Chest X-rays

Question 1

How do you treat a pneumothorax?

Answer 1

Bilateral/haemodynamically unstable? Yes= chest drain

> 50? smoking Hx/ evidence of underlying chest pathology on CXR or exam? Yes= secondary pneumothorax.

Primary Pneumothorax- >2cm and/or breathless = aspirate with needle. (success or No )= discharge and review in ODP in 2-4 weeks.

Secondary Pneumothorax=

1) 1-2 cm No= admit + oxygen and observe 24hrs. Yes= needle decompression, if now under 1cm = sucess and admit
2) >2cm or breathless = chest drain

Question 2

where to you measure the size of a pneumothorax

Answer 2

inter-pleural space at level of the hilum

Question 3

How do you treat heart failure acutely?

Answer 3

Loop Diuretics
Morphine 
Nitrates
Oxygen 
Postition+ Positive pressure ventilation

Question 4

What is CURB-65?

Answer 4

C- confusion
U- urea over 7 
R- RR>30
B- SBP <90 mmHg or DBP <60 mmHg 
65- over 65

Question 5

How does CURB-65 effect treatment?

Answer 5

1 = low risk manage in community 
2= probable admission vs close ODP monitoring 
3-5= admit treat as severe

Question 6

How do you assess a CXR?

Answer 6

Name DOB
PA or AP. Rotation
Expansion= 7 anterior ribs
Exposure- Apcies to diaphragm
Penetration= 3 verterbral discs behind mediastinum 

A= airway.
Trachae- central vs deviated
Bronchi

B= Breathing
Hilar
Lung Fields- clear, symetrical, extend to pleura?

C= Cardiac?
Heart borders
Mediastinal contours (aortic knuckle)
cardiac diameter

D= diaphragm
hemidiaphragm- higher on the right?
costophrenic/ costocardiac angles?

E= extras
Bones
Soft Tisse

Question 7

How do you manage Heart Failure Chronically?

Answer 7

CONSERVATIVE:
treat cause
stop smoking/alcohol
annual influenza
MDT: HF nurse 

MEDICAL:
ACE inhibitor+ Beta-blocker
spironolactone
diuretics for fluid overload
digoxin

SURGICAL:
LV assist
cardiac resynchronisation
transplantation

Question 8

What does COPD look like on a chest X-ray?

Answer 8

Hyperinflated lungs- hemidiaphragm below 7th rib anteriorly

Floating heart sign

Question 9

How would you manage and acute exacerbation of COPD?

Answer 9

ABCDE approach
Oxygen 2L aiming for 88-92%
5mg neb salbutamol
500mcg neb ipratropium
Venous Access
100mg IV hydrocortisone
Abx as per guidline

Question 10

How do you manage COPD chronically

Answer 10

CONSERVATIVE:
Stop smoking, excercise, flu vaccine
Pulmonary Rehabilitation

MEDICAL:
1) Bronchodialator Therapy SABA

2) FEV1 >50 LABA eg salmeterol
FEV1<50 LABA + ICS

3) Oral theophylline
4) long term oxygen therapy if PO2 <7.3

Question 11

What does a Left lower lobe collapse look like on CXR?

Answer 11

Tracheal Deviation to Left

Sail Sign- have a dense edge of the left lower lobe behind the mediastinum which has been squaished into a triangle.

Loss of left hemi-diaphragm
as LLL no longer has air in it it is the same density as the diaphragm and therefore blends into it

Question 12

What causes lobe collapse?

Answer 12

Malignancy
Foreign Body
Mucous plug eg post op atelectasis

Question 13

How do you manage a lobular collapse?

Answer 13

ABCDE
Treat Cause (post surgical- physiotherapy, coughing, walking)
Consider CPAP if hypoxic on air
Abx if infective
Analgesia
Consider bronchoscopy to remove mucous plug.

Question 14

What is Light’s criteria?

Answer 14

determinate of an exudative vs transudative pleural effusion.

Exudate if one or more is present=

1) effusion protein/serum protein >5
2) effusion LDH/serum LDH >0.6
3) effusion LDH >2/3 the upper limit of normal serum LDH

Question 15

Common Causes of Transudates?

Answer 15

Heartfailure
Cirrhosis
Hypoalbuminaemia
Peritoneal Dialysis

Question 16

common causes of exudates?

Answer 16

Pneumonia
Malignancy 
PE
pancreatitis
autoimmune

Question 17

Management of pleural effusions?

Answer 17

ABCDE
1) bloods:
FBC, CRP, U&E, BNP
2) pleural aspiration: Lights criteria, cytoscopy, microbiology
3) contrasr CT chest for malignancy