Medicine: Imaging and investigations Flashcards
What’s that and what’s the diagnosis?
What’s that? Possible diagnosis?
What’s that?
Possible diagnosis
Describe the layers (colours)
Name the type of haemorrhage
Intraparenchymal haemorrhage
Name the type of haemorrhage (marked as red colour)
Subarachnoid haemorrhage
Name the type of haemorrhage (red colour)
Subdural haemorrhage
Name type of haemorrhage
Extradural haemorrhage
Jane is 35 and has attended her GP surgery complaining of a 2-day history of chest pain, worse on inspiration and shortness of breath on exertion.
• What important features of her history should her GP elicit?
- History of trauma
- Any chest wall tenderness
- Symptoms of infection such as cough, temperature
- Recent travel, immobility, surgery
- Relevant medical history - malignancy / pregnancy / coagulopathy / previous DVT / PE / OCP
- e.g. swelling, pain / tenderness
Jane is 35 and has attended her GP surgery complaining of a 2-day history of chest pain, worse on inspiration and shortness of breath on exertion.
Her heart rate is 110, BP 120/75, O2 sats 95% on room air and her chest is clear on examination.
Her GP organises some immediate investigations; what should they be?
- CXR
- D-dimer
- ECG
- May also consider adding Pro-BNP, ESR, FBC, Troponin-T level
- If deemed moderate risk, consider a CTPA
General approach to interpretation of chest x-ray
- Check the patient identifiers
- Check the film is adequate, check side marker
R-non-rotated/rotated
I-adequate inspiration
P-good penetration
- Tubes and lines
A- Airway - trachea central, main bronchi
B- Breathing - lung consolidation or collapse, masses
C- Circulation - heart and mediastinum- cardiomegaly, mediastinal enlargement, hilar abnormalities
D- Diaphragms and pleural spaces - effusions, elevated diaphragm, free gas
E- Everything else - bones and soft tissue masses / displaced fractures etc.
What can be seen on this CPTA scan?
- Axial CT of the chest
- Contrast-enhanced with good opacification of the pulmonary arteries
There is a filing defect at the bifurcation of the MPA extending into both branch Pas, saddle embolus.
What are the risks associated with the use of CTPA for diagnosis of PE?
Contrast-related:
- Contrast nephropathy
- Anaphylaxis
- Suspected risk of contrast-induced foetal hypothyroidism in pregnancy
Radiation-related:
- Equivalent to 400 chest X-rays
- Increased cancer deaths
- Risk of childhood cancer induction in pregnant women
- High dose to maternal breast tissue
What circumstances may make you consider alternative imaging to CTPA in a patient with suspected PE?
- Renal impairment
V/Q scan does not involve iodinated contrast.
- Pregnancy
Dose to mother higher for CTPA than V/Q scan, particularly to maternal breasts.
Suspected increased risk of hypothyroidism in foetus.
Foetal radiation dose is higher with V/Q scan (0.5 mGy compared with 0.1 mGy for CTPA), though perfusion (Q scan) can be performed with less of a dose
- Leg symptoms in pregnancy
Venous Doppler can be performed as first line and if positive patient can be treated.
However, If negative and still high index of suspicion, CTPA / VQ still required.
- Massive PE causing cardiovascular instability and collapse
CTPA or bedside ECHO may be used.
Thrombolysis may be given on clinical grounds initially without imaging
Intervention, such as catheter angiogram and thrombus fragmentation with IVC filter considered.
John is a 24-year-old man is brought in to the Emergency Department by ambulance. He was walking home from work when he was assaulted by 3 youths approximately 3 hours earlier. A witness reported that he was punched in the face and fell to the floor and hit his head on the curb. His girlfriend, who is with him, reports that he appears confused.
• What is the likely diagnosis?
Head Injury
John is a 24-year-old man is brought in to the Emergency Department by ambulance. He was walking home from work when he was assaulted by 3 youths approximately 3 hours earlier. A witness reported that he was punched in the face and fell to the floor and hit his head on the curb. His girlfriend, who is with him, reports that he appears confused.
What information is essential from his immediate history and examination?
Immediate assessment:
- ABC
- GCS
History:
- Mechanism of injury
- Seizure
- LOC
- Vomiting
- Amnesia
Relevant PMHx - coagulopathies
Relevant DHx - anticoagulation
History of seizure, loss of consciousness, vomiting, amnesia
O/E:
- Signs of basal skull fracture: blood in ear / behind tympanic membrane. Panda eyes or , Battles sign, CSF leak from nose or ear
John is a 24-year-old man is brought in to the Emergency Department by ambulance. He was walking home from work when he was assaulted by 3 youths approximately 3 hours earlier. A witness reported that he was punched in the face and fell to the floor and hit his head on the curb. His girlfriend, who is with him, reports that he appears confused.
What is the important diagnosis that needs to be considered?
Acute intracranial bleed / haemorrhage
Head injury; suspected intracranial bleed
- What imaging should be requested?
- What timescale is indicated for the imaging in this case?
Imaging → CT brain ; done ASAP (within ONE hour)
Describe the image
- Axial CT
- Non contrast
- Lenticular high density / high attenuation over the right cerebral hemisphere → acute subdural haemorrhage
- Mass effect with resulting midline shift
Indications for acute brain CT in head injury
- Reduced GCS
- Post traumatic seizure
- Focal neurology
- Vomiting
- LOC / amnesia
- Coagulopathy
- Significant MOI
- Anticoagulants
Suspected head injury/intracranial haemorrhage
Should CT head be avoided in pregnancy?
- If CT head is indicated pregnancy does not preclude the need for CT brain
- The radiation dose to the foetus is very low
- The only risk is of increasing the risk of childhood cancer by 1 in every 1,000,000 scans.
Suspected head injury/intracranial haemorrhage
Should CT head be avoided in children?
No - if indicated we should do CT head
- there are slightly different guidelines for children, e.g. in non-accidental injury investigation and significant soft tissue swelling
