Download INTERACTIVE CASE DISCUSSIONS


HISTORY OF PRESENT
ILLNESS

30/F
CC: cough

1 wk PTC

(+) cough
(+) difficulty of breathing
(-) fever

Persistence.


PHYSICAL EXAMINATION
Consult.
VS HR 120/80 HR 96 RR 28 T 36.4°C
 in respiratory distress, supraclavicular,
intercostal and subcostal retractions
 symmetric chest expansion,  BS left lower
lung, (+) coarse crackles & rhonchi, L

AP SUPINE
LEFT LAT DECUBITUS
CLERK’S GUIDE: Discuss first the basics of a normal chest x-ray.
action of the body takes to get rid of
substances that are irritating the air
passages
 occurs when mechanical or chemical
afferent nerves get irritated and trigger a
chain of events
 Air in lungs is forced out under high
pressure.


Cough
› Acute < 3weeks
› Persistent >3weeks
› Chronic >8weeks
› Acute cough
 Infectious
 Non infectious
Acute Cough – signs and symptoms
Infectious
Non infectious
Fever, chills, body aches, sore
throat vomiting, headache, sinus
pressure, runny nose, night sweats,
and postnasal drip. sputum, or
phlegm,
exposure to certain chemicals or
irritants in the environment,
coughs that may improve with
inhalers or allergy medications
For patient with acute cough
 Abnormal vital signs
 Chest examination suggestive of
pneumonia
Patient: RR 28
› in respiratory distress, supraclavicular,
intercostal and subcostal retractions
› symmetric chest expansion,  BS left lower
lung, (+) coarse crackles & rhonchi, L
if px can’t assume upright position,
though
 can’t critically evaluate the size of the
heart because of hypoventilation,
diaphragmatic elevation pushing the
base of the heart upwards.

px lies on right or left side; the beam
traverses the body in horizontal position
 px w/pleural effusion, pneumothorax –
presence of fluid gravitates to
dependent portions
 demonstrate fluid levels in cavities


Ribs
› Anterior ribs
 obliquely placed
 wider intercostals
spaces
› Posterior ribs
 horizontally placed
 narrower intercostals
spaces
› Intercostal Spaces

Diaphragm: right and
left
› middle segment
partially obscured
› Normal level
 10th post rib / 5th ant rib
 right higher than the left
(liver)
› dome-shaped

Costophrenic angle / sinus
and Cardiophrenic angle
› Sharp, well defined and
not blunted

Trachea and
mediastinum
› radioluscent: means
›
›
›
›
it has an air
bifurcates at T5
(carina) into right
and left bronchus
normal: midline
right bronchus:
shorter and more
vertical
left bronchus: longer
and more horizontal

Hila, bronchovascular
markings
› pulmonary artery and vein
› bronchial artery and vein
› bronchus
› lymph nodes

Normal:
› left hilum higher than the right
› pulmonary artery crosses
above the left and below the
right bronchus
› size of hilum varies depending
on pulmonary blood flow

Lungs
› Radiolucent

Inner, middle, outer zones
› Inner zone: from sternoclavicular
joint draw a vertical line following
contour of the chest, big blood
vessels are located
› middle zone: medium blood
vessels are located
› outer zone: junction of the clavicle
and 1st rib draw a vertical line;
small blood vessels are located

Upper, middle, lower
lung fields
› landmarks: 2nd and
4th anterior ribs
› upper lung field:
further subdivided by
the clavicle into
supraclavicular
(apex) and
infraclavicular
› significance: for
localization of the
lesions

Lobar anatomy
› right lobe
 major fissure: divides lower lobe from upper
and middle
 minor fissure: divides upper and middle
› left lobe
 for upper and lower lobes only

Heart shadow
› Superior mediastinum
 draw a line from the
sternal angle to the 4th
vertebra
› Anterior mediastinum
 bounded by posterior
surface of the sternum
and anterior surface of
the heart
› Posterior mediastinum
 bounded by posterior
part of the heart and
anterior spinal muscle
S
A
P

Size
› Cardiothoracic ratio
› Easiest gross determination
› Compare size of the heart with
the thorax
› Normal 2:1
› Get the widest transverse
diameter of the heart compare
with the widestinternal
transverse diameter of the
thorax

Shape
› Variable
› neonate: globular

Right border
› Superior vena cava
› Right atrium
› Inferior vena cava

Right border
› Superior vena cava
› Right atrium
› Inferior vena cava

Left border
› Aortic knob
› Main pulmonary trunk
› Left ventricle
trachea
AORTA
Main Pulmonary Artery
RS
Left atrium
Left
ventricle
Right ventricle
RC
AP SUPINE
LEFT LAT DECUBITUS
CLERK’S GUIDE: Discuss first the basics of a normal chest x-ray.
Obscured diagphragmatic sulci at the
left
 Narrow intercostal space
 No shifting of the mediastinal structures
Cardiac shadow not appreciated
 Hyperluscency of the right lung
 Homogenous opacification of the left
lung

Consolidation
 Atelectasis
 Pleural effusion
 Mass lesions

Mass
Consolidation
Pleural effusion
Atelectasis
Duration
Chronic
Sub acute to
chronic
Sub acute to chronic
Acute to sub acute
A-abdomen
and thorax,
costophrenc
and
cardiophreni
c sulci,
diaphragm
May be
affected
depending on
the location of
the mass
Blunted/
normal
Blunting of
costrophrenic sulcus,
nor visualization of
hemidiaphragm, due
to presence of fluid
Hemidiaphragm may be
affected depending on
the size of atelectasis
T-thoracic
cage
normal
Normal
+/- widenend
interspaces on
affected side
Narrowed interspaces on
affected side with
compensatory widening
on opposite side
Mmediastinum
+/- shifting
depends on
the size and
location
Normal
+/- shifting
contralaterally
+/- shifting ipsilaterally
LL- Lung
comparison
Solitary ,
calcificied,
ildefined,
spiculations,
irreguar,
cavitations,
hilar
enlargement,
effusions
Air
bronchogram
Homogenous
opacification with a
lateral upward
curve(meniscus sign)
Lat decubitus viewfree fluid within the
pleural space +layering
oon the dependent
part
Homogenous
opacification of affected
side
means “lack of stretch”
 refers to collapse or loss of lung volume
 2 types: Obstructive or Non obstructive


Obstructive
› blockage of an airway
› Air retained distal to the occlusion is then
resorbed from nonventilated alveoli
› affected regions become totally airless

Non obstructive
› caused by loss of contact between the
parietal and visceral pleurae, parenchymal
compression, loss of surfactant, or
replacement of lung tissue by scarring or
infiltrative disease.

Direct signs
› displacement of fissures
› increased opacification of the airless lobe.

Indirect signs
› displacement of hilar structures,
› cardiomediastinal shift toward the side of
collapse,
› narrowing of ipsilateral intercostal spaces,
› elevation of the ipsilateral hemidiaphragm,
compensatory hyperinflation and hyperlucency
of the remaining aerated parts of the lung, and
› obscuring of structures adjacent to the
collapsed lung, such as the diaphragm, heart, or
pulmonary vessels.


can distinguish between obstructive and
nonobstructive atelectasis
Obstructive atelectasis
› displays high signal intensity on T2-weighted images
due to proton-rich mucus accumulation.

Nonobstructive atelectasis
› low signal intensity on T1 and T2 weighted spin-echo
images, since the residual alveolar gas has a low
proton concentration, and magnetic susceptibility
effects between alveolar walls lead to a decrease in
signal.
The use of MRI in diagnosing atelectasis is still
experimental, and more experience needs to be
accrued
Continuous positive airway pressure
(CPAP)
 Fiberoptic bronchoscopy for the
extraction of secretions
 Mucolytic therapy
