?
| What is a diagnostic issue?
Older male who smokes and has reflux
| Chest x-ray can appear normal
323
What are the hallmark images for diagnosing Non-Specific Interstitial Fibrosis
Ground glass opacities
| Traction bronchioectosis
324
Whole lung atelectasis is caused by what?
Obstruction of main bronchus
325
What is usually the cause of atelectasis in younger, older, and critically ill PTs?
Older- bronchogenic carcinoma
Younger- asthma/inspiration
Critical- mucus plug
326
Massive pleural effusions are usually a result of ?
| CHF produces ? type of effusion?
Malignancy
| Bilateral
327
What two issues are notorious for creating large but clinically silent effusions?
Hemothorax
| TB
328
Adult PT presents with opacified hemothorax, no shifted of structures, and no bronchogram is indicative of ?
Obstructive Bronchiogenic Carcinom
329
What does FAST stand for?
Focused Assesment Sonography in Trauma
330
Mobile structures shift in what direction after complete healing process after a pneumonectomy?
Towards opacification
331
Which way do fissures move when an atelectasis is present?
| How does the hemidiaphragm move?
Towards atelectasis
| Up on effected side
332
What type of tracheal shift is deemed as normal?
Trachea goes to R due to L side of aortic knob
333
Round atelectasis is a form of ____ atelectasis
Compressive
334
How fast does a lung collapse when a PT is on room air and on 100% air?
Room- 18-24hrs
| 100%- one hr
335
Where are the fan-like landmarks of an atelectasis facing?
Base- pleural surface
| Apex- hilum
336
Sign of Golden is associated with atelectasis of what lobe?
RUL
337
Critically ill PTs develop atelectasis most frequently in what lobe?
LLL
338
Improper ET tube placement causes what atelectasis result?
Entire L lung
339
What is the first step in detecting pleural effusions?
CT
340
Two examples of diseases that cause bilateral effusions?
Lupus
| CHF
341
Unilateral effusions can be caused by what three things?
TB
Thromboembolic Dz
Trauma
342
Left sided effusions are caused by what three things?
Pancreatitis
Distal thoracic duct obstruction
Dressler Syndrome
343
Right sided effusions are caused by what three things?
Abdominal Dz related to liver/ovaries
RA
Proximal thoracic duct obstruction
344
What three circumstances is a Decubitus View used?
To confirm pleural effusion
Determine if it flows freely
Uncover portion of hidden lower lung
345
If a lung is completely opacified by a large effusion, what modality is used to assess the lung?
CT
346
Laminar effusions are a result of what heart issue?
Elevated L atrium pressure
347
What are 3 common causes of hydropneumothorax?
Surgery
Trauma
Recent thoracentesis
348
Bronchopleural fistula falls under what paragraph/category in the text book?
Hydropneumothorax
349
Definition of pneumonia
Consolidation of the lung produced by inflammatory exudate from an infectious agent
350
How are most cases of pneumonia acquired?
Inhalation
| Aspiration
351
Pneumocystitis Carinii pneumonia is seen in what PT population?
Most common clinically recognized infection in AIDS PTs
352
Aspiration of bland foods/water produces what type of issues?
Not a pneumonia, no infectious agents
353
Define Mendelson's Syndrome
Large quantities of non-neutralized gastric acids are aspirated causing chemical pneumonitis
354
What type of lung disease can be localized with ONLY a frontal image?
Pneumonia
355
Define Pneumopericardium
Traumatic entry of air into the pericardium
356
What does the term parenchymal tissue mean for the lungs?
Gas transfer: alveoli, alveolar duct, respiratory bronchioles
357
What is the function of a throacotomy tube?
Remove air/fluid from pleural spaces
358
What is the different placement purposes for pleural drainages?
Anterior Superior= Pneumothorax
| Posterior Inferior= effusion
359
Rapid drainage of large effusions/pneumothorax can lead to what counter issue?
Re-Expansion pulmonary edema
360
If a thoracotomy tube is misplaced, what has more than likely happened to the tube?
What issues can this lead to?
Placed into a major fissure
Inadequate drainage
Subcutaneous emphysema
361
What are 3 major issues that can result from inserting drainage tubes into the chest?
Lacerated intercostal artery
Lacerated liver/spleen
Re-Expansion Pulmonary Edema
362
What is the difference between distension and dilation?
Dilation- abnormal
| Distension- normal
363
There is almost always air in the stomach unless ?
Recently vomited
| Nasogastric tube insertion
364
There is normally air in about ______ loops of non-dilated small bowel?
2- 3
365
Normally the large intestine can be distended how much?
As much as it is during a barium enema study
366
Define Aerophagia
Numerous polygonal-shaped, air-containing loops of bowel, none of which is dilated
367
Why would a PT have numerous air-fluid levels in their colon?
Recent enema
| Taking medication with anticholinergic/antiperistaltic effect
368
What is the most important part of assessing gas patterns in abdominal series?
Overall appearance of the bowel gas pattern, including how much air and fluid there is and its most likely location, is more important
369
In order to see an air-fluid level on an x-ray, three criteria have to happen first
Air
Fluid
Horizontal x-ray beam
370
What are the two fundamental ways of recognizing the presence and estimating the size of soft-tissue masses or organs on conventional radiographs?
Direct visualization of the edges
| Pathologic displacement of air-filled loops of bowel
371
A spleen is probably enlarged if what two things are evident?
Extends below ribs
| Displaces gastric bubble
372
What makes the bladder visible on an x-ray
| How is enlargement seen?
Fat on dome of bladder
| Vertical displacement of bowel
373
Why is a pelvic soft-tissue mass is more likely to be a dilated bladder in a male than a female?
Bladder outlet obstruction is much more common in men from enlargement of the prostate
374
What are iodine contrast agents made up of?
Nonionic, low-osmolar solutions containing a high concentration of iodine
375
Oral contrast is usually not employed in chest CT scanning unless?
Esophagus concerns
376
When is oral contrast not given prior to CT?
Trauma
Aorta exam
Stone search study
377
If there is concern for bowel perforation and the possibility that contrast may exit from the lumen of the bowel, what contrast is used?
iodine-based, water-soluble contrast is sometimes used Gastrografin
378
What defines a liver's anatomy?
Vascular distribution
379
What are the 3 lobes of the liver?
Right
Left
Caudate
380
What structure separates the medial and lateral segments of the left lobe of the liver?
Falciform ligament and ligamentum teres (formerly the umbilical vein)
381
A liver's density on CT is compared to what organ's density for reference?
Spleen
382
What part of the pancreas curves around the superior mesenteric vein?
Head, placed in the duodenal loop
383
The main pancreatic duct empties into the duodenum as the?
Duct of Wirsung, sometimes through an accessory Duct of Santorini
384
What does extraperitoneal mean and what organ is located in it?
Continuous with retroperitoneal
| Bladder
385
What are three major radiographic signs of free intraperitoneal air?
Air below diaphragm
Visualization of both sides of bowel walls
Visualization of Falciform ligament
386
IF PT is unable to be upright for x-ray, what position are they placed in to capture imaging to evaluate for free air in abdomen?
Left lateral decubitus view- PT lays on right side
387
What is the most common cause of free intraperitoneal air?
Rupture of an air-containing loop of bowel, either stomach, small or large bowel
Perforated peptic ulcer- most common cause of perforated stomach/duodenum and is most common cause of free air
388
Hos is a pneumomediastinum created?
Extraperitoneal air may extend through a diaphragmatic hiatus into the mediastinum
389
Air in the bowel wall is most easily recognized on abdominal radiographs when
Seen in profile producing a linear radiolucency whose contour exactly parallels the bowel lumen
390
Pneumatosis intestinalis can be divided into what two major categories
A rare, primary form called pneumatosis cystoides intestinalis that usually affects the left colon
Chronic obstructive pulmonary disease, presumably secondary to air from ruptured blebs dissecting through the mediastinum to the abdomen
391
Gas in the biliary system may be a “normal” finding if ?
Incompetent Sphincter of Odi
392
What is the study of choice for abdominal trauma?
CT w/ contrast
393
What are the most commonly affected solid organs in blunt abdominal trauma in order of decreasing frequency are?
Spleen, liver, kidney, and urinary bladder
Liver is most frequently (right posterior lobe) injured in penetrating and blunt trauma and causes most deaths in PTs from abdominal trauma
394
How is the spleen usually injured?
Deceleration injuries since its the most vascular organ in the abdomen
395
Kidney trauma is most commonly caused by ?
MVA
396
Define Shock Bowel
Blunt force trauma causing hypovolemia/ HOTN
397
What are the two types of bladder ruptures?
Extraperitoneal- pelvic Fx w/ direct puncture of bladder
| Intraperitoneal- pelvic Fx w/ blow to distended bladder
398
Urethral injuries are investigated in what two circumstances?
What imaging modality used?
Straddle Fx
Puncture/penetration injury
Retrograde urethroscopy
399
What is the most common urethral injury?
Rupture of posterior urethra through urethrogenital diaphragm
400
Define Collar Sign
Intra-abdominal contents may be constricted where they pass through the diaphragm foramen
401
What criteria is needed to DEFINITIVELY Dx a tension pneumothorax?
Visual identification of visceral pleural line
402
How is a pneumothorax identified on a supine chest x-ray?
Deep sulcus sign
403
What are the 3 pitfalls of diagnosing a pneumothorax on x-rays?
Cysts in lungs
Skin folds
Scapula border
404
What method may be helpful in demonstrating a pneumothorax in an infant
Lateral decubitus films of the chest with the affected side “up” and the x-ray beam directed horizontally
405
Delayed films are sometimes obtained about how long after penetrating injuries?
6hrs
406
What are the most frequent parenchymal complications of blunt chest trauma?
What do they represent?
Pulmonary contusions
Hemorrhage into lung
407
Pulmonary laceration is also called what two names?
Traumatic pneumatocele
| Hematoma
408
Presumably because of the looser connective tissue in the lungs of children and young adults, pulmonary interstitial emphysema is more likely to occur in those under what age
40 y/o
409
Define Boerhaave's syndrome
Pneumomediastinum
Rupture of the distal esophagus, usually the left posterolateral wall, can occur with increased intraesophageal pressure from retching
410
Pneumopericardium is usually due to direct penetrating injuries to ? and tend to be more common in ? PTs
Pericardium
| Peds
