Chest imaging

Question 1

rigler’s sign

Answer 1

sign of pneumoperitoneum. air seen on both sides of bowel wall.

Question 2

deep sulcus sign

Answer 2

pneumothorax on suprine chest radiograph when one costophrenic sulcus appears much deeper and lucent than the other due to air collecting there.

Question 3

continuous hemidiaphragm sign

Answer 3

sign of pneumomediastinum on chest radiograph when there appears to be a lucent line connecting both hemidiaphragms due to air btw pericardial sac and the diaphragm

Question 4

preop CXR

Answer 4

pt with Cardiorespiratory sx or >65yo+ stable CRD and no CSR for 6mo

Question 5

nodule factors

Answer 5

size (>1 incr malign), edge (smooth, lobulated, speculated, ill-defined), calcification, growth

Question 6

pt factors for nodules

Answer 6

hx of lung fibrosis/ asbestosis, age (>40 incr malign), smoking hx, travel hx (endemic granulomatous disease- 40% in places with endemic histoplasmosis), hx of other malign disease

Question 7

lung ca screening

Answer 7

mostly detect adenocarcinoma. not good for SCC of central airway or small cell lung ca.

Question 8

evaluation of lung nodules

Answer 8

1) xray 2) CT 3) PET scan bc most lung ca has high metabolic activity and can assess for metastases (95% sensitive, 85% specific) 4) CT guided needle biopsy if in periphery. can consider bronchoscopy guided if central and flour guided if not close to heart 5) post bx need rescan to evaluate for pneumothorax or hemorrhage for erect expiratory CXR or CL lateral decubitus CXR

Question 9

tension pneumothorax CXR

Answer 9

mediastinal shift away from pneumothorax, diaphragmatic depression on side of pneumothorax, lung complete collapsed, usually large.

Question 10

Aunt Minni sign

Answer 10

upper lobe essential cases. faint fail like opacification of 2/3 of hemithorax, tracheal sift to TV

Question 11

opacification of hemithorax DD

Answer 11

pneumonectomy, huge pleural effusion, total long pneumonia, large mass

Question 12

pneumonectomy

Answer 12

marked V less with tracheal shift, mediastinal shift and diaphragmatic elevation. ribs closer on ban side. chest is dull to percussion, absent breath sounds and shifted brachia apex beat.

Question 13

huge pleural effusion

Answer 13

mediastinal shift away from side of effusion. very dense. absent breath sounds, dull to percussion,

Question 14

total lung pneumonia

Answer 14

air bronchograms, no evidence of volume loss. residual aerated lung. incr breath sounds an inspiratory crakes. no tracheal shift or decr expansion.

Question 15

visceral pleural white line

Answer 15

seen when air enter pleural space, sep parietal and visceral pleura- white line- needed to dx Ppneumothorax

Question 16

absence of lung marking dd

Answer 16

pneumothorax, bullous disease, large cyst, PE. important to DD since tx PTX with chest tube but hat can cause intractable PTX in bulla

Question 17

skin fold

Answer 17

dd from visceral pleural white line by seeing edge between density and lucency white in PTX see line with lucency on both sides

Question 18

pneumothorax causes

Answer 18

1) spontaneous rupture of apical sub-pleural bleb in tall thin male.
2) trauma: thorugh chest wall- stab wound, internal (rupture of a bronchus from MVA)
3) disease that decr lung compliance (chronic fibrotic disease, disease that stiffen lung),
4) rupture of an alveolus or bronchiole (asthma)

Question 19

peribronchial cuffing

Answer 19

doughnuts seen distal to hillier area that rep fluid in bronchial walls when seen in connection with other signs of CHF

Question 20

HF signs

Answer 20

kerley B lines, peribronchial cuff, fluid in fissure (btw visceral pleura and lung parenchyma), pleural effusion, pulmonary alveolar edema-batwing configuration bc outer 1/3 of lung frequently spared

Question 21

aortic dissection imaging

Answer 21

CTA with contrast. can’t see wo contrast. see crescent of high intensity in wall of aorta which is hard to see w contrast. but then contrast allow id of dissection flap. if have IC, then think CT with lower dose, MRI w/wo gad depending on GFR, TEE if unstable.

Question 22

PE imaging

Answer 22

CTA unless CI for IV contrast then do VQ scan.

Question 23

3 Indications for IVC filter

Answer 23

free floating clot in IVC, failure to anticoag (PE or LE clot propagation while anti-coagulated), CI for anticoag, prophylactic in major multi fracture trauma prior to major OR procedure with high thrombotic risk

Question 24

D dimer v PE

Answer 24

good for healthy outpatient. 95% sensitivity for PE. so neg excludes PE in low risk pt. but very low specificity so in pos test or in high risk pt, do CTA or VQ scan

Question 25

methods to decr renal toxic in pt with impaired renal function

Answer 25

1) lower dosage
2) pre and post hydration
3) use dif contrast- iso-osmolar contrast that has less renal to.
4) mucomyst - N-acetylcysteine.
5) urine alkalinization

Question 26

measurements defining thresholds for normal and abnormal cardiac silhouette

Answer 26

PA: maximum internal thoracic ratio >2x max cardiac ratio wo fat pad

Question 27

Kerley B lines

Answer 27

seen in cariogenic but not non-cardiogenic edema. also in lymphangitis carcinomatosis, viral pneumonia, asbestosis, mitral stenosis, firbosing mediastinhtis, pulmonary vein stenosis

Question 28

pulmonary edema findings in ordor of severity

Answer 28

.

Question 29

emphysema and COPD on CXR

Answer 29

hyperinflation, incr lucency, central pulmonary arteries enlarged, heart narrowed and smaller from overinflation, flat hemidiaphragm- best sign of hyperinflation. course and distorted bronchovascular and interstitial markings (more on choleric bronchitis than emphysema), peribronchial cuffing, saber sheath trachea

Question 30

air bronchograms causes

Answer 30

lung consolidation, pulmonary edema, non-obstructive atelectasis, severe intersitial lung disease, lung cancer, normal expiration

Question 31

unilateral whiteout DD

Answer 31

total lung collapse, massive pleural effusion with underlying collapse. pneumonia with total lung consolidation, very large tumor, pneumonectomy, severe unilateral pulmonary edema, severe aspiration event

Question 32

unilateral white out next step

Answer 32

CT, US, or bronchoscopy. not decubitus film