Clinical cases

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Clinical cases

• A chance to apply some of your new knowledge to
  real clinical scenarios

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Case 1

• A 60 year old non-smoking woman complained of
  cough, dyspnoea and right sided pleuritic chest
  pain for 3 days. She was pyrexial (39.3 C) and a
  pleural rub was audible at the right lung base.
  Her white cell count was raised.
• What are the notable observations ?

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Case 1

• A 60 year old non-smoking woman complained of
  cough, dyspnoea and right sided pleuritic chest
  pain for 3 days. She was pyrexial (39.3 C) and a
  pleural rub was audible at the right lung base.
  Her white cell count was raised.

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Case 1 diagnosis

• Right lower lobe pneumonia

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Case 2

• This 25 year old woman, visiting Scotland on a
  hen weekend, was admitted with central chest pain
  which began during an episode of vomiting. She
  complained that her neck had become swollen. On
  examination he had a tachycardia and mild pyrexia
  (38.1 C). Palpation of her neck and chest wall
  gave rise to a crackling sensation

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Case 2

• This 25 year old woman, visiting Scotland on a
  hen weekend, was admitted with central chest pain
  which began during an episode of vomiting. She
  complained that her neck had become swollen. On
  examination he had a tachycardia and mild pyrexia
  (38.1 C). Palpation of her neck and chest wall
  gave rise to a crackling sensation.

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Case 2 diagnosis

• Pneumomediastinum from oesophageal perforation

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Case 3

• This 55 year old man collapsed whilst out
  shopping with his wife. The paramedics noted his
  breathing to be laboured and intubated him at the
  scene. This CXR was obtained on admission to
  hospital

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Case 3

• This 55 year old man collapsed whilst out
  shopping with his wife. The paramedics noted his
  breathing to be laboured and intubated him at the
  scene. This CXR was obtained on admission to
  hospital

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Case 3 diagnosis

• Endotracheal tube inserted too far into right
  main bronchus.

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Correctly sited endotracheal tube
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Case 4

• This 22 year old woman complained of sudden onset
  right sided chest pain, followed by progressive
  dyspnoea. By admission, she was in distress and
  appeared cyanosed. Her pulse was 140, with
  respiratory rate 40. On chest auscultation,
  breath sounds were noted to be quiet, especially
  on the right

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Case 4

• This 22 year old woman complained of sudden onset
  right sided chest pain, followed by progressive
  dyspnoea. By admission, she was in distress and
  appeared cyanosed. Her pulse was 140, with
  respiratory rate 40. On chest auscultation,
  breath sounds were noted to be quiet, especially
  on the right.

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Case 4 diagnosis

• Tension pneumothorax

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Case 5

• This 67 year old man, a lifelong smoker,
  complained of several weeks of reduced exercise
  tolerance due to dyspnoea. He had a chronic cough
  productive of white sputum but recently it had
  been blood stained. He had lost 10kg in weight.

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Case 5

• This 67 year old man, a lifelong smoker,
  complained of several weeks of reduced exercise
  tolerance due to dyspnoea. He had a chronic cough
  productive of white sputum but recently it had
  been blood stained. He had lost 10kg in weight.

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Case 5 diagnosis

• Right middle and lower lobe collapse

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Case 6

• This 68 year old man was admitted with a
  myocardial infarct 5 days ago. He became acutely
  breathless at 3am. On examination he was sitting
  up in bed and sweating. His respiratory rate was
  40 and pulse 130. His chest was dull to
  percussion at the bases and crackles were heard
  there on auscultation.

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Case 6

• This 68 year old man was admitted with a
  myocardial infarct 5 days ago. He became acutely
  breathless at 3am. On examination he was sitting
  up in bed and sweating. His respiratory rate was
  40 and pulse 130. His chest was dull to
  percussion at the bases and crackles were heard
  there on auscultation.

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Case 6 diagnosis

• Acute pulmonary oedema due to congestive cardiac
  failure.

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QUIZ TIMEIs this CXR normal or abnormal
?(correct answer 1 point) If you think it is
abnormal, what is the diagnosis ?(correct answer
1 bonus point)
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QUIZ TIME

• This is a chance to see if youve acquired any
  CXR interpretation skills
• 8 normal CXR (correctly sited lines normal)
• 8 abnormal CXR
• maximum score 24 points
• additional points may be given for entertaining
  incorrect answers, at the discretion of the
  moderator

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ANSWERS
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1

• Normal

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2

• Left lower lobe consolidation/pneumonia

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3

• Normal right internal jugular-brachiocephalic and
  left subclavian-brachiocephalic vein catheters

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4

• Normal

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• Right middle lobe consolidation/pneumonia

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• Left pneumothorax

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• Right upper lobe collapse

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8

• Normal

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9

• Normal

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• Right midzone consolidation/pneumonia

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• Normal

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• Misplaced NG tube in right main bronchus

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• Normal

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• Left lower lobe collapse

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• Normal

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• Right lower zone consolidation