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Drs. Milam and Thomas's CMC X-Ray Mastery Project: September Cases

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Drs. Claire Milam and Alyssa Thomas are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides on: Septic Pulmonary Emboli, Severe Rib Fractures, Left Lower Lobe Resection, Pneumonia, Esophageal Stent, COPD, Hyperinflation, Pulmonary Contusion, Aortic Dissection, Tuberculosis

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Drs. Milam and Thomas's CMC X-Ray Mastery Project: September Cases

  1. 1. Adult Chest X-Rays Of The Month Alyssa Thomas MD & Claire Milam MD Department of Emergency Medicine Carolinas Medical Center & Levine Children’s Hospital Michael Gibbs MD, Faculty Editor Chest X-Ray Mastery Project September 2019
  2. 2. Disclosures  This ongoing chest X-ray interpretation series is proudly sponsored by the Emergency Medicine Residency Program at Carolinas Medical Center.  The goal is to promote widespread mastery of CXR interpretation.  There is no personal health information [PHI] within, and ages have been changed to protect patient confidentiality.
  3. 3. Process  Many are providing cases and these slides are shared with all contributors.  Contributors from many CMC/LCH departments, and now from EM colleagues in Brazil, Chile and Tanzania.  Cases submitted this month will be distributed next month.  When reviewing the presentation, the 1st image will show a chest X-ray without identifiers and the 2nd image will reveal the diagnosis.
  4. 4. It’s All About The Anatomy!
  5. 5. Airway Bones Cardiac Diaphragm Effusion Foreign body Gastric Hilum
  6. 6. 26 Year Old IV Drug User Presents With Back Pain And Fever
  7. 7. 26 Year Old IV Drug User Presents With Back Pain And Fever Bilateral Rounded Densities
  8. 8. 26 Year Old IV Drug User Presents With Back Pain And Fever Septic Pulmonary Emboli
  9. 9. 30 Year Old With A History Of Intravenous Drug Abuse Presents With Weakness and Shortness of Breath
  10. 10. 30 Year Old With A History Of Intravenous Drug Abuse Presents With Weakness and Shortness of Breath Bilateral Rounded Densities
  11. 11. 30 Year Old With A History Of Intravenous Drug Abuse Presents With Weakness and Shortness of Breath Septic Pulmonary Emboli
  12. 12. 22 Year Old With A History Of Intravenous Drug Abuse Presents With Fever, Chest Pain & Cough
  13. 13. 22 Year Old With A History Of Intravenous Drug Abuse Presents With Fever, Chest Pain & Cough Bilateral Rounded Densities
  14. 14. 22 Year Old With A History Of Intravenous Drug Abuse Presents With Fever, Chest Pain & Cough Septic Pulmonary Emboli
  15. 15. 22 Year Old With A History Of Intravenous Drug Abuse Presents With Fever, Chest Pain & Cough Point Of Care ED Echo: Tricuspid Valve Vegetation
  16. 16. Here Is The 3rd Patient’s Chest X-Ray One Month Ago!
  17. 17. In One Week We Received Three Cases Of Septic Pulmonary Emboli In Young, IV Drug-Dependent Adults With Endocarditis. This Seems Like A Lot!
  18. 18. In One Week We Received Three Cases Of Septic Pulmonary Emboli In Young, IV Drug-Dependent Adults With Endocarditis. This Seems Like A Lot! Let’s Look At Some North Carolina-Specific CDC Data
  19. 19.  12-fold increase in the incidence of hospitalization  Incidence increasing most rapidly amongst drug users who are younger, white (87%), non-Hispanic (92%), and from rural areas  18-fold increase in the total cost of hospitalization  Median hospital charges $54,281  In 2015 42% of patients were either uninsured or receiving Medicaid
  20. 20. Empiric Antibiotics In The ED First Choice Vancomycin + Cefepime Severe PCN Allergy Vancomycin + Aztreonam
  21. 21. Another More Recent Case 39Year Old With A History Of Intravenous Drug Abuse Presents With Fever, Chest Pain & Cough Bilateral Rounded Densities
  22. 22. 39 Year Old With A History Of Intravenous Drug Abuse Presents With Fever, Chest Pain & Cough Septic Pulmonary Emboli
  23. 23. 37 Year-Old With A Remote History Of Severe Esophagitis & Perforation
  24. 24. Esophageal Stent 37 Year-Old With A Remote History Of Severe Esophagitis & Perforation
  25. 25.  Esophageal stents are used to palliate esophageal malignancies and a number of non-malignant conditions, including: refracture strictures, tracheoesophageal fistulas, and complex esophageal perforations.  Self-expanding plastic stents (SEPS) and self-expanding metal stents (SEMS) exist.
  26. 26. Esophageal Stent Complications Acute (<4 Weeks)1,2 Chronic (>4 Weeks)3  Chest pain  Fever  Bleeding  Globus sensation  Perforation  Migration  Tumor ingrowth  Stent migration  Stent occlusion  Esophageal fistula development  Recurrence of strictures 1Complications in up to 30% 2Stent migration most common 3Complications in 50-60%
  27. 27. Old Surgical Clips
  28. 28. Old Surgical Clips Prior Left Lower Lobectomy
  29. 29. 47 Year-Old With A Long History Of COPD
  30. 30. 47 Year-Old With A Long History Of COPD ED CXR During Exacerbation Demonstrated Hyperinflation Follow-Up Office CXR: Hyperinflation Resolves
  31. 31. Two Recent Cases With A Common Theme
  32. 32. 55 Year Old With Fever And Dyspnea Single AP View Portable CXR Obtained At The Bedside
  33. 33. 55 Year Old With Fever And Dyspnea Single AP View Portable CXR Obtained At The Bedside Sent For A Chest CT After This CXR Was Taken
  34. 34. 55 Year Old With Fever And Dyspnea Retrocardiac LLL Pneumonia
  35. 35. 55 Year Old With Fever And Dyspnea Let’s Take Another Look At The CXR!
  36. 36. 55 Year Old With Fever And Dyspnea Let’s Take Another Look At The CXR! The Left Hemidiaphragm Is Indistinct
  37. 37. 40 Year Old With Fever And Dyspnea Single AP View Portable CXR Obtained At The Bedside
  38. 38. 40 Year Old With Fever And Dyspnea Single AP View Portable CXR Obtained At The Bedside Sent For A Chest CT After This CXR Was Taken
  39. 39. 40 Year Old With Fever And Dyspnea Retrocardiac LLL Pneumonia
  40. 40. 40 Year Old With Fever And Dyspnea Let’s Take Another Look At The CXR!
  41. 41. 40 Year Old With Fever And Dyspnea Let’s Take Another Look At The CXR! The Left Hemidiaphragm Is Indistinct
  42. 42.  In patients who are sick [i.e.: challenging from them to travel to Radiology] – we may start with a single-view AP chest X-ray.  In these two cases the “next step” was a CT scan of the chest.  Another option would have been to obtain a higher quality two-view study that would have provides the benefit of the lateral projection.
  43. 43. CMC/LCH Technical Charges – August 2019 1 view chest X-ray $296 2 view chest X-ray $369 CT chest with contrast $2,628 CT chest with contrast - angiogram $3,398
  44. 44. 25 Year Old In High-Speed MVC
  45. 45. 25 Year Old In High-Speed MVC Bilateral Pulmonary Contusions
  46. 46. 25 Year Old In High-Speed MVC Bilateral Pulmonary Contusions
  47. 47. 25 Year Old In High-Speed MVC Bilateral Pulmonary Contusions
  48. 48. 35 Year Old With Poorly Controlled HPTN Presents With 2 Days Chest Pain Today 1 Year Ago
  49. 49. 35 Year Old With Poorly Controlled HPTN Presents With 2 Days Chest Pain False Lumen True Lumen Type A Acute Aortic Dissection
  50. 50. 55 Year Old Female With HPTN With Chest And Abdominal Pain.
  51. 51. Type A Acute Aortic Dissection
  52. 52. Type A Acute Aortic Dissection
  53. 53. Type A Acute Aortic Dissection Avascular Right Kidney
  54. 54. 48 Year Old From Mexico With Fever And Hemoptysis
  55. 55. 48 Year Old From Mexico With Fever And Hemoptysis Cavitary Tuberculosis
  56. 56. 27 Year Old Involved In A High-Speed MVC With Roll Over
  57. 57. 27 Year Old Involved In A High-Speed MVC With Roll Over Multiple Left Upper Rib Fractures Left Pulmonary Contusion
  58. 58. 27 Year Old Involved In A High-Speed MVC With Roll Over Multiple Left Upper Rib Fractures
  59. 59. 27 Year Old Involved In A High-Speed MVC With Roll Over Post-Injury Day 2 Notice That The Fractures Are More Displaced Because Of Ongoing Mechanical Ventilation
  60. 60. 27 Year Old Involved In A High-Speed MVC With Roll Over Post-Injury Day 3 A Perfect Case For Rib-Plating!
  61. 61. Summary Of Diagnoses This Month  Septic pulmonary emboli  Left lower lobe lung resection  Esophageal stent after perforation  COPD with hyperinflation  The value of the lateral view  Pulmonary contusion  Aortic dissection  Pulmonary tuberculosis  Severe rib fractures with plating
  62. 62. See You Next Month!

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