Anwser,s 8

Anwser,s
Dr :ANAS SAHLE
1. Chest xr cases.
2. Chest clinical case.
3. Chest ct cases.
4. MRCP exam.
:http://www.facebook.com/dranas224

Monday, December 31, 2012

chest xr cases
Dr :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

Aspergillosis
Sub-acute Invasive Form

CXR-33b

Cavitation with return of white count
Resembling fungous ball with crescentic air
Non- mobile fungous ball

CXR-33c

Cavitation with return of white count
Resembling fungous ball with crescentic air
Non- mobile fungous ball

CXR-35b

Lingular pneumonia Lingular pneumonia
Post obstructive pneumonia Post obstructive pneumonia

DIAGNOSIS: Broncholith

DIAGNOSIS: Broncholith


CXR-36
DIAGNOSIS: Left Cervical Rib

You identify the rib by the transverse process with which it
articulates.
A: Transverse process cervical vertebra: Horizontal
B: Transverse process dorsal vertebra: Upward

CXR-37

DIAGNOSIS: Dextrocardia

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:

chest clinical cases
A 20 Year-Old with a
Mediastinal Mass
Submitted by
Tyler B. Anderson, MD
Fellow
Division of Pulmonary, Allergy, Critical Care and Sleep Medicine
The Ohio State University Medical Center
Columbus, Ohio
Jonathan P. Parsons, MD, MSc, FCCP
Associate Professor of Internal Medicine
Division of Pulmonary, Allergy, Critical Care and Sleep Medicine
The Ohio State University Medical Center
Columbus, Ohio

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.


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.


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)


cxr


Ct


• 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.


Question 1
• What is the most common cause of an
anterior mediastinal neoplasm?

• A. Germ cell tumor
• B. Lymphoma
• C. Parathyroid adenoma
• D. Thymoma


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.


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)


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.


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


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.

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


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.

Question 5
• What is the treatment of choice for
RTH?
• A. Chemotherapy
• B. Observation
• C. Radiation therapy
• D. Surgical resection


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.

chest ct cases-7
Dr :anas sahle
http://www.facebook.com/dranas224

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 centrilobular
c) Primarily pleural
d) 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

• 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-2

• Find 2 centrilobular nodules in the right lung.
• Find a nodule at the end of a vessel in the
posterior right lung.

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

MRCP EXAM
Respiratory

12/31/2012

Q1
A 9 month old child presents with respiratory distress,
worsening over 2 days. Blood gases show a
pH of 7.25, a PCO of 7.5kPa, a PO of 8.5kPa, and a base
2 2

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.

12/31/2012

A1
A 9 month old child presents with respiratory
distress, worsening over 2 days. Blood gases
show a
pH of 7.25, a PCO of 7.5kPa, a PO of 8.5kPa, and a
2 2

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)

12/31/2012

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.


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)


Q3
The 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


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)


Q4
In 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.


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)


Q5
Regarding 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.


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)


Q6
Recognised causes of acute upper
airway obstruction include:
A- Angio-oedema
B- Asthma
C- Mumps
D- Retro-pharyngeal abscess
E- Laryngomalacia


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)


Q7
The 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.


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)


Q8
Concerning 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.


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)


Q9
The 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.

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)


Q10
Lung 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.

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)

Anwser,s 8

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