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Afternoon Delight

Clinical Skills Conference: CXRs July 22 nd , 2010. Afternoon Delight. The Teaser : 22 yo Asthmatic. Continuous diaphragm sign. Air beneath and posterior to the heart.

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Afternoon Delight

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  1. Clinical Skills Conference: CXRs July 22nd, 2010 Afternoon Delight

  2. The Teaser: 22 yo Asthmatic

  3. Continuous diaphragm sign Air beneath and posterior to the heart Continuous diaphragm sign of pneumomediastinum: the entire diaphragm is visualized from one side to the other because air in the mediastinum outlines the central portion which is usually obscured by the heart and mediastinal softtissue structures that are in contact with the diaphragm.

  4. Pneumomediastinum • Lung • Ruptured Alveolus with dissection of air back along perivascular sheaths to hilum and mediastinum • Increase in Intrapulmonary Pressure • Asthma • Vomiting • Valsalva maneuver • Artificial ventilation • Closed chest trauma • Sudden drop in atmospheric pressure • Mediastinal airways • Rupture of trachea or mainstem bronchus • Usually produced by accidental trauma • Esophagus • Ruptured esophagus • Boerhaave’s Syndrome • Vomiting* • Labor * • Severe asthmatic attacks* • Strenuous exercise* • Site of perforation • Left, posterolateral wall, distal 8 cm *each of these can produce pneumomediastinum w/o esophageal rupture

  5. A B F Lung Fields H D C E Heart Effusion? G Gastric Bubble

  6. 28 yo man presents with SOB

  7. After a Procedure…

  8. Pneumothorax • A wide range of diseases may cause secondary spontaneous pneumothorax, with COPD the commonest cause. • Other important clinical entities include: • Cystic fibrosis • Asthma • Tuberculosis (TB) • Pneumocystis jiroveci pneumonia • Interstitial lung diseases (especially lymphangioleiomyomatosis) • Connective tissue–related lung disease • Catamennial

  9. Paged about Respiratory Distress

  10. 18 yo woman presenting w/ SOB

  11. 18 yo woman presenting w/ SOB

  12. Multiple pulmonary nodules 44 yo woman with hx of breast cancer

  13. Pulmonary Nodules: DDx • Metastatic disease • Breast, renal, melanoma • Non-Hodgkin’s Lymphoma • Infection • Abcesses • Septic Emboli • Fungal: • cryptococcus, aspergillus, coccidio • Paragonimus • TB • Inflammatory • Rheumatoid Arthritis • Amyloidosis • Sarcoidosis • Wegner’s • Churg-strauss • Vascular • AVMs • HHT/Osler Weber Rendu • Exposure • Pneumoconiosis • Silicosis

  14. 60 yo man presenting with Chest pain

  15. 60 yo man presenting with Chest pain

  16. 76 yo man presenting with hemoptysis

  17. Cavitary lesions • Pulmonary dx • Pulmonary embolism with infarction • Histiocytosis X • BOOP • Infectious • Bacterial/Mycobacterial • Septic Emboli • Lung Abcess • Actinomyces • Nocardia • TB • MAI • Fungal • Aspergillus • Mucor • Histoplasmosis • Blastomycosis • Coccidiomycosis • Cryptococcus • Malignancy • Primary lung • Lymphoma/Kaposi’s • Metastatic • Rheumatologic • Wegner’s granulomatosis • Sarcoid L. Beth Gadkowski and Jason E. Stout . Cavitary Pulmonary Disease. Clin. Microbiol 2008. Rev. 21(2):305-333.

  18. 44 yo man with hx of HIV presenting with fever

  19. 42 yo woman with hx of PTX

  20. Bullous Lung disease • Most patients with bullae have a significant cigarette smoking history suggestive of copd/emphysema • Other causes: • Cocaine pulmonary • sarcoidosis • 1-antitrypsin deficiency • 1-antichymotrypsin deficiency • Marfan’s syndrome • Ehlers-Danlos syndrome • inhaled fiberglass exposure • Congential/cysts

  21. 57 yo woman with fever and SOB

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