Unit 2: DDX and CXR Flashcards
Know what air, fat, soft-tissue/water, bone, metal looks like on a CXR
Air: Block (least dense = radiolucent) Fat: Intermediate dare (grey) Soft-Tissue/water: Intermediate (grey) Bone: Whitish (more dense = radiopaque) Metal: Solid white
Where the diaphragm should be in comparison with the ribs
Anterior Ribs: 6-7, with the 7th rib piercing the diaphragm
Posterior Ribs: 8-10
Hyperventilation: 10 or more ribs with other correlating signs
Positioning of the patient to Dx a pneumothorax
Erect positioning on expiration is most ideal
Lateral decubitus position in a bed-bound patient with the suspected lung up
Best test to assess for free floating air in a suspected bowel perforation
Abdominal Series: Consists of spine & upright abdominal & chest x-rays
How distance affects viewing
The further an object is away from the x-ray receptor, the greater the magnification. The greater the magnification, the larger the casting shadow is = the object appears larger and less sharp than in reality.
The closer an object is to the x-ray receptor, the less magnified and more sharp is object is.
The further away from the x-ray tube, the less magnified and more sharp an object is.
The closer to the x-ray tube, the more magnified and less sharp an object is.
Best way to assess a bed-ridden patient with right or left pneumothorax
Suspect Right: left lateral decubitus
Suspected Left: right lateral decubitus
Gravity causes air to accumulate superiorly
Best way to assess a bed-ridden patient with right or left free pleural fluid
Suspect Right: Right lateral decubitus
Suspected Left: Left lateral decubitus
Gravity causes fluid to accumulate posteriorly
Best way to assess for a bullet in the heart
Fluoroscopy: can see in real-time, turn the patient, and watch motion of heart/bullet
Best way to assess for air trapping
Expiratory PA or fluoroscopy:
On expiration: the effected lobe will remain radiolucent, while the other lobes will become more dense with the surround interstitium
Which side of the diaphragm appears higher on cxrs
The right hemidiaphragm d/t underlying structures (Liver). Usually 1-2 cm above the left hemidiaphragm
What film is more sensitive to assess for detection of small effusions?
Lateral Film: posterior costophrenic sulci lie below the dome of the anterior hemidiaphragm on the AP/PA, and therefore, are not visible in these positions. The lateral film is able to detect effusions from 75ml. The PA, AP aspects take 175-250ml of fluid to be able to detect fluid.
Lateral decubitus is also helpful: 5ml
What causes overly white x-ray films
Under penetration, Under/short exposure
Normal anatomical positioning of the clavicles, sternum, trachea
Trachea: Trachea is midline and overlies the spine. Is equidistant from the medial aspects of the clavicles
Sternum: midline. Generally obscured on PA view d/t underlying mediastinal objects. Easily seen on lateral view
Clavicles: Spinous process should dissect the medial ends of the clavicles. You should not be able to see the medial end of the clavicle more on one side. should appear the same
Evaluating Pulmonary Nodules
Nodules are considered anything <3cm.
Anything >3cm is considered a mass.
Solitary nodules should always be evaluated.
Most valuable method to assessing nodules is comparing new and old films.
Benign nodules tend to remain unchanged over times.
Calcified nodules are mostly benign: Central laminar, diffuse, or popcorn
Malignant nodules: may have eccentric or stippled calcification
Smokers who are 55-74 should be evaluated for lung cancer
Benign nodules are more often found in non-smokers < 35 y/o
Assessing pleural effusions
3 Patterns of pleural effusions:
1 - Blunted costophrenic angle
2 - Meniscus sign
3 - Subpulmonic effusion
2 Types:
1 - Free Flowing: makes a meniscus respective of gravity. Fluid will shift d/t gravity on lateral decubitus view
2 - Loculated: effusion in an unusual location that defies gravity. Fluid will not shift or may partially shift on lateral decubitus view
2 Sub Types:
1 - Subpulmonic Effusion: Fluid between lung base and diaphragm that does not track up the pleura.
a: doesn’t blunt costophrenic angle
b: diaphragm more horizontal than normal (apex shifts laterally)
c: Left side: Stomach bubble sign
d: Right side: abnormally high horizontal/minor fissure
2 - Pseudotumor: Fluid collection trapped within a fissure…gives the appearance of a lung mass
a: loculated at a fissure (usually minor)
b: smooth lenticular contour to “mass”
PA/AP: requires 175-250ml of fluid to blunt one of the sulci
Lateral: requires 75ml of fluid to detect
Decubitus: good for assessing if effusion is loculated of free-flowing
Supine: just don’t do it
CXR finding with COPD
Hyperinflation: Film will have diffuse lucency with small heart structures, horizontal hemidiaphragms and > 10 ribs
Definitions of acini, interstitium, bronchioles, pleura
Acini: Cluster of alveoli arranged around terminal airways that form a secondary pulmonary lobule
Interstitium: Collection of vessels, lymphatics, bronchi, and connective tissue that is the supporting framework of the alveoli
Bronchioles: Branches from which the bronchus divides
Pleura: Serous membranes lining the thorax and enveloping the lungs
a: Parietal pleura: membrane which is attached to the inner surface of the thoracic cavity b: Visceral pleura: membrane that layers the individual lobes of the lungs
Clostridium Botulinum (Botulism)
Nature of sxs: Neurological
Onset: 12-72 hours
Source: Home canned or poorly canned food contain low acid)
Associated sxs: blurred vision, diplopia, ptosis, slurred speech, muscles weakness
Giardiasis
Nature of sxs: Foul-smelling, explosive, watery diarrhea
Onset: 1-4 weeks
Source: Contaminated water (farm wells, streams, lakes)
Associated sxs: mucus in stool, increased flatulence**, greasy stools
Gastroenteritis (viral/bacterial)
MOST COMMON CAUSE OF DIARRHEA
Nature of sxs: abrupt onset of diarrhea that usually lasts < 1 weeks, with no other signs of organ involvement
Onset: insidious
Associated sxs: fever, NVD, cramping pain, hyperactive peristalsis
Drug-Induced
Laxatives and ABx
Laxative drug-induced diarrhea
Usually women.
May present with hysterical behavior
Sodium Hydroxide Test: phenolphthalein in the laxative causes stool to turn red with the sodium is introduced to it
Associated sxs: Muscles weakness, hypokalemia, lassitude
Abx induced diarrhea
Causes: ampicillin, tetracycline, lincomycin, clindamycin, chloramphenicol
Sxs: mild/watery diarrhea, nonspecific cramping abdominal pain, low-grade fever
Pseudomembranous Entercolitis
AKA antibiotic associated colitis
Nature of sxs: Severe colitis with pseudomembrane formation.
Onset: days or weeks after taking abx
Source: too much bacteria build up (abx, immunosuppressed, hospital, surgery)
Associated sxs: Severe diarrhea, pus in stool, fever, dehydration, hypotension
Life-threatening diarrhea of colonic dysenteric type, generally caused by clindamycin, c-diff superinfection can precipitate
Staphylcococcus Toxin
Nature of sxs: Severe NVD
Onset: 2-4 hours after eating contaminated food (
Source: usually meat or dairy
Dysentery Syndrome
Nature of sxs: Acute, watery diarrhea (prior history of good health)
Onset: 1-3 days
Source: Usually shigella bacteria or amoeba in contaminated food or water
Associated sxs: Bloody diarrhea***, feeling of incomplete defecation, cramps, fever, malaise, NV
Tension HA
Most common
Location: occipital/suboccipital and bilateral
Pain: Constrictive band around the head or scalp tightness. May go down neck and back
Duration: Persists all days for several days
***May awaken with HA but rarely have one at night
Cluster HA
More common in men
Location: periorbital and unilateral
Pain: severe pain in eye that might radiate to the front of the face/temporal regions
Duration: 20-60 minutes (attacks short lasting, usually develop cluster/pattern of frequent attacks)
- ***usually an early morning HA
- ***usually occur pattern or cluster
Migraines
Classic Migraine and Common Migraine
Classic Migraine
Nature of sxs: Aura and prodrome prominent, pt will go to sleep and HA will be gone
Location: Periorbital and Unilateral
Pain: Severe throbbing
Onset: Prodrome has abrupt onset and lasts about 15 prior to HA.
Duration: 2-8 days.
Common Migraine
***More common
Nature of sxs: Aura and prodrome vague or absent (prodrome may manifest by personality change, malaise, NV)
Location: Frontotemporal or supraorbital region and is unilateral/bilateral
Pain: Throbbing
Onset: Gradual
Duration: 4-72 hours
HA induced by Glaucoma
Nature of sxs: localized to eye and patient sees halo(s)
Location: localized to eye(s)
Pain: increased with intraocular pressure
NV with Esophageal Obstruction/achalasia
Sxs: Vomiting regurgitated or undigested food, Odorless vomitus, Usually occurs in early morning or after large meals
NV with Increase ICP
Sxs: Projectile vomiting not preceded by nausea, Papilledema
NV associated with hepatic capsule distention/mesentertic congestion
Sxs: consistent with CHF (tachycardia, gallop rhythm, peripheral edema)
NV associated with hepatitis/cirrhosis
sxs: Jaundice or hepatomegaly
Presumptive DDx
diagnosis made solely on symptomology, prior to testing/confirmation from testing
DDX
diagnosis which examines all the possible causes for a set of sxs in order to arrive at a diagnosis
Appendicitis
Pain: colicky progressing to constant
Location: early - epigastrium/periumbilical. late - RLQ
Associated sxs: fever, vomiting after pain has started, constipation, involuntary guarding, rebound tenderness
Precipitating: movement and coughing
Ameliorating: lying still
Diverticulitis
Pain: intermittent, cramping
Location: LLQ
Associated sxs: Constipation/diarrhea, might have palpable mass in LLQ
Cholecystitis
Pain: colicky progressing to constant
Location: RUQ radiating to inferior scapula
Associated sxs: NV, dark urine, light stools, jaundice. Murphy’s sign, tenderness to RUQ
Precipitating: fatty foods, PO contraceptives, drugs
IBS
Pain: Recurrent
Location: most coming in LLQ
Associated sxs: Alternating periods of constipation/ diarrhea, mucus in stool, small marble-like stools
Precipitating: stress
Ameliorating: defecation
Carcinoma of the ampulla of vater
Hx of occasional silver-colored stools alternating with normal or light-colored stools
(d/t a mixture of upper GI blood from the carcinoma with alcoholic stools)
Pancreatitis
Pain: steady and severe
Location: LUQ, epigastric, radiates to back
Associated sxs: NV, prostration (prone position), diaphoresis, diffuse rebound tenderness
Precipitating: lying supine
Ameliorating: leaning forward
Most common cause of LBP
Mechanical origin: acute lumbosacral strain, postural backache, degenerative lumbosacral arthritis
Sensitive diagnostic test for suspected herniated disk/tumor
MRI
Airway deviation toward affected lung
marked atelectasis/collapsed lung
Lobectomy/pneumonectomy
pleural fibrosis
pulmonary fibrosis
airway deviation away from affected lung
Tension pneumothorax
pleural effusion
Large mass
SOB worse when upright and better when lying down (platypnea)
Intracardiac shunt and/or vascular lung shunt
SOB associated with hyperventilation/anxiety
dizziness, lightheadedness, paresthesia (especially in perioral region and extremities), palpitations, sighing respirations, Normal PFT, “can’t get enough air
SOB d/t cardiac etiology
Paroxysmal nocturnal dyspnea, SOB intensified with recumbency, slow recovery period from dyspnea and tachycardia
SOB d/t pulmonary etiology
Intensified with exertion, dialy productive cough, postural changes have little or no effect, fast recovery priod from dyspnea and tachycardia
**dont usually have dyspnea at rest
Chest pain with MI
Nature of pain can be different for each patient.
Pain might not be relieved from nitro
Angina Pectoris
Nature of pain: Substernal, paroxysmal, and in same spot every time for the patient. generally lasts 30s to a few minutes
Precipitating: exertion, cold exposure, emotional stress, sexual activity
Ameliorating: Nitro and rest
***pain generally not sticky or sharp
Variant Angina
Nature of pain: Substernal
Precipitating: Vasospasm not exertion…commonly occurs at rest or sleep
Ameliorating: nitro
**not usually sharp or sticky
Cervical Angina
“pseudoangina”
Mimics angina symptomology but is not brought on my exertion
Precipitating: cervical movement, cough/sneeze, lateral head movements
GERD
***Most common cause of noncardiac CP
Nature of pain: Burning (may be indentical to angina)
Precipitating: overeating, recumbency, may awaken during sleep
Ameliorating: Antacids, PPI
Physical findings: water brash, heartburn
Esophageal Spasm
***especially obese people
Nature of pain: Burning (may be identical to angina)
Precipitating: Induced by ingestion of alcohol or cold liquids
Ameliorating: Occasionally relieved by nitro
Mitral Valve Prolapse
Nature of pain: Sticky quality, lasts several hours, usually occurs @ rest, pain is not substernal
Precipitating:
Ameliorating: Recumbency and BB
Physical findings: Click/late systolic murmur, palpitations, arrhythmias, syncope
HCM
Nature of pain: Similar to angina
Precipitating: Nitro
Ameliorating: Squatting and BB
Physical findings: Murmur intensified by nitro and valsalva maneuver. LVH and LAE
Cervicodorsal Arthritis
Nature of pain: Sharp or sticky…only lasts a few seconds
Precipitating: Body movement, cough/sneeze, prolonged recumbency
PE
Nature of pain: Pleuritic
Precipitating: PO contraceptives, CV risk factors, prolonged immobilization, DVT
Ameliorating:
Physical findings: DVT, tachypnea, SOB, hemoptysis, tachycardia, decreased oxygen saturation
Pneumonia
Physical findings: SIRS, cough, egophony on percussion
Pericarditis
Nature of pain: Precordial, sharp/dull, protracted duration
Physical findings: Fever, recent viral infection, pericardial friction rub, diffuse ST segment elevation
Chest Wall Syndrome
Nature of pain: Sharp and stick, fleeting
Precipitating: Recumbency, palpation
Physical findings: Local tenderness on palpation, crowing rooster, reproducaple
Gas Entrapment Syndrome
Nature of pain: Dull, achy
Precipitating: Bending and tight garments
Ameliorating: Passage of flatus, nitro
Causes of acute cough
Viral URI, allergies, bacterial pneumonia
Causes of chronic cough
Upper airway cough syndrome (PND), asthma, CHF, GERD, Psychogenic
Viral URI associated cough
***Most common cause for acute cough
Nature of sxs: acute onset of noisey cough over hours or days, lasts 7-10 days, cough is worse at night, Sputum thick and yellow BUT minimally produced
Associated sxs: fever, sore throat, general aches/pains
**if > 14 days assess for secondary bacteral infection
Allergy associated cough
Nature of sxs: reccurrent cough without dyspnea, minimally productive, may be seasonal
Associated sxs: sneezing, itching of eyes, conjunctivitis, tearing, boggy/edematous nasal mucosa
Bacterial pneumonia associated cough
Nature of sxs: Acute onset of noisy cough, cough worse at night, incidence highest in winter
Associated sxs: SIRS criteria, fever/chills
Upper Airway Cough Syndrome (PND)
***may not be aware of condition
Nature of sxs: frequent throat clearing and hawking, cough worse in morning
Precipitating: recumbency, various sinusitis/rhinitis
Physical findings: Mucoid secretions in posterior pharynx, Mucosa of nose and oropharynx presents with a cobble stone appearance
Asthma associated cough
Nature of sxs: recurrent cough, minimally/not productive, worse in later afternoon/night
Associated sxs: SOB, wheezing
Precipitating: exercise, allergens
CHF associated cough
Nature of sxs: Cough often nocturnal
Associated sxs: Dyspnea on exertion
Precipitating: Recumbency
Physical findings: CHF
GERD associated cough
Nature of sxs: Irritative, nonproductive cough
Associated sxs: Heartburn, eructation, sour tase
Precipitating: recumbency, ingestion of chocolate, caffeine, alcohol
Physical findings: none
Psychogenic (HABIT) cough
coughs only when awake (not during sleep), can stop coughing on demand
Chronic Bronchitis associated cough
***most common chronic cough in adults (especially smokers)
Nature of sxs: minimally productive, may be worse in morning
