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Tuesday, April 11, 2023
Anwser,sDr :ANAS SAHLE
1. Chest xr cases.2. Chest clinical case.
3. Chest ct cases.4. MRCP exam.
:http://www.facebook.com/dranas224
chest xr casesDr :anas sahle
http://www.facebook.com/dranas224
CXR-31
DIAGNOSIS: Aneurysm of Descending Aorta
CXR-32
DIAGNOSIS: Fungous Ball
Crescent sign - semilunar air space above mass density
CXR-33a
AspergillosisSub-acute Invasive Form
CXR-33b
Cavitation with return of white countResembling fungous ball with crescentic air
Non- mobile fungous ball
CXR-33c
Cavitation with return of white countResembling fungous ball with crescentic air
Non- mobile fungous ball
CXR-34
DIAGNOSIS: Blebs
CXR-35a
CXR-35b
DIAGNOSIS: Broncholith
Lingular pneumoniaPost obstructive pneumonia
Lingular pneumoniaPost obstructive pneumonia
Tuesday, April 11, 2023
DIAGNOSIS: Broncholith
CXR-36DIAGNOSIS: Left Cervical Rib
You identify the rib by the transverse process with which it articulates .
A: Transverse process cervical vertebra: HorizontalB: Transverse process dorsal vertebra: Upward
CXR-37
DIAGNOSIS: Dextrocardia
Tuesday, April 11, 2023
Note
• Stomach bubble on left• Right diaphragm lower – Position of heart determines which diaphragm is
lower, not liver.• Pectus accounts for increased density on left
CXR-38
DIAGNOSIS: Dextrocardia / Kertagener's Syndrome :
Tuesday, April 11, 2023
chest clinical casesA 20 Year-Old with a
Mediastinal MassSubmitted byTyler B. Anderson, MDFellowDivision of Pulmonary, Allergy, Critical Care and Sleep MedicineThe Ohio State University Medical CenterColumbus, OhioJonathan P. Parsons, MD, MSc, FCCPAssociate Professor of Internal MedicineDivision of Pulmonary, Allergy, Critical Care and Sleep MedicineThe Ohio State University Medical CenterColumbus, Ohio
Tuesday, April 11, 2023
History • A 20 year old Caucasian man with no significant past
medical history presented to his primary care physician for chest discomfort and cough.
• Two months prior to presentation, he reported having an unremarkable viral syndrome which resolved with no medical intervention.
• His primary care physician prescribed a short course of antibiotics for empiric treatment of pneumonia with some initial improvement in symptoms.
• His chest discomfort returned and he developed progressive dyspnea on exertion which led to a chest radiography.
Tuesday, April 11, 2023
Physical Exam• The patient was in no acute distress. • Vital signs were unremarkable. • Cardiac exam demonstrated regular rate and rhythm with no
murmur, gallop or rub. • Lungs were clear to auscultation bilaterally without wheezes or
rales. • Abdomen was soft with no hepato/spleno-megaly. • There was no palpable cervical, supra-clavicular or axillary
lymphadenopathy. • Genitourinary exam was negative for testicular masses.
Neurologic exam showed no focal deficits. • Cranial nerves appeared intact.
Tuesday, April 11, 2023
Lab• White blood cell count 7.2 K/uL, 56%
Neutrophils, 28% Lymphocytes, 7% Eosinophils• Chemistry and liver function testing was within
normal limits• Human chorionic Gonadotropin (HCG), serum
<0.5 MIU/mL (normal in males <5.0 MIU/ml)• Alpha-fetoprotein (AFP), serum 2.2 NG/mL
(normal 0.0-8.3 NG/ML)
Tuesday, April 11, 2023
cxr
Tuesday, April 11, 2023
Ct
Tuesday, April 11, 2023
• An abnormality was noted in the left mediastinum which prompted his physician to order a computed tomography (CT) of the chest and to refer him to a pulmonary specialist.
• This CT scan revealed a rounded, well-demarcated mass in the superoanterior mediastinal compartment.
• The largest diameter measured 6.8 x 4.8cm.
Tuesday, April 11, 2023
Question 1• What is the most common cause of an
anterior mediastinal neoplasm?
• A. Germ cell tumor • B. Lymphoma • C. Parathyroid adenoma • D. Thymoma
Tuesday, April 11, 2023
Discussion • The mediastinum is located in the central portion of the thorax. • The boundaries are the pleural cavities laterally, the thoracic inlet superiorly and the
diaphragm inferiorly. • The anterior compartment refers to the retrosternal space that is anterior to the heart and
great vessels. • It contains the thymus, lymph nodes, adipose and connective tissue. • Approximately one half of mediastinal tumors occur in the anterior mediastinum1. • Thymomas, lymphomas and germ cell tumors are the most frequently diagnosed tumors of
the anterior mediastinum with a relative incidence of 30%, 20% and 18%, respectively 2. • Thymomas are the most common neoplasm of the anterior mediastinum with an incidence
of 0.15 cases per 100,0003. • Interestingly, mass location tends to predict malignancy. • Approximately two thirds of all mediastinal tumors are benign, but masses in the anterior
compartment are more likely to be malignant1.• A retrospective review of 400 patients by Davis et al found that 59% of anterior masses
were malignant, compared to masses in middle mediastinum (29%) and posterior mediastinum (16%)2.
Tuesday, April 11, 2023
Question 2• What is the most common presenting
symptom in a patient with a mediastinal mass?
• A. Chest pain Systemic • B. Dysphagia • C. Hemoptysis • D. "B" symptoms (fever, weight loss, night
sweats)
Tuesday, April 11, 2023
Discussion • About two thirds (62%) of patients with mediastinal masses of
any etiology will have symptoms at the time of diagnosis2. • Chest pain is the most frequently reported symptom (30%)
followed by fever and chills (20%)2. • Anterior mediastinal masses produce symptoms at a greater
frequency (75%) than masses from middle or posterior compartments, 45% and 50% respectively2.
• Similar to mass location, presence of symptoms at diagnosis also predicts malignancy.
• Overall, 85% of patients with a malignant neoplasm were symptomatic at presentation, while only 46% of patients with benign neoplasms had symptoms2.
Tuesday, April 11, 2023
Question 3• What is the most common syndrome
associated with thymoma?• A. Hypogammaglobulinemia • B. Myasthenia gravis • C. Pure red cell aplasia • D. Superior vena cava syndrome
Tuesday, April 11, 2023
Discussion • Symptoms of myasthenia gravis include generalized weakness and fatigue, along with diplopia, ptosis and
dysphagia. • Myasthenia gravis occurs in 30-50% of patients with thymoma; however, only about 15% of patients with
myasthenia gravis have a thymoma4. • Given this strong association between thymoma and myasthenia gravis, it is recommended that all patients
diagnosed with myasthenia gravis undergo CT or magnetic resonance imaging (MRI) to evaluate the mediastinum for thymoma.
• Conversely, all patients with clinically suspected thymoma should have a serum antiacetylcholine receptor antibody level examined even if they are asymptomatic1.
• Thymectomy gradually alleviates symptoms in approximately 25% of myasthenic patients with thymoma5. • Thymoma has been associated with a number of other paraneoplastic syndromes as well. • Hypogammaglobulinemia is then next most common paraneoplastic syndrome, and is present in approximately
10% of patients with thymoma6. • Pure red cell aplasia and Good syndrome have also been reported to be associated with thymoma in rare cases.• The patient was referred to thoracic surgery for a surgical biopsy as the diagnosis was in question. • A left parasternal mediastinoscopy (Chamberlain approach) was performed. Pathology from this specimen
revealed small fragments of thymic tissue with preservation of normal architecture. • There was no histologic evidence to support malignancy and flow cytometry was negative for lymphoma. • A positron emission tomography (PET) scan revealed diffuse mild activity; the standardized uptake value (SUV)
max was 3.9, consistent with benign thymic tissue. • He was diagnosed with rebound thymic hyperplasia following the viral illness in the weeks prior to presentation .
Tuesday, April 11, 2023
Question 4• Which condition(s) is/are associated
with Rebound Thymic Hyperplasia (RTH)?
• A. Addison disease • B. Cancer, post chemotherapy • C. Hyperthyroidism • D. Severe burns • E. All of the above
Tuesday, April 11, 2023
Discussion • Rebound thymic hyperplasia (RTH) is a form of true thymic hyperplasia
which can occur in children and young adults recovering from systemic illness or after treatment of various malignancies.
• It is characterized by generalized hyperplasia with preservation of normal thymic architecture and immunohistologic appearance7.
• RTH has been documented in many clinical conditions including hyperthyroidism, Addison disease, severe burns or after chemotherapy8.
• During stress, the thymus may shrink to 40% of its original volume; then over time usually grows back to its original size within 9 months9.
• In RTH, the thymus can grow 50% larger than its original size9. • This may present a diagnostic challenge as RTH can clinically or
radiologically mimic recurrent or metastatic mediastinal neoplasms.
Tuesday, April 11, 2023
Question 5• What is the treatment of choice for
RTH?• A. Chemotherapy • B. Observation • C. Radiation therapy • D. Surgical resection
Tuesday, April 11, 2023
Discussion • The thymus is functionally active in childhood and adolescence
and may be susceptible to fluctuation in corticosteroid levels10. • The reversal of elevated endogenous corticosteroids in many of
the aforementioned conditions is thought to be a causative factor in RTH10.
• Although steroids will shrink a hyperplastic thymus11 this is usually not necessary as the transient overgrowth will resolve over time.
• The patient was observed with follow up CT scans of his chest. • The mass had decreased by greater than 50% of its original size at
3 months. • At 6 months (Figure 5) and 9 months the CT chest continued to
show further decrease in size of the mediastinal mass with no evidence of local invasion or progressive lymphadenopathy.
Tuesday, April 11, 2023
chest ct cases-7Dr :anas sahle
http://www.facebook.com/dranas224
images 1 and 2.
Look at images 1 and 2. • This case shows multiple nodules. • Asymmetry of the lungs is due to collapse of
the left upper lobe.• 1. Are the nodules focal or diffuse? • 2. What is the anatomic location of the
nodules? • a) Primarily bronchovascular
b) Primarily centrilobularc) Primarily pleurald) Random
Look at images 1 and 2. • This case shows multiple nodules. • Asymmetry of the lungs is due to collapse of the left
upper lobe.• 1. Are the nodules focal or diffuse?• diffuse • 2. What is the anatomic location of the nodules? • a) Primarily bronchovascular• b) Primarily centrilobular• c) Primarily pleural• d) Random
HRCT-1
HRCT-1
• Find the left upper lobe bronchus leading into the left upper lobe.
• Outline the collapsed left upper lobe.• In the right lung, find 3 pleural nodules.• Find 3 nodules at the end of vessels in the
right lung.• Find 4 or 5 nodules along the fissure (F) in the
right lung.
HRCT-1
HRCT-2
HRCT-2
• Find 2 centrilobular nodules in the right lung.• Find a nodule at the end of a vessel in the
posterior right lung.
HRCT-2
Histology of a Nodule
Q
• This rounded, subpleural structure, about 0.5 cm in diameter, corresponds to the subpleural lesions in the images above.
• In this case, no cellular structures are present except at the edge.
• 1. What are possible causes of this nodule? • 2. What does the homogeneous pink material
in the nodule represent?
Answer
• 1. Possible causes include infection and tumor. – This particular patient had known
metastatic testicular carcinoma. – The necrosis of the tumor may have
resulted from therapy or ischemia or both.• 2. The homogeneous pink material represents
necrosis.
Differential diagnosis of random nodules on HRCT:
• hematogenous metastasis (particularly from thyroid, kidney, and breast)
• Miliary infections. Langerhans' cell histiocytosis, sarcoidosis, and silicosis are common causes of
nodules, but such nodules are rarely diffuse and haphazard.
Histologic differential diagnosis:
• Metastatic tumor. • Infection should be considered.
HRCT diagnosis:
• Metastatic breast cancer with hematogenous spread throughout the lungs and endobronchial metastasis to the left upper lobe, resulting in collapse.
Summary
• diagnostic features of numerous hematogenous metastatic nodules on HRCT• Usually random distribution • Often smooth, well-defined • Varying size common
Tuesday, April 11, 2023
04/11/202353
MRCP EXAMRespiratory
04/11/202354
Q1A 9 month old child presents with respiratory distress,
worsening over 2 days. Blood gases show a
pH of 7.25, a PCO2 of 7.5kPa, a PO2 of 8.5kPa, and a base excess of -4.
• A -Results are consistent with bronchopulmonary dysplasia.
• B -Blood gases suggest type 1 respiratory failure. • C- Immediate intubation is required. • D -Results are consistent with late severe asthma. • E -Bicarbonate may be necessary to correct the
acidosis.
04/11/202355
A1 A 9 month old child presents with respiratory
distress, worsening over 2 days. Blood gases show a
pH of 7.25, a PCO2 of 7.5kPa, a PO2 of 8.5kPa, and a base excess of -4.
• A -Results are consistent with bronchopulmonary dysplasia. (False)• B -Blood gases suggest type 1 respiratory failure. (False)• C- Immediate intubation is required. (False)
• D -Results are consistent with late severe asthma.(true)
• E -Bicarbonate may be necessary to correct the acidosis. (False)
Tuesday, April 11, 2023
Q2• Long-acting ß2 agonists:
• A -Can be used to prevent activity-induced symptoms without anti-inflammatory therapy.
• B- Become less effective over time (tolerance). • C- Are beneficial in acute viral croup. • D- Protect against allergen challenge for up to 48
hours. • E -Should not be used in association with
erythromycin.
Tuesday, April 11, 2023
A2 • Long-acting ß2 agonists:
• A -Can be used to prevent activity-induced symptoms without anti-inflammatory therapy.(true)
• B- Become less effective over time (tolerance). (False) • C- Are beneficial in acute viral croup. (False)• D- Protect against allergen challenge for up to 48 hours.
(False) • E -Should not be used in association with erythromycin.
(False)
Tuesday, April 11, 2023
Q3The oxygen dissociation curve is shifted to the right by:
A- Decreased haemoglobin concentration
B- Reduced temperature
C- Reduced pH
D- Increased partial pressure of carbon dioxide
E- Increased DPG
Tuesday, April 11, 2023
A3 The oxygen dissociation curve is shifted to the right by:
A- Decreased haemoglobin concentration (False)B- Reduced temperature (False)C- Reduced pH (True)
D- Increased partial pressure of carbon dioxide (True)
E- Increased DPG (True)
Tuesday, April 11, 2023
Q4In lung empyema:
A- Strep. pneumoniae is usually isolated from the pleural cavity .B- Installation of urokinase may be helpful .
C- Anti-TB triple therapy is indicated if the fever does not settle within 14 days .D- An underlying malignancy should be excluded .
E- Initial treatment of the pneumonia has been inadequate.
Tuesday, April 11, 2023
A4 In lung empyema:
A- Strep. pneumoniae is usually isolated from the pleural cavity. (False) B- Installation of urokinase may be helpful. (True)
C- Anti-TB triple therapy is indicated if the fever does not settle within 14 days. (False) D- An underlying malignancy should be excluded. (True)
E- Initial treatment of the pneumonia has been inadequate. (False)
Tuesday, April 11, 2023
Q5Regarding lung development:
A- The pseudoglandular phase lasts between 16 and 26 weeks .
B- Alveolar capillaries first appear about 20 weeks of gestation .
C- The primitive airways appear as a dorsal outpouching of the foregut epithelium .D- The pulmonary vascularture is derived from endoderm .
E- The peribronchial mesenchyme (spalnchnopleura) plays an essential role in shaping the lungs during embryogenesis.
Tuesday, April 11, 2023
A5 Regarding lung development:
A- The pseudoglandular phase lasts between 16 and 26 weeks. (False)B- Alveolar capillaries first appear about 20 weeks of gestation. (False)C- The primitive airways appear as a dorsal outpouching of the foregut epithelium. (False)D- The pulmonary vascularture is derived from endoderm. (False)E- The peribronchial mesenchyme (spalnchnopleura) plays an essential role in shaping the lungs during embryogenesis. (True)
Tuesday, April 11, 2023
Q6Recognised causes of acute upper airway obstruction include:
A- Angio-oedema
B- Asthma
C- Mumps
D- Retro-pharyngeal abscess
E- Laryngomalacia
Tuesday, April 11, 2023
A6 Recognised causes of acute upper airway obstruction include:
A- Angio-oedema(True)
B- Asthma(False)C- Mumps(False)D- Retro-pharyngeal abscess(True)
E- Laryngomalacia(False)
Tuesday, April 11, 2023
Q7The following lung function tests are compatible with severe scoliosis:A- An FEV1 of 65% of normal .B- An FEV1/2 of 65% of normal .C- Total lung capacity of 95% of normal .D- Tidal volume of 105% of normal .E- Peak flow of 50% of normal.
Tuesday, April 11, 2023
A7 The following lung function tests are compatible with severe scoliosis:A- An FEV1 of 65% of normal. (True) B- An FEV1/2 of 65% of normal. (False) C- Total lung capacity of 95% of normal. (False) D- Tidal volume of 105% of normal. (True) E- Peak flow of 50% of normal. (True)
Tuesday, April 11, 2023
Q8Concerning Tuberculosis:
A- The infection rate is increased in Crohn's Disease .B- Overcrowded living conditions do not significantly affect prevalence .
C- The treatment of lymph node infection is of a greater duration than pulmonary infection.D- The tuberculin skin test is a good indicator of disease activity .
E- In pregnant women treatment should be delayed until after birth.
Tuesday, April 11, 2023
A8 Concerning Tuberculosis:
A- The infection rate is increased in Crohn's Disease. (False) B- Overcrowded living conditions do not significantly affect prevalence. (False)
C- The treatment of lymph node infection is of a greater duration than pulmonary infection. (False)D- The tuberculin skin test is a good indicator of disease activity. (False)
E- In pregnant women treatment should be delayed until after birth. (False)
Tuesday, April 11, 2023
Q9The following are signs of severe asthma:
A- A silent chest in a 7 year old girl .B- Inability to feed in a 10 month old child .C- A heart rate of >90 in a 5 year old child .
D- Decreased right-sided breath sounds in a 10 year old girl .E- A respiratory rate of 60 in a 2 year old boy.
Tuesday, April 11, 2023
A9 The following are signs of severe asthma:
A- A silent chest in a 7 year old girl. (True) B- Inability to feed in a 10 month old child. (True) C- A heart rate of >90 in a 5 year old child. (False)
D- Decreased right-sided breath sounds in a 10 year old girl. (False) E- A respiratory rate of 60 in a 2 year old boy. (True)
Tuesday, April 11, 2023
Q10Lung biopsy may be useful in the following cases:
A- A 6 month old boy ventilated for adenovirus infection .
B- A 2 year old with leukaemia and possible adreamycin toxicity .
C- A 4 year old child with dense lower zone opacities on chest x-ray .
D- A 3 month old Afro-Caribbean boy with "ground glass" chest x-ray .
E- A 4 month old with severe confirmed RSV positive bronchiolitis.
Tuesday, April 11, 2023
A10 Lung biopsy may be useful in the following cases:
A- A 6 month old boy ventilated for adenovirus infection. (True)
B- A 2 year old with leukaemia and possible adreamycin toxicity. (False)
C- A 4 year old child with dense lower zone opacities on chest x-ray. (False) D- A 3 month old Afro-Caribbean boy with "ground glass" chest x-ray. (True)
E- A 4 month old with severe confirmed RSV positive bronchiolitis. (False)
Tuesday, April 11, 2023