Inflammation - Clinical Diagnosis - X-Rays; Skin; Rheumatology; Musculoskeletal Flashcards
What bony structures are usually prominent in AP CXRs but not PA CXRs?
Scapulae
What are the disadvantages of an AP CXR?
False cardiomegaly
(false magnification of the heart on imaging);
decreased inspiratory effort
(likely);
scapulae in image
What marker on a CXR allows you to identify the left and right sides of the patient along with whether the patient was upright or not?
The marker in the upper corner
(letter indicates which side;
the BBs indicate the effects of gravity on the patient; i.e., upright or laying down)
How do you know if the patient is rotated in their CXR?
The tracheal column and vertebral spinous processes should be straight and aligned; the clavicles should be symmetrical
An adequate inspiratory effort will reveal how many ribs in a CXR?
9
If inspiratory effort is poor, then the lung fields in a CXR will be ________ (more/less) opaque.
If inspiratory effort is poor, then the lung fields in a CXR will be more opaque.
True/False.
In obtaining an X-ray, adjustments must be made for body habitus; e.g., the technique may be different for an obese individual as compared to a thin individual.
True.
Describe the effects of over- or under-penetration on X-ray quality.
How should the spine appear in a CXR with proper penetration?
As individual vertebral bodies
(until you reach the diaphragm/abdomen)
Is this CXR over- or under-penetrated?
What does this mean?
Slightly over-penetrated;
it is blacker than actually expected
Is this CXR over- or under-penetrated?
Neither
(individual vertebral bodies and pulmonary vasculature clear)
When evaluating a CXR, you should move from the ________ to the ________.
(Inside/Outside)
When evaluating a CXR, you should move from the outside to the inside.
What is the order in which a CXR should be read?
Skin / soft tissue: _________
Spine / ribs: _________
Heart / great vessels: < ______ of thoracic diameter
_________ / _________ angles
Skin / soft tissue: symmetry
Spine / ribs: symmetry, fractures, density
Heart / great vessels: < 1/2 of thoracic diameter
Costophrenic / costovertebral angles
Is this CXR PA or AP?
Is the inspiratory effort sufficient?
Is it rotated?
Does it have the right degree of penetration?
PA;
yes;
no;
yes
What do you notice about this CXR?
The patient has had a left-sided mastectomy
What do you notice in this CXR?
Fractured posterior portion of ribs 9 and 10
Name some of the anatomical structures visible in a CXR.
On a lateral CXR, the space visible anterior to the heart is called the ________________ space and the space visible posterior to the heart is called the ________________ space.
On a lateral CXR, the space visible anterior to the heart is called the retosternal space and the space visible posterior to the heart is called the retrocardiac space.
What is the primary thing you notice in this CXR?
Cardiomegaly
(>50% of thoracic diameter)
Is this patient most likely to be <18, 18 - 65, or > 65 years of age?
How do you know?
> 60 years of age;
osteopenia, prominent aortic knob, kyphosis / degenerative changes
This patient is a long-time smoker.
What is your diagnosis?
Emphysema
(barrel-chest / increased AP diameter; flattened diaphragm; huge inspiratory effort)
What do you notice in this CXR?
Is the film over- or under-penetrated?
Right-sided pneumothorax;
under
What position is a patient in if you have them lie on their side for an X-ray?
Lateral decubitus
What is your diagnosis?
Pleural effusion
How could you cheaply and easily figure out what space this fluid is occupying?
Take a lateral decubitus film
(a pleural effusion in this case)
True/False.
The heart is the most anterior structure of the thoracic cavity that is seen in a CXR.
True.
Where is the pneumonia in this CXR?
The right middle lobe
(it is obscuring the heart’s right border)
Where is the pneumonia in this CXR?
The right lower lobe
(it is NOT obscuring the heart’s right border)
Which of these infiltrates is in the lingula?
Which is in the left lower lobe?
Right;
left
The lingula protrudes from the _______ lobe of the left lung in the symmetrical position as the _______ lobe of the right lung.
The lingula protrudes from the upper lobe of the left lung in the symmetrical position as the middle lobe of the right lung.
Where is the pathology located?
The middle lobe of the right lung
Where is the pathology located?
The left lower lobe
If a lung pathology obscures the right heart border on CXR, then the pathology is located in which part of the lung?
If a lung pathology obscures the left heart border on CXR, then the pathology is located in which part of the lung?
The right middle lobe;
the lingula (of the left upper lobe)
If a lung pathology does not obscure the right heart border on CXR, then the pathology is located in which part of the right lung?
If a lung pathology does not obscure the left heart border on CXR, then the pathology is located in which part of the left lung?
The right lower lobe;
the left lower lobe
Where is the pathology located?
The right lower lobe
(it is posterior to the heart, so it cannot be the middle lobe)
All tubes meant to enter the body will have what on them to illustrate them on radioimaging?
A radioopaque line
When evaluating a fracture, the information to ask for is:
the patient’s ____
____ the injury occurred
the ____ of the injury
if is there any ____
if are ____ and ____ intact
When evaluating a patient’s fracture, the information to ask for is:
the patient’s age
when the injury occurred
the physics of the injury
if is there any brusing or deformity
if are pulses and motor strength are intact
For what fracture type(s) should you get multiple x-rays to get a three dimensional representation?
What views are commonly obtained?
All fractures;
AP, lateral, oblique
A(n) _________ fracture is bone broken into >2 pieces.
A(n) _________ fracture is exposed to air.
A(n) _________ fracture is out of normal anatomical placement.
A comminuted fracture is bone broken into >2 pieces.
An open (compound) fracture is exposed to air.
A displaced fracture is out of normal anatomical placement.
A bony shaft fracture can be described according to the shape of the break.
What are a few examples of this?
For evaluating a fracture, you should get at least ____ x-rays.
For evaluating a fracture, you should get at least 2 x-rays.
How would you describe this fracture?
Midportion comminuted ulnar and radial fractures with posterior displacement
What type of hip fracture is this?
Intertrochanteric
What is the orthopedics term for incising the skin to realign fractured bones and then holding the bones together with metal screws and/or plates?
Open reduction internal fixation
(ORIF)
A man presents in the ED after ‘slipping in the ice’ on his way home from church services. He appears to be in great pain, and his right leg is externally rotated and 2 inches shorter than his left leg.
What explains the presentation?
Hip fracture;
unopposed gluteal muscles are pulling his leg up and externally rotating it
What are the two more common forms of hip fracture?
Transcervical neck fracture;
intertrochanteric fracture
Where is the fracture?
The femoral neck
Fracture-related laceration of an artery (probably the hip lacerating the femoral artery)
What is the most common fracture to be sustained while punching a solid object?
Right fifth metacarpal
(boxer’s fracture)
Are most injuries sustained to pedestrians in MVAs going to be left- or right-sided?
Left
(reversed in UK)
What bones are most likely to be fractured in pedestrian involved in a MVA?
Femur or pelvis
A patient falls on his side while carrying a box of expensive family heirlooms. He complains of inspiratory pain, and you get the attached X-ray.
What is the diagnosis?
Costal fractures
(posterior part of ribs 8 and 9 on the left)
Why are left-sided fractures common in restrained passengers in MVAs?
Seat belts
What X-ray should you always get in cases of a high-speed impact?
C-spine
A patient with rheumatoid arthritis becomes suddenly paralyzed after an elective surgery for which the patient was intubated and under general anesthesia.
The patient can blink but is unable to breathe on her own or move her extremities.
What is the likely cause?
Alanto-axial subluxation
What is an example of a medical procedure that can result in atlanto-axial subluxation and paraylsis in a patient with rheumatoid arthritis?
Intubation
(due to neck hyperextension)
What pathology is shown here?
Avascular necrosis of the femoral head
What pathology is described below?
Thoracic crush fracture
What are the black spots in this radioimage of the spine?
‘Vacuum phenonenom’
nitrogen bubbles leaking from / collecting in degenerated disc (low pressure area)
This patient has hearing loss and elevated ALP.
What’s your diagnosis?
Paget’s disease of the bone
What term describes flat lesions of the superficial skin?
Macules
What term describes palpable lesions of the superficial skin?
Papules
What is a generic term that describes fluid-filled lesions?
Vesicles
What term refers to vesicles filled with pus?
Pustules
What term describes large (>1 cm) vesicles?
Bullous vesicles
What term describes rough lesions of the superficial skin?
Plaques (lichenified)
What term describes warty lesions of the skin?
Verrucoid lesions (hyperkeratotic)
What term describes skin lesions that are initially separate but are becoming confluent with one another?
Coalescent lesions
What term describes skin lesions that are snake-like in shape?
Serpinginous lesions
What term describes lesions of the skin that have central, open craters?
Ulcerated lesions
(most often due to venous stasis in distal extremities)
What term describes lesions of the dermal/subcutaneous regions that are palpable, solid, and at least 1 cm?
Nodular lesions
What term describes the dermal edema known as ‘hives’?
Wheals
In certain pre-sensitized individuals, the ______-and-______ reaction may occur when pressure is applied to the skin due to release of _________.
In certain pre-sensitized individuals, the wheal-and-flair reaction may occur when pressure is applied to the skin due to release of histamine.
What term refers to lesions that bleed easily?
Friable lesions
What term refers to a circumscribed proliferation of skin cells?
Nevus
Note: can be of melanocytes (a ‘mole’) or keratinocytes (a ‘skin tag’)
What are the ABCDEs of melanoma?
Asymmetry
Irregular Border
Color
Diameter > 6 mm
Evolution
Purpura are large skin lesions often seen in _________ and/or _________ disorders.
Purpura are large skin lesions often seen in vascular and/or autoimmune disorders.
Head lice often leave small _____ _____ that can be seen on individual hairs and pruritic lesions on the back of the _______ and _______.
Head lice often leave small egg sacs that can be seen on individual hairs and pruritic lesions on the back of the neck and ears.
What causes the depicted lesion causing a central region of hair loss in an annular lesion?
Tinea spp. (e.g. capitis, corporis) (ringworm — a fungal infection)
What term refers to the anxiety disorder characterized by a stressed patient pulling their own hair out (can be consciously or unconsciously done)?
Trichotillomania
_______ are infections with mites that burrow into the skin and cause pruritic lesions, especially favoring body _______, such as the axilla and between fingers.
Scabies are infections with mites that burrow into the skin and cause pruritic lesions, especially favoring body creases, such as the axilla and between fingers.
Herpes zoster causes a rash that is: dermatomal, vesicular, and coalescing. It most frequently follows a _________ dermatome and can lead to _________ if it affects the face.
Herpes zoster causes a rash that is: dermatomal, vesicular, and coalescing. It most frequently follows a thoracic dermatome and can lead to blindness if it affects the face.
What is shown in the attached images?
What could it potentially indicate?
Acanthosis nigricans;
insulin resistance or occult malignancy
Do SLE malar rashes differ in individuals of different skin tones?
Yes.
What term refers to plaque-like, serpiginous lesions found covering extensor surfaces?
Psoriasis
Blue sclerae a sign of what?
Yellow sclerae a sign of what?
Osteogenesis imperfecta;
jaundice
Rhinophyma is caused by _______ _______ hypertrophy and _______ _______.
Rhinophyma is caused by sebaceous gland hypertrophy and arteriolar dilatation.
The lesion shown in this image is an example of what?
Squamous cell carcinoma
The lesions shown in these images are examples of what?
Basal cell carcinoma
Osteoarthritis typically affects which joints of the hand?
Rheumatoid arthritis typically affects which joints of the hand?
PIP (Bouchard’s nodes), DIP (Heberden’s nodes);
affects MCP (ulnar drift; swan neck deformities) and wrist
________ arthritis is often unilateral.
________ arthritis is typically bilateral.
Osteoarthritis is often unilateral.
Rheumatoid arthritis is typically bilateral.
Which spinal levels are most affected by osteoarthritis?
Cervical and lumbar
(these bend the most)
True/False.
Gouty tophi can be come chronic issues that do not easily resolve.
True.
Paget’s disease of the bone often shows __________ (increased/decreased) radioisotope uptake in affected areas.
There is an increased risk of __________ __________ (malignancy).
Paget’s disease often shows increased radioisotope uptake in affected areas.
There is an increased risk of osteogenic osteosarcoma.
True/False
Paget’s disease of the bone is a common occurrence.
True.
Most cases are asymptomatic.
Rheumatoid arthritis can be described as ____________ arthritis.
Osteoarthritis can be described as ____________ arthritis.
Gout can be described as ____________ arthritis.
Rheumatoid arthritis can be described as autoimmune arthritis.
Osteoarthritis can be described as degenerative arthritis.
Gout can be described as metabolic arthritis.
What disorder presentation is otften characterized by elevated ALP and some hearing loss?
Paget’s disease of the bone
(bone turnover leads to elevated ALP and narrowed cranial foramina)
Dermatomyositis is an autoimmune condition characterized by:
inflammatory _____pathy
_________ muscle weakness (increasing over weeks or months)
Elevated ________
A heliotrope rash (malar + eyelids)
Gottron’s papules on hand dorsum
Dermatomyositis is an autoimmune condition characterized by:
inflammatory myopathy
Proximal muscle weakness (increasing over weeks or months)
Elevated CPK (creatine phosphokinase)
A heliotrope rash (malar + eyelids)
Gottron’s papules on hand dorsum
Dermatomyositis is an autoimmune condition characterized by:
inflammatory myopathy
Proximal muscle weakness (increasing over weeks or months)
Elevated CPK (creatine phosphokinase)
A(n) ___________ rash
__________ papules on __________
Dermatomyositis is an autoimmune condition characterized by:
inflammatory myopathy
Proximal muscle weakness (increasing over weeks or months)
Elevated CPK (creatine phosphokinase)
A heliotrope rash (malar + eyelids)
Gottron’s papules on hand dorsum
Make the diagnosis.
Polymyalgia rheumatica
The morning pain associated with osteoarthritis lasts ____ than an hour and ______ (does/does not) worsen significantly with use.
The morning pain associated with rheumatoid arthritis lasts ____ than an hour and ______ (does/does not) worsen significantly with use.
The morning pain associated with osteoarthritis lasts less than an hour and does worsen significantly with use.
The morning pain associated with rheumatoid arthritis lasts more than an hour and does not worsen significantly with use.
Inflammatory myopathies are often associated with elevated _____.
Associated muscle weakness is often ________ (proximal/distal).
Diagnosis is typically made by _______________.
Inflammatory myopathies are often associated with elevated CPK.
Associated muscle weakness is often proximal.
Diagnosis is typically made by muscle biopsy.
Inclusion body myositis typically presents with _________ (proximal/distal) muscle weakness.
Inclusion body myositis typically presents with proximal muscle weakness.
___% of patients with myasthenia gravis will also have thymomas.
15% of patients with myasthenia gravis will also have thymomas.
________________ syndrome is a paraneoplastic syndrome associated with small cell carcinoma of the lung characterized by proximal muscle weakness due to antibodies against ___synaptic ____ channels.
Lambert-Eaton syndrome is a paraneoplastic syndrome associated with small cell carcinoma of the lung characterized by proximal muscle weakness due to antibodies against presynaptic Ca2+ channels.
Make the diagnosis.
Ankylosing spondylitis
Make the diagnosis.
SLE
(foamy urine = high degree of proteinuria)
What would you prescribe to clinch the diagnosis?
Edrophonium
(Myasthenia gravis)
This woman responded dramatically well to steroid therapy. What is your diagnosis?
Polymyalgia rheumatica
Make the diagnosis.
What would be your initial thought if no rash were present?
Dermatomyositis;
hypothyroidism
This man has had episodes before. He is a drinker and eats plenty of steak and potatoes.
Make the likely diagnosis.
Acute gouty arthritis
Make the likely diagnosis.
Rheumatoid arthritis
(early stage)
