1st September [30th-5th] Flashcards
1
Q
Differentials for chest pain
A
- hearstburn - chest sprain - shingles - chest infection like pneumonia - pericarditis - angina - MI - hypertrophic cardiomyopathy - pulmonary embolism - pneuothorax - asthma - COPD - oesophageal contaction disorder - epetic ulcers - pancreatiti
2
Q
Causes of pancreatitis
A
Idiopathic Gallstones Ethanol Trauma Steroids Mumps/malignancy Autoimmune Scorpion sting Hypertriglycaemia/hypercalcaemia ERCP Drugs
3
Q
Chest wall tenderness causes
A
- MSK problems [most common] o Injury/trauma o Costochondritis o Tietze’s syndrome o Muscle strain o Rib fracture o Nerve entrapment o Fibromyalgia o Rheumatic diseases like RA
4
Q
Which tool can be used to asses risk of someone having an acute cardiac event?
A
History suspicious [/2] ECG [/2] Age [<65 then /2] RF [3+ then 2] Troponin [over x3 normal limit then 2] score
5
Q
initial tests for MI
A
- FBC, U&E, glucose, HsTnT
6
Q
9) Which cardiac enzyme assay is currently in use in your hospital? What is the practical difference between CK, CK-MB, Troponins and hs-Tropinins?
A
- Two types of troponins measured in blood: T and I - Before troponins, heart muscle damage looked at by CK-MB, now outdated - Troponin released with heart muscle damage - Can take 3-12 hrs for troponin to increase in blood after cardiac damage, will peak around 24-48 hours, damage proportional to level of troponin - Both high diagnostic accuracy I and T, I superior early presenters, T in late presenters, prognostic accuracy for all-cause mortality higher in TnT - Hs-Trop have been developed in an effort to improve detection of an MI -> can detect much lower concentrations
7
Q
How long does it take for troponin to peak in the blood?
A
- Can take 3-12 hrs for troponin to increase in blood after cardiac damage, will peak around 24-48 hours, damage proportional to level of troponin
8
Q
Is it possible to have an ECG normal in an MI?
A
Yes, because of a NSTEMI
9
Q
Initial pain relieving drugs to give during an MI? What else should be given?
A
- GTN and morphine, possibly paracetamol - Can be given oxygen
10
Q
Where would an anterior MI show on an ECG?
A
V1-V6 ST elevation, with no ST depression. LAD artery. Think minaly V3-4 in anterior.
11
Q
ECG changes of an MI?
A
ECG changes MI [within 12 hours] 1. ST elevation in more than one consecutive leads 2. Elevation: more 2mm chest leads, more than 1mm in limb leads
12
Q
What procedure does a person with an MI need?
A
- Coronary angioplasty [or PCI] can be done within a few hours of symptoms starting -> Primary Percutaneous Coronary Intervention
13
Q
How quickly should a PCI be done?
A
- The 2006 Occluded Artery Trial [OAT] determined that performing angioplasty delivered no tangible benefit to people who’d had a heart attack more than 24 hours earlier and who no longer had symptoms
14
Q
How does PI work?
A
- Opens up a narrowed artery around the heart - Surgeon inserts tube into an artery in the groin/wrist -> insert tube into affected artery -> insert balloon or stent to open artery
15
Q
Which Tx should be given if procedure unavailable?
A
- Injection of clot-busting medicine -> given easily and quickly [thrombolise him] - Done for conditions which involve blocked arteries: stroke, PE, DVT, acute arterial thrombus in leg, blocked surgical bypasses [blocked dialysis fistulas or catheters]
16
Q
Name three thrombolytic drugs
A
- Four thrombolytic drugs currently available in the UK o Altepase o Reteplase o Streptokinase o Tenecteplase
17
Q
CI for those thrombolytic drugs
A
Besides risk of serious internal bleeding, other possible risks include: • Bruising or bleeding at the access site • Damage to the blood vessel • Migration of the blood clot to another part of vascular system • Kidney damage in patients with diabetes or other pre-existing kidney disease
18
Q
Which patients would thrombolysis not be recommended for?
A
Thrombolysis may not be recommended for patients who use blood-thinning medication, herbs, or dietary supplements, or for people with certain conditions associated with an increased risk of bleeding. These conditions include: • Severe high blood pressure • Active bleeding or severe blood loss • Hemorrhagic stroke from bleeding in the brain • Severe kidney disease • Recent surgery
19
Q
What other drugs should be considered during emergency Tx of ACS
A
Holy trinity 1. Aspirin 300mg 2. Dalteparin 3. Ticagrelor 180mg
20
Q
What key information do you need with paracetamol poinsoinng?
A
- What time did they take the poisonous substance? - How much of the poisonous substance did they take? - Medicine in tablet/caplet/liquid/soluble form - Whether they had alcohol or not - Have they had any symptoms? How long have these been present? - What else have they taken since having the poison? - Precipitating reason for taking OD. Any suicide risk, such as whether a note was written. - Any DA? - Above 150mg/kg then toxic - Anything over 250mg can be fatal
21
Q
Which organ primarily site of paracetamol toxicity?
A
- Liver is the principal organ affected - Brain scan also be affected with confusion and disorientation [encephalopathy] - Also, kidneys can be affected with reduction in urine, and kidney failure can occur
22
Q
What is the toxic metabolite created by the ingestion of paracetamol?
A
N-acetyl-p-benzoquinone imine [NAPQI]
23
Q
Where is it formed NAPQI?
A
In the liver by cytochrome P450 2E1
24
Q
What does the increased amount of NAPQI cause?
A
The small amounts of NAPQI produced after therapeutic doses are detoxified by irreversible glutathione-dependent conjugation reactions to two non-toxic metabolites.
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How does NAC work?
Hence NAC works as a glutathione donor preventing NAPQI accumulation
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RFs for low glutathione
anorexics, alcoholics, P450 inducing drugs so paracetamol overdose
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What Ix should all patients recieeve with paracetamol OD?
- Serum paracetamol concentration - ALT/AST - Coagulation and INR
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Which other Ix do they also require?
- VBG [pH and lactate] - EUC - Glucose - Coagulation - Calcium/magnesium/phosphate
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Why are paracetamol levels taken 4 hours post ingestion?
The paracetamol nomogram is used to plot paracetamol concentration against time from ingestion. If the paracetamol concentration lies on or above the treatment line, NAC should be administered. This is used for patients who have ingested paracetamol over one hour or less and presented within 8 hours. As the plasma paracetamol concentration reaches its peak at 4 hours, it is important not to take a paracetamol level within 4 hours of the last ingestion. Patients who have a delayed presentation, or where the paracetamol level will not be available within 8 hours from last ingestion, NAC is started whilst awaiting investigations. Paracetamol levels can be interpreted up to 24 hours, but any detectable level of paracetamol beyond 16 hours is concerning.
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When would give charcoal?
\<2 hours post ingestion
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2-8 hours post ingestion give what for patient?
Measure serum paracetamol concentration and ALT then plot nomongram and a treat if above line
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If over 8 hours of staggered dosing Tx?
Start NAC
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Which scoring system can be used to detect risk of further harm of the patient?
Sex Age Depressed Previous suicide attempts Excessive salcohol use Rational thiking loss Single Organised attempt No social support Stated future intent score: - 0-5 then may be safe to discahrge - 6-8 probab;y requires psychiatric consultation - 8+ probabaly requires hospital admission
34
What should all OD patients have?
Seen by mentla health practitioners
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patient flushed and vomited after NAC, what's happened?
- Anaphylactoid reactions occur anywhere between 10-50% and are more likely to occur in patients with lower paracetamol ingestions (NAPQI appears to be protective). Typically, this reaction occurs after the first bag of NAC.
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What to do if patient has anaphylactoid reaction to NAC?
o Stop the infusion o Treat with loratadine 10mg (2.5mg \<12kg, 5mg \<30kg) PO or promethazine 12.5 mg IV (0.25mg/kg) o The NAC can then be recommenced once symptoms settle at half rate for 30 minutes and then recommenced as per normal protocol.
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What is maximum daily dose of paracetamol?
4g
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DDx for a PE
- Pulmonary embolism - Infection: viral [most commonly], bacterial [pneumonia or TB] - Injury or trauma [causing a fracture/bruising] - Lung Ca near the pleural surface [with smoking 20 a day] - Autoimmune disorder like RA or lupus - Pneumothorax - Pleural effusion - Pericarditis - Heart problem - GORD - Anxiety - Costochondritis
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Sx of a pleural effusion
Shortness of breath Dry cough Pain Feeling of chest heaviness or tightness Inability to lie flat Inability to exercise Generally feeling unwell
40
Most common cause of pleural effusion?
The most common causes of transudative (watery fluid) pleural effusions include: Heart failure. Pulmonary embolism. Cirrhosis
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What is normal pleural fluid?
Typical findings of normal pleural fluid are as follows: Appearance: clear pH: 7.60-7.64 Protein: \< 2% (1-2 g/dL) White blood cells (WBC): \< 1000/mm³ Glucose: similar to that of plasma LDH: \<50% plasma concentration Amylase: 30-110 U/L Triglycerides: \<2 mmol/l Cholesterol: 3.5–6.5 mmol/l
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What are transudative pleural effusions?
Transudative pleural effusions are defined as effusions that are caused by factors that alter hydrostatic pressure, pleural permeability, and oncotic pressure.
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Conditions associated with transudative pleural effusions?
Conditions associated with transudative pleural effusions include: Congestive heart failure Liver cirrhosis Severe hypoalbuminemia Nephrotic syndrome
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What are exudative pleural effusions?
Exudative pleural effusions are caused by changes to the local factors that influence the formation and absorption of pleural fluid.
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Conditions associated with exudative pleural effusions
Conditions associated with exudative pleural effusions include: Malignancy Infection (e.g. empyema due to bacterial pneumonia) Trauma Pulmonary infarction Pulmonary embolism
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Diagnostic criteria for pleural effusions
Diagnostic criteria for pleural effusion Transudate Protein \<30 g/L (in patients with a normal serum protein level) Exudate Protein \>30 g/L (in patients with a normal serum protein level)
47
Which level of amylase indicates pancreatitis?
think it's above 200U/l
48
What is Light's criteria?
Light’s criteria are more accurate for the diagnosis of exudative effusions. The fluid is considered an exudate if any of the following are present: The ratio of pleural fluid to serum protein is greater than 0.5 The ratio of pleural fluid to serum LDH is greater than 0.6 The pleural fluid LDH value is greater than two-thirds of the upper limit of the normal serum value If a patient is thought to have a transudative pleural effusion but the Light’s Criteria suggest an exudate, the serum–pleural fluid protein gradient should be examined
49
What to do first with chest XR?
Begin chest X-ray interpretation by checking the following details: Patient details: name, date of birth and unique identification number. Date and time the film was taken Previous imaging: useful for comparison
50
What to do after confirming CXR to assess image quality?
Assess image quality Next, you should assess the quality of the image: a mnemonic you may find useful is ‘RIPE’. Rotation The medial aspect of each clavicle should be equidistant from the spinous processes. The spinous processes should also be in vertically orientated against the vertebral bodies. Inspiration The 5-6 anterior ribs, lung apices, both costophrenic angles and the lateral rib edges should be visible. Projection Note if the film is AP or PA: if there is no label, then assume it’s a PA film (if the scapulae are not projected within the chest, it’s PA). Exposure The left hemidiaphragm should be visible to the spine and the vertebrae should be visible behind the heart
51
What is the ABCDE approach to CXR?
Airway: trachea, carina, bronchi and hilar structures. Breathing: lungs and pleura. Cardiac: heart size and borders. Diaphragm: including assessment of costophrenic angles. Everything else: mediastinal contours, bones, soft tissues, tubes, valves, pacemakers and review areas
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Causes of true tracheal deviation
True tracheal deviation: Pushing of the trachea: large pleural effusion or tension pneumothorax. Pulling of the trachea: consolidation with associated lobar collapse.
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Causes of apparent tracheal deviation
Apparent tracheal deviation: Rotation of the patient can give the appearance of apparent tracheal deviation, so as mentioned above, inspect the clavicles to rule out the presence of rotation
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What should an NG tube do on an CXR if it is correctly placed?
On appropriately exposed chest X-ray, this division should be clearly visible. The carina is an important landmark when assessing nasogastric (NG) tube placement, as the NG tube should bisect the carina if it is correctly placed in the gastrointestinal tract.
55
Compare the R to the L main bronchus
The right main bronchus is generally wider, shorter and more vertical than the left main bronchus.
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What does that mean pathologically for the bronchus if it is shaped differently?
As a result of this difference in size and orientation, it is more common for inhaled foreign objects to become lodged in the right main bronchus.
57
What are the hilar strcutures?
The hilar consist of the main pulmonary vasculature and the major bronchi.
58
In healthy individuals what should not be visibile hilar structures?
Each hilar also has a collection of lymph nodes which aren’t usually visible in healthy individuals.
59
Which hilar structure is slightly higher in individuals?
The left hilum is often positioned slightly higher than the right, but there is a wide degree of variability between individuals.
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Are hilar differently sized?
The hilar are usually the same size, so asymmetry should raise suspicion of pathology.
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What is the hilar point?
The hilar point is also a very important landmark; anatomically it is where the descending pulmonary artery intersects the superior pulmonary vein. When this is lost, consider the possibility of a lesion here (e.g. lung tumour or enlarged lymph nodes).
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Causes of hilar enlargement?
Hilar enlargement can be caused by a number of different pathologies: Bilateral symmetrical enlargement is typically associated with sarcoidosis. Unilateral/asymmetrical enlargement may be due to underlying malignancy.
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Causes of abnormal hilar position
Abnormal hilar position can also be due to a range of different pathologies. You should inspect for evidence of the hilar being pushed (e.g. by an enlarging soft tissue mass) or pulled (e.g. lobar collapse).
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how to inspect the lungs in B part of A to E
When interpreting a chest X-ray you should divide each of the lungs into three zones, each occupying one-third of the height of the lung. These zones do not equate to lung lobes (e.g. the left lung has three zones but only two lobes). Inspect the lung zones ensuring that lung markings are present throughout. Compare each zone between lungs, noting any asymmetry (some asymmetry is normal and caused by the presence of various anatomical structures e.g. the heart). Some lung pathology causes symmetrical changes in the lung fields, which can make it more difficult to recognise, so it’s important to keep this in mind (e.g. pulmonary oedema). Increased airspace shadowing in a given area of a lung field may indicate pathology (e.g. consolidation/malignant lesion). The complete absence of lung markings should raise suspicion of a pneumothorax.
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How many lobes does the lung have on each side?
left has two lobes, right has three
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What can absence of lung markings raise the suspicion of?
The complete absence of lung markings should raise suspicion of a pneumothorax.
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How to inspect the pleura?
Inspect the pleura for abnormalities: The pleura are not usually visible in healthy individuals. If the pleura are visible it indicates the presence of pleural thickening which is typically associated with mesothelioma. Inspect the borders of each lung to ensure lung markings extend all the way to the edges of the lung fields (the absence of lung markings is suggestive of pneumothorax). Fluid (hydrothorax) or blood (haemothorax) can accumulate in the pleural space, resulting in an area of increased opacity on a chest X-ray. In some cases, a combination of air and fluid can accumulate in the pleural space (hydropneumothorax), resulting in a mixed pattern of both increased and decreased opacity within the pleural cavity.
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What is a tension pnueothorax?
A tension pneumothorax is a life-threatening condition which involves an increasing amount of air being trapped within the pleural cavity displacing (pushing away) mediastinal structures (e.g. the trachea) and impairing cardiac function.
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How is a tension pneuothorax susepcted clinically?
If a tension pneumothorax is suspected clinically (shortness of breath and tracheal deviation) then immediate intervention should be performed without waiting for imaging as this condition will result in death if left untreated.
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in health individual, how large should the heart be?
In a healthy individual, the heart should occupy no more than 50% of the thoracic width (e.g. a cardiothoracic ratio of less than 0.5). This rule only applies to PA chest X-rays (as AP films exaggerate heart size), so you should not draw any conclusions about heart size from an AP film.
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What can cardiomegaly develop from?
Cardiomegaly is said to be present if the heart occupies more than 50% of the thoracic width on a PA chest X-ray. Cardiomegaly can develop for a wide variety of reasons including valvular heart disease, cardiomyopathy, pulmonary hypertension and pericardial effusion.
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Biliary colic signs
A person with biliary colic typically feels pain in the middle to right upper abdomen. The pain can feel sharp, crampy, or like a constant dull ache. Colic often occurs in the evening, especially after eating a heavy meal. Some people feel it after bedtime. The worst pain of biliary colic commonly lasts for 30 minutes to an hour, but may continue at a lower intensity for several more hours. The pain stops when the gallstone breaks free of the bile duct and passes into the intestine.
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Biliary colic vs cholescystitis
Biliary colic vs. cholecystitis Cholecystitis is an inflammation of the gallbladder. It requires immediate medical care. Similar to biliary colic, gallstones are a common cause of cholecystitis. Cholecystitis is a possible complication of biliary colic. Its symptoms are more severe than those associated with biliary colic, and they last longer. Symptoms of cholecystitis may include: prolonged abdominal pain that doesn’t get better fever or chills nausea and vomiting yellowish tinge to the skin and eyes, which is known as jaundice tea-colored urine and pale stools
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Reversible causes of cardiac arrest: 4 Hs
Hypoxia (low levels of oxygen) Hypovolemia (shock) Hyperkalemia/hypokalemia/hypoglycemia/hypocalcemia (+ other metabolic disturbances) Hypothermia
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Reversible causes of cardaic arrest: 4 Ts
Thrombosis (coronary or pulmonary) Tension pneumothorax Tamponade (cardiac) Toxins
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How to assess the heart borders
Inspect the borders of the heart which should be well defined in healthy individuals: The right atrium makes up most of the right heart border. The left ventricle makes up most of the left heart border. The heart borders may become difficult to distinguish from the lung fields as a result of pathology which increases the opacity of overlying lung tissue: Reduced definition of the right heart border is typically associated with right middle lobe consolidation. Reduced definition of the left heart border is typically associated with lingular consolidation.
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Which side of the diaphragm raised healthy individuals?
The right hemidiaphragm is, in most cases, higher than the left in healthy individuals (due to the presence of the liver). The stomach underlies the left hemidiaphragm and is best identified by the gastric bubble located within it.
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Healthy individuals how should the diaphragm look?
The diaphragm should be indistinguishable from the underlying liver in healthy individuals on an erect chest X-ray, however, if free gas is present (often as a result of bowel perforation), air accumulates under the diaphragm causing it to lift and become visibly separate from the liver. If you see free gas under the diaphragm you should seek urgent senior review, as further imaging (e.g. CT abdomen) will likely be required to identify the source of free gas.
79
Which conditions can give false impression free gas under the diaphragm?
There are some conditions which can result in the false impression of free gas under the diaphragm, known as pseudo-pneumoperitoneum, including Chilaiditi syndrome. Chilaiditi syndrome involves the abnormal position of the colon between the liver and the diaphragm resulting in the appearance of free gas under the diaphragm (because the bowel wall and diaphragm become indistinguishable due to their proximity). As a junior doctor, you should always discuss a scan that appears to show free gas with a senior colleague immediately.
80
What would loss of costophrenic angles indicate?
The costophrenic angles are formed from the dome of each hemidiaphragm and the lateral chest wall. In a healthy individual, the costophrenic angles should be clearly visible on a normal chest X-ray as a well defined acute angle. Loss of this acute angle, sometimes referred to as costophrenic blunting, can indicate the presence of fluid or consolidation in the area. Costophrenic blunting can also develop secondary to lung hyperinflation as a result of diaphragmatic flattening and subsequent loss of the acute angle (e.g. chronic obstructive pulmonary disease).
81
What are the mediastinal contours?
The mediastinum contains the heart, great vessels, lymphoid tissue and a number of potential spaces where pathology can develop. The exact boundaries of the mediastinum aren’t particularly visible on a chest X-ray, however, there are some important structures that you should assess.
82
Aortic knuckle?
The aortic knuckle is located at the left lateral edge of the aorta as it arches back over the left main bronchus. Reduced definition of the aortic knuckle contours can occur in the context of an aneurysm.
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What is the aortopulmonary window?
The aortopulmonary window is a space located between the arch of the aorta and the pulmonary arteries. This space can be lost as a result of mediastinal lymphadenopathy (e.g. malignancy).
84
What should look for bones/soft tissues?
Bones Inspect the visible skeletal structures looking for abnormalities (e.g. fractures, lytic lesions). Soft tissues Inspect the soft tissues for obvious abnormalities (e.g. large haematoma).
85
Tubes/valaves/pacemakers?
Tubes Nasogastric tube placement is something you’ll often be asked to assess on a chest X-ray to confirm safe placement for feeding. See our NG tube placement guide for more details. Lines Various tubes and cables will be visible as radio-opaque lines on the chest X-ray (e.g. central line, ECG cables). Artificial heart valves Artificial heart valves typically appear as ring-shaped structures on a chest X-ray within the region of the heart (e.g. aortic valve replacement). Pacemaker Pacemakers typically appear as a radio-opaque disc or oval in the infraclavicular region connected to pacemaker wires which are positioned within the heart.
86
Who assesses the NG tube placement?
Has to be registrar and upwards
87
What is this?
Pleural effusion
88
Label
89
This
90
CXR
Lung tumour
91
CXR
RS pneumothrax
92
CXR
Pleural thickening context of mesothelioma
93
Sign of
94
Sign of
95
Sign of
Chilaiditi syndrome
96
CXR
costophrenic blunting secondary to pneuomonia
97
Label
Aortic knucle, aorta-pulomnary window
98
Finding?
meniscus sign of pleural effusion
99
finding
Calified pleural plaques: typical appearacne sof clacified pleural plaques seocnday to asbestos exposure. This is diffeent from asbestosis whihc is lung fibroiss seocndary to asboesos exposure
100
20 y/o female high temperature and cough
Consolidation
## Footnote
There is no rotation; this is a good quality image in a patient with a thoracic spine scoliosis.
Increased density with air bronchogram in the left lower zone indicates consolidation. Compare with the clear right lower zone. A chest X-ray is not diagnostic of lung cancer and this diagnosis is very unlikely in this age group.
The costophrenic angles remain well-defined indicating there is no pleural effusion
101
Finding?
102
Cough, weight loss and finger clubbing?
103
Finding?
104
Findings?
Septal lines [kerley B lines: Septal lines are a subtle but very useful sign. In the context of clinically suspected heart failure they indicate interstitial pulmonary oedema.]
105
Wrong with this patient?
NG tube should be removed:The endotracheal tube tip is located approximately 3 cm above the carina. If anything, it should be withdrawn a little.
## Footnote
There is no reason to remove the right internal jugular catheter. For long term use it may be appropriate to advance further.
The nasogastric tube has passed down the right main bronchus into the right lung. It should be removed.
Although lung markings are likely exaggerated by patient positioning and incomplete inspiration, they can’t be called normal.
106
Physical examinatino sign expect for this CXR?
107
Most liklely cause of chest pain in this person?
Trauma:Atelectasis at the left lung base may be related to any of these causes, however there is a displaced rib fracture indicating trauma.
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