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					                                         Instructions
Case 5
                                         Duration

A 50 year old female with shortness of   Questions
breath                                   Navigation

                                         Score
Author: Dr Tim Hoare
                                         to user on completion. User is
                                         correct answers/feedback sec

                                         Exit application.
Instructions

Duration: 5 - 10 minutes

Questions:True / False (x10)

Navigation: Forward / Back arrows

Score: T/F answers marked and score presented
to user on completion. User is then taken to the
correct answers/feedback section.

Exit application.




                                       Start
                                      PA Chest




A 50 year old female with shortness
of breath.
1
Lateral chest
2
There is evidence of consolidation
The lungs are hyperexpanded
Her symptoms are caused by a pneumothorax
                                                        Radiographic Findings
There is evidence of pulmonary hypertension
A pulmonary embolus can be excluded
              (Click True or False)



                                                                      Group Box 18
         1. There is evidence of consolidation.                         1T       1F
          There is evidence of consolidation
          The lungs are hyperexpanded                                 Group Box 21
          Her symptoms are hyperexpanded.
         2. The lungsare caused by a pneumothorax
          There is evidence of pulmonary hypertension                   2T           2F
          A pulmonary embolus can be excluded
                                                                      Group Box 25
         3. Her symptoms are caused by a pneumothorax.
                                                                        3T           3F


                                                                      Group Box 39
         4. There is evidence of pulmonary hypertension.
                                                                         4T          4F


                                                                      Group Box 42
         5. A pulmonary embolus can be excluded.
                                                                          5T          5F
indings



                     3
Group Box 18

           1F


Group Box 21

               2F


Group Box 25

               3F


Group Box 39

               4F


Group Box 42

                5F
                             Regarding Chronic Obstructive Pulmonary Disease (COPD)

     (Click True or False)

6    The diagnosis cannot be excluded on a normal chest radiograph.


7    Pulmonary function tests typically give a restrictive defect.


8    Spontaneous pneumothorax is a serious complication in these patients.


9    Cor pulmonale is right heart failure secondary to chronic pulmonary disease.


10   COPD is a radiological diagnosis.




                                         End of questions -
                                         Please check your score after which you will be taken to
                                         the correct answers/feedback section.
tive Pulmonary Disease (COPD)


                                    Group Box 17

                                     6T        6F
                                                         4
                                    Group Box 23

                                     7T            7F


                                    Group Box 26
                                      8T           8F


                                    Group Box 30
c pulmonary disease.
                                      9T           9F


                                    Group Box 85

                                      10T          10F




 after which you will be taken to
                     Answers T/F & Feedback Section (Click on corresponding button for further inform

                                            Radiographic Findings

1. There is evidence of consolidation = F

2. The lungs are hyperexpanded = T          Bronchial wall thickening
                                                                        Bronchial wall thickening
                                                                          - Look on magnified area of PA film, j
                                                                        right hilum
                                                                          - The small circle is a bronchus seen
                                                                          - Its wall should be like a pencil line
                                                                          - It represents thickened, inflamed mu
                                                                          - However, it is a non specific finding
                                                                             seen in asthma, infection, left heart



                                                                          3. Her symptoms are caused by a

                                                                          4. There is evidence of pulmonary


Pulmonary Artery Enlargement
                                                                          5. A pulmonary embolus can be exc
  - Secondary to pulmonary artery hypertension
  - (look up 'cor pulmonale'- interesting patho-
    physiology)
(Click on corresponding button for further information)




                                                            5
  Bronchial wall thickening
    Look on magnified area of PA film, just above

     The small circle is a bronchus seen end on
     Its wall should be like a pencil line
     It represents thickened, inflamed mucosa
     However, it is a non specific finding (also
      seen in asthma, infection, left heart failure ....)



     3. Her symptoms are caused by a pneumothorax = F

     4. There is evidence of pulmonary hypertension = T

                         Pulmonary Artery Enlargement


     5. A pulmonary embolus can be excluded = F
                          Answers T/F & Feedback Section (Click on corresponding button for further in

                                               COPD - Radiological Perspective

                                                         COPD

6    The diagnosis cannot be excluded on a normal chest radiograph = T

7    Pulmonary function tests typically give a restrictive defect = F

8    Spontaneous pneumothorax is a serious complication in these patients = T

9    Cor pulmonale is right heart failure secondary to chronic pulmonary disease =

10   COPD is a radiological diagnosis = F




                                                                        10= True; 7 = False
                                                                         6 & 9 = True
                                                                         8
                                                                         COPD
                                                                           - Chronic Bronchitis
                                                                                   Main provide positive
                                                                        Radiology can risk factor is fr
                                                                         In practice, diagnosis made
                                                                               * Clinical diagnosis
                                                                         examination and role is in inv
                                                                        findings, but mainpulmonary f
                                                                               * Chronic recurrent prod
                                                                        complications.
                                                                         (obstructive defect).
                                                                           - Emphysema
                                                                               * Pathological diagnosis
                                                                               * Airspace destruction
on corresponding button for further information)

l Perspective

                              COPD

                                                      6
                               6/7F


 patients = T
                               8/9F
onary disease = T


                               10F




  6 = True; 7 = False
  8 & 9 = True
     Chronic Bronchitis
            Main provide positive diagnostic
 Radiology can risk factor is smoking
  In practice, diagnosis made from history,
       * Clinical diagnosis
  examination and role is in investigating possible
 findings, but mainpulmonary function tests
       * Chronic recurrent productive cough
 complications.
  (obstructive defect).
     Emphysema
       * Pathological diagnosis
       * Airspace destruction
                       Answers / Feedback Section (Click on corresponding button for further informa


                                       Chest Radiograph Findings




CXR normal in 20 - 30% of chronic bronchitics.


But there are positive CXR findings.

                                                                 PA
                                           Lung Hyperinflation - Lateral
Lung Hyperinflation:
        PA       LATERAL                         - counting findings are in ribs above
                                             - Most robust visible anterior lateral film. hemi
                                                   diaphragm
                                             - Flat hemidiaphragms
                                             - Large retrosternal airspace (right ventricle usually
                                                 - If >/= 7 then suggestive of hyperinflation
                                               touches sternum.
                                             - (also note increase AP diameter of upper chest
                                               chest).
 (Click on corresponding button for further information)



 raph Findings
                                                           7




               Lateral

bust visible anterior ribs above
nting findings are in lateral film. hemi-

etrosternal airspace (right ventricle usually
= 7 then suggestive of hyperinflation
 te increase AP diameter of upper chest - barrel
     Answers / Feedback Section (Click on corresponding button for further informa

                          Radiographic Findings

PA




                               Lateral
                                Bulky pulmonary arteries
                                and descending pulmonary
                               Note enlarged left interlobar
                               artery arching over left main
                                branches.
                               bronchus in lateral film.




     Joint effusion
     Compare medial joint space on left to right
  (Click on corresponding button for further information)

phic Findings

                                       Lateral

                                                            8




 pulmonary arteries
 escending pulmonary
nlarged left interlobar
arching over left main
         Answers / Feedback (Click on corresponding button for feedback)


                   Chest Radiograph in COPD



Important in investigation of complications

 - Assessment during acute exacerbation

     * Consolidation                                10
                                                    9
                                                    6
                                                    8
                                                    7
     * Pneumothorax
                                                Usually occurs in 1
                                                Male : Female 5 : 4
                                                Association5with trau
                                                Avascular necrosis o
                                                Bilateral in
                                                epiphysis of uncertai
 - Remember, smokers have increased risk of bronchogenic carcinoma
orresponding button for feedback)



in COPD
                                                   9



           10
           9
           6
           8
           7

          Association5with : 4
          Usually occurs 5 trauma in range.
          Bilateral in - in 1
          Male : Female 15%.- age 30%.
          Avascular necrosis of8proximal femoral
          epiphysis of uncertain aetiology.
sk of bronchogenic carcinoma
                             Disclaimer




Preceding case is not meant to be a comprehensive overview of a very
important subject, but to show only a small aspect with a practical
radiological slant

As junior doctors you will be looking after many patients with COPD
common, disabling disease with a high mortality and being comfortable wit
its acute assessment and management is highly recommended so please
read up.
                                                 10
ehensive overview of a very
aspect with a practical


any patients with COPD – it is a
ality and being comfortable with
ghly recommended so please




                                   End of Case
Q's       TRUE   FALSE   TScore       FScore
      1   TRUE   FALSE            0            0
      2   TRUE   FALSE            0            1
      3   TRUE   FALSE            0            0
      4   TRUE   FALSE            0            1
      5   TRUE   FALSE            0            0

  6       TRUE   FALSE            0            1
  7       TRUE   FALSE            0            0
  8       TRUE   FALSE            0            1
  9       TRUE   FALSE            0            1
  10      TRUE   FALSE            0            0
                         TScore       FScore
                                  1            2
                                  0            0

                                  0

				
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