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Acute Shortness of Breath and the House Officer: A Radiological Guide By Andrew Clegg

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68 y/o Gentleman, presenting with a 3/7 Hx of increasing ... Radiology suggests pulmonary sarcoid (Stage 1) Definitive diagnosis on transbronchial biopsy ... – PowerPoint PPT presentation

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Title: Acute Shortness of Breath and the House Officer: A Radiological Guide By Andrew Clegg


1
Acute Shortness of Breath and the House Officer
A Radiological GuideByAndrew Clegg
2
Case Study 1
68 y/o Gentleman, presenting with a 3/7 Hx of
increasing shortness of breath, with right sided
pleuritic chest pain and productive cough. Hint
This patient also has leukaemia
3
Radiological Diagnosis
  • Fluffy alveolar shadowing in L mid and lower
    zones
  • Alveolar shadowing in R lower zone
  • Loss of definition of left heart border,
    maintenance of diaphragmatic border
  • Findings support left upper lobe pneumonia, with
    right sided infiltration
  • Staph, Strep, Haemophilus most common infecting
    agents in CLL

4
Case Study 2
34 y/o female smoker presents with acute onset
shortness of breath and left sided pleuritic
chest pain. This patient is also
menstruating. Hint Look for the Vascular Markings
5
Radiological Diagnosis
  • Loss of vascular markings to the lung periphery
    on the left side
  • Tracheal deviation to the right
  • Findings are consistent with primary spontaneous
    tension pneumothorax
  • Female heavy smokers increase risk of
    pneumothorax by 68 times
  • Unlikely to be catamenial pneumothorax

6
Case Study 3
72 y/o gentleman presents with a 4/52 history of
increasing shortness of breath on exertion, on a
background of a long history of IHD Hint O/E
reveals a third heart sound
7
Radiological Diagnosis
  • Underpenetrated film
  • Enlarged heart
  • Bilateral alveolar shadowing in lung bases
  • Loss of definition at costophrenic angles
  • Note aortic calcification
  • Findings are consistent with pulmonary oedema
    secondary to heart failure
  • Heart failure secondary to IHD

8
Case Study 4
68 y/o male presents with a 4/7 history of
increasing SOB after an episode of
pneumonia Hint look at the upper border
9
Radiological Diagnosis
  • Homogeneous opacification of R mid and lower
    zones with concave upper border
  • Some residual signs of infection in right apex
  • Findings suggest medium sized R pleural effusion
  • Inadequately treated pneumonia has led to empyema
    formation
  • Perform thoracocentesis and send fluid for
    analysis

10
Case Study 5
63 y/o male heavy smoker with 5/52 Hx increasing
SOB, weight loss and recent onset
haemoptysis. Hint need I say more
11
Radiological Diagnosis
  • Large, well defined round mass in L hilar region
  • This is bronchogenic carcinoma until proven
    otherwise
  • Perform diagnostic bronchoscopy with biopsy CT
    thorax for staging
  • ?ca likely due to secretion of PTHrP
  • PTH secreted by SCC
  • Prognosis is likely to be poor

12
Case Study 6
77 y/o male smoker presents with 2/7 history of
worsening SOB and cough with yellow sputum. Hint
count the ribs
13
Radiological Diagnosis
  • 8 anterior ribs to MCL on R side
  • Hyperexpanded lung fields
  • Flattened diaphragm
  • Enlarged central pulmonary arteries
  • No focal signs of infection
  • Radiology consistent with COPD
  • Clinical findings consistent with acute
    (infective) exacerbation of COPD
  • COPD Dx by spirometry

14
Case Study 7
A 40 y/o Irish lady presents with a 6/52 history
of dry cough. Examination reveals a blue-red
facial rash. Hint raised calcium on blood tests
15
Radiological Diagnosis
  • Bilateral hilar shadowing
  • No interstitial infiltrates
  • Hyperinflated lung fields with 7 anterior ribs
  • Radiology suggests pulmonary sarcoid (Stage 1)
  • Definitive diagnosis on transbronchial biopsy
  • NCGs secrete Vitamin D (?Ca) and ACE
  • Facial rash is lupus pernio

16
Case Study 8
44 y/o homeless gentleman presents with a 4/52
Hx of worsening SOB, cough, and fever. Hint
Look at the apices
17
Radiological Diagnosis
  • Cavitatary opacity present in the R upper zone
  • Focal area of opacification in R mid zone
  • Increased R hilar shadowing
  • Radiology and clinically consistent with TB
  • Presence of lymphadenopathy distinguishes TB from
    other infectious processes
  • Must consider the possibility of associated
    immunodeficiency

18
Case Study 9
58 y/o male with Ca pancreas presents with acute
onset severe SOB with pleuritic chest pain. He
is tachycardic and hypotensive. RR 36. Chest
clear. Hint High index of Clinical Suspicion
19
Radiological Diagnosis
  • Loss of left costophrenic angle with concave
    upper border
  • Suggestive of small pleural effusion
  • No other abnormalities noted
  • V/Q scan equivocal

20
Spiral CT
  • Intraluminal filling defect in L pulmonary artery
  • Extensive wedge shaped infarct inferior aspect
    of L lung
  • Dx pulmonary embolism

21
Whittington Hospital PE Algorithm
To receive radiological review
This section to be arranged by radiologists
D DIMER Do not test patients with recent
surgery or infection. Proceed to perfusion scan.
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