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Differential Diagnosis of CXRs

Differential Diagnosis of CXRs. David Kirk. How to Learn. Personally look at every film every day. Examine every film the same way. Write down your opinion *before* you compare to the radiologist opinion. Re-examine the film *after* reading the radiology opinion.

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Differential Diagnosis of CXRs

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  1. Differential Diagnosis of CXRs David Kirk

  2. How to Learn • Personally look at every film every day. • Examine every film the same way. • Write down your opinion *before* you compare to the radiologist opinion. • Re-examine the film *after* reading the radiology opinion. • Force your doc to read the film with you.

  3. My Pattern • Outside to Inside • Date / Patient • External / Hardware • ABCDE -- Airway, Bones (ribs/clavicles), Cardiac, diaphragm, everything else • Borders • Parenchyma

  4. http://cdn.lifeinthefastlane.com/wp-content/uploads/2012/08/CXR-AP.jpghttp://cdn.lifeinthefastlane.com/wp-content/uploads/2012/08/CXR-AP.jpg

  5. http://cdn.lifeinthefastlane.com/wp-content/uploads/2012/08/CXR-AP.jpghttp://cdn.lifeinthefastlane.com/wp-content/uploads/2012/08/CXR-AP.jpg

  6. http://www.wikiradiography.net/page/Lung+Anatomy

  7. http://www.wikiradiography.net/page/Lung+Anatomy

  8. Rules • Bunch of cases… thus we will move quickly • Guessing, shouting, participation required • Average computer monitor has 3 times less resolution than film. Projection decreases resolution even more…

  9. First Case • 51 year old male currently receiving treatment for hepatocellular carcinoma presents with several months of cough (+/- productive) and progressive DOE. • PFTs: • FVC is 94% predicted • FEV1 is 64% predicted • FEV1/FVC and FEF 25-75 percent are both markedly reduced

  10. What’s the Call? Based on the CXR findings including bilateral bullous changes in the bases, you make the diagnosis…

  11. Alpha-1-Antitrypsin • 3 hints that a patient’s obstructive disease is alpha-1-antitrypsin deficiency and not COPD. • Presents earlier (Median ages: 46 vs 52) • Bullous changes at bases instead of apex • Liver disease • Cirrhosis in 12 percent and hepatocellular carcinoma in 3 percent

  12. Everybody else… COPD CXRs

  13. Case 2 • 39 year old female with long history of sinusitis presents with SOB, DOE, and months of productive cough. • PMHx significant for congenital heart defect and recent pacemaker placement.

  14. Situs Inversus • What’s the syndrome? • Primary ciliary dyskinesia • What is Kartagener’s triad? • Chronic sinusitis • Bronchiectasis • Situs inversus • What percentage of PCD have situs inversus? • 50% • What percentage of situs inversus patients also have PCD? • 20-25%

  15. Case 3 • 65 year old WF presents to you with DOE/SOB, orthopnea, and diffuse muscle weakness. Worse when sleeping flat. • PMHx: Polio as a child requiring braces for ambulation. • You send the patient for inspiratory and expiratory CXRs.

  16. Inspiratory Muscle Weakness • What should the patient’s Aa gradient be? • Normal. (No impairment in diffusion…) • What’s the differential diagnosis of inspiratory muscle weakness? (12) • ALS • MS • Tetanus • Polio / Post-Polio Syndrome • Guillian Barre’ • Lyme Disease • Myasthenia Gravis • Botulism • Lambert-Eaton • Botulism • Muscular dystrophy • Polymyositis / Dermatomyositis

  17. Case 5 • 42 year old female presents with SOB, wt loss, joint tenderness, and chest pain. • Serial CXRs have shown diffuse, migratory infiltrates. • She has been treated in the ER for atypical pneumonia on several occasions.

  18. DDx of “Migratory” Infiltrates (10) • Asthma with mucus plugging • Allergic brochopulmonary aspergillosis • BOOP • Recurrent Aspiration • Allergic alveolitis • Pulmonary Edema • Eosinophilic infiltrates • Alveolar hemorrhage syndromes • Vasculitis • Collagen Vascular Diseases

  19. Pulmonary Hemorrhage • Bronchoscopy -> pulmonary hemorrhage • UA -> Active sediment with RBCs • Differential… (3) • Vasculitis (particularly Wegener's) • Usually C-ANCA/PR3-ANCA positive • Lupus • Goodpasture’s

  20. Case 6 • 28 year old F presents with encephalitis. As pt sits in the ER her MS continues to decline. Pt becomes hypoxic with increased WOB and is intubated. • Her initial CXR was normal. • Her current CXR is…

  21. Where’d that Lung go? • Differential Diagnosis (3) • Massive Effusion • Bronchial Occlusion -> atelectasis • Bronchial Torsion • How do you tell effusion vs atelectasis? • Effusions shift the heart away • Atelectasis shift the heart toward • Subsequent CXR post-bronchoscopy…

  22. Atelectasis vs Effusion

  23. Case 7 • 81 yo WM presents with URI and persistent cough for two weeks. His wife is in the hospital and the nurses on the floor convince him to go to the ED. • CXR obtained in the ED shows…

  24. What’s that big honkin’ thang? Thoracic Aorta Aneurysm

  25. Case 8 • 24 year old college student presents with inguinal discomfort, fatigue, and cough. • Palpation discovers an inguinal mass. Mild scrotal swelling is noticed. • CXR…

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