Case Study #1 CAPA 2011 Christy Wilson PA C 46 yo female presents with community acquired PNA (CAP). Her condition worsened and she was transferred to the ICU and placed on mechanical ventilation. Describe her CXR What is your differential diagnosis? Case Study #1 cont Describe the CXR Bilateral diffuse alveolar infiltrates ET tube placed No cardiomegaly seen No pleural effusions seen Differential Diagnosis ARDS Pulmonary Edema/Flash Pulmonary Edema Diffuse Alveolar Hemorrhage Decompensated CHF Case Study #2 LH is 78 yowf with PMHx of metz breast CA presents to ER with worsening SOB Initial CXR Describe the CXR What is your differential diagnosis? What is your next step? 1
Describe the CXR: Blunting of the right costophrenic angle c/w large pleural effusion Differential Diagnosis: Volume overload, malignant effusion, empyema, parapneumonic effusion Next Step: Decubitus CXR Bilateral Decubitus CXR Is the fluid loculated or layering? Approximately how much fluid is present (in cm)? What is the most logical next step for diagnosis and treatment? 1. Watch the fluid with serial CXR 2. Diuresis with Lasix 3. Ultrasound guided Thorocentesis 4. Chest tube with suction Is the fluid loculated or layering? Layering Approximately how much fluid is present (in cm)? 5 cm What is the most logical next step for diagnosis and treatment? 1. Watch the fluid with serial CXR 2. Diuresis with Lasix 3. Ultrasound guided Thorocentesis 4. Chest tube with suction What is the most likely cause of the pleural effusion? 1. Malignancy 2. Infection 3. Volume overload 4. Parapneumonic effusion 2
What is the most likely cause of the pleural effusion? 1. Malignancy 2. Infection 3. Volume overload 4. Parapneumonic effusion Cytology from the pleural effusion showed atypical cells consistent with metastatic adenocarcinoma. Within 3 days patient s pleural effusion returned. What is the most appropriate long term treatment for a recurrent pleural effusion? 1. Serial CXRs but no invasive procedures 2. Repeat thorocentesis 3. VATS pleuradesis 4. Chest tube placement Cytology from the pleural effusion showed atypical cells consistent with metastatic adenocarcinoma. Within 3 days patient s pleural effusion returned. What is the most appropriate long term treatment for a recurrent pleural effusion? 1. Serial CXRs but no invasive procedures 2. Repeat thorocentesis 3. VATS pleuradesis 4. Chest tube placement Case Study #3 DK is a 51 yowf who presents with atypical CP and dry cough. Unremarkable PMHx Initial CXR Describe this CXR 3
Case Study #3 cont After reviewing the CXR, the most likely cause of the patient s symptoms are: 1. Pneumonia 2. Esophageal dilatation 3. Decompensated CHF 4. Pneumothorax Case Study #3 cont After reviewing the CXR, the most likely cause of the patient s symptoms are: 1. Pneumonia 2. Esophageal dilataion 3. Decompensated CHF 4. Pneumothorax Case Study #3 cont Patient was seen by a GI specialist, underwent an EGD and was found to have extensive esophageal candidiasis. Case Study #4 Patient is a 67 yo female with chronic SOB presents to the ED with worsening dyspnea and productive cough. Patient had bilateral crackles and clubbing on PE VS: HR 102 BP 134/78 R 22 Pulse ox 84% on RA (room air) Describe the CXR What is your differential diagnosis? 4
Case Study #4 cont Describe the CRX: Diffuse interstitial infiltrates Ground glass opacities bilaterally Blunting of the left costophrenic angle consistent with a small pleural effusion Heart size is within normal limits Differential Diagnosis: Interstitial Lung Disease Congestive Heart Failure TB Occupational Lung Disease Sarcoidosis Case Study #5 85 yo female presents to the ED with sudden onset right sided chest pain and SOB Describe the initial CXR: What is the most likely cause of the finding on CXR? Case Study #5 cont Describe the initial CXR: Right Apical pneumothorax measuring approx. 2 cm Right basilar atelectasis Pacemaker present L chest Look at the other 2 CXRs Describe any changes... Case Study #5 cont Describe the second and third CXRs CXR # 2 Persistent small right apical PTX (pneumothorax) New small right pleural effusion CXR 3 # Persistent small right apical PTX Blunting of both costophrenic angles consistent with pleural effusions RLL atelectasis 5
Case Study #5 cont What would be your next step for treating a persistent pneumothorax? Case Study #6 Patient is a 57 yo male who recently underwent major surgery. Consider chest tube placement d/t persistent PTX Consider pleuradesis What type of surgery has the patient undergone? What appliances (foreign bodies) do you see on the CXR? Case Study # 6 cont Review the CXR: What type of surgery has the patient undergone? Left pneumonectomy Case Study #6 cont After reviewing the CXR, what is your differential diagnosis if you did not know the patient s surgical history? What appliances (foreign bodies) do you see on the CXR? Tracheostomy EKG wires Staples on the left side Massive Left sided pleural effusion Compressive atelectasis of the left lung Mucus plugging causing atelectasis of the left lung 6
Case Study #7 Patient is a 63 yo female with PMHx of COPD presents to the clinic with worsening SOB and productive cough. Patient smokes 1 ½ ppd x 45 years. Here is her initial CXR: Differential Diagnosis: Case Study #7 Differential Diagnosis: Community Acquired Pneumonia Atelectasis Fungal pneumonia BOOP(bronchiolitis obliterans organizing PNA)/ COP (cryptogenic organizing PNA) Malignancy COPD Acute Exacerbation MAC (mycobacterium avium complex)/ MAI TB Case Study #7 cont Patient was placed on PO antibiotics to cover community acquired pneumonia Her s/sx didn t improve on the antibiotics and she represented to the clinic and had a follow up CXR. Describe the follow up CXR: Case Study #7 cont After reviewing the follow up CXR, what is your next step in diagnosis and treatment? CT scan chest Bronchoscopy with TBBX (transbronchial biopsies) The bronchoscopy /TBBX showed Organizing pneumonia, no malignant cells present 7
Case Study #7 cont Patient was diagnosed with BOOP (bronchiolitis obliterans organizing pneumonia) or COP (cryptogenic organizing pneumonia) Treatment: long term oral corticosteroids and serial CXRs to make sure the infiltrates improve Prognosis: good Case Study #8 Patient is a 85 yo female with PMHx of breast cancer 10 years ago and A. Fib. who presents to the clinic with increasing SOB and non productive cough She denies any Fever, Chills, N/V/D but states it is harder to sleep at night, and she is now sleeping in her recliner in the living room VS: HR 92, BP 110/65, afebrile, pulse ox 84% on RA, RR 22 Labs: CBC and BMP WNL, BNP 395, INR 2.3 Please describe her CXR: look closely at both the PA and lateral view Case Study #8 cont What is your differential diagnosis? The CXR shows left greater than right pleural effusions What is your next step to further eval these effusions? Case Study #8 cont What is your differential diagnosis? Pulmonary edema/ decomp CHF Pleural effusions Infection/Pneumonia PE The CXR shows left greater than right pleural effusions What is your next step to further eval these effusions? Order B/L decubitus films to determine if the effusions are loculated or layering and to further determine the size of the effusions 8
Case Study #8 cont Patient underwent B/L decub films Review the Decub CXR and describe: All of the following would be an appropriate next step in diagnosis and treatment of the patient except: 1. Admit to the hospital for monitoring and repeat CXR 2. Echocardiogram and EKG 3. Bedside thorocentesis 4. Diuresis with Lasix 5. Supplemental Oxygen Case Study #8 cont All of the following would be an appropriate next step in diagnosis and treatment of the patient except: 1. Admit to the hospital for monitoring and repeat CXR 2. Echocardiogram and EKG 3. Bedside thorocentesis Would not do a procedure on a patient with an INR of 2.3 unless it is emergent, instead would hold anticoagulation and watch, consider procedure once INR is lower 4. Diuresis with Lasix 5. Supplemental Oxygen Case Study #9 AB is a 32 yowm who presents to the ER with worsening SOB, fevers and hypoxemia. Describe the initial CXR What is your differential diagnosis? Empyema Community Acquired PNA Pulmonary Abscess Acute Lung Injury/ Sepsis Case Study #9 cont After seeing this CXR, all of the following are correct in the diagnosis/treatment of this patient except: 1. Admit and place on broad spectrum antibiotics 2. CT scan chest 3. Discharge home on PO antibiotics 4. Ultrasound guided thorocentesis 9
Case Study #9 cont After seeing this CXR, all of the following are correct in the diagnosis/treatment of this patient except: 1. Admit and place on broad spectrum antibiotics 2. CT scan chest 3. Discharge home on PO antibiotics 4. Ultrasound guided thorocentesis Case Study #9 cont Patient was admitted to the hospital, placed on broad spectrum antibiotics. A right sided ultrasound guided thorocentesis was attempted but unable to be completed d/t loculated fluid. Thoracic surgery was consulted. Patient s condition worsened and here is a follow up CXR Describe the CXR Case Study #9 cont After describing the CXR, what is the most likely diagnosis? 1. empyema 2. decompensated CHF 3. pulmonary contusion 4. flash pulmonary edema Case Study #9 cont After describing the CXR, what is the most likely diagnosis? 1. empyema 2. decompensated CHF 3. pulmonary contusion 4. flash pulmonary edema 10
Case Study #9 cont Patient developed respiratory failure and was placed on mechanical ventilation d/t severe sepsis from a right sided empyema. The patient underwent VATS decortication Here is the post op CXR: Please describe: Case #10 WB is a 53yo male with PMHx of COPD who presents to the ED with sudden onset shortness of breath and chest pain Differential Diagnosis: COPD A/E Spontaneous PTX Pneumonia Pulmonary Edema PE Acute MI What does his chest x ray show? Case Study #10 cont After reviewing the CXR, what is the correct treatment? 1. Diuresis 2. Broad spectrum antibiotics 3. Anticoagulation 4. Chest tube placement 5. Heart Cath Case Study #10 cont After reviewing the CXR, what is the correct treatment? 1. Diuresis 2. Broad spectrum antibiotics 3. Anticoagulation 4. Chest tube placement 5. Heart Cath 11
Case Study #10 cont Here is the follow up CXR: Please describe: Case Study #10 cont The next step would be pleuradesis. If the PTX does not resolve once the chest tube is clamped, what is the next step for treatment? Questions? Thank You Christy.p.wilson@gmail.com 12