Picture This.Pdf

Slide 1 ______Picture This: A Clinician’s Guide to Diagnostic Imaging ______

BETSY GAFFNEY M.S.N., CRNP, FNP - BC ______

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Slide 2 ______Considerations

2  Lack of ethical concerns  Cost effectiveness ______ Risk vs. Benefits  Excessive radiographic procedures ______

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Slide 3 ______Patient Stressors

3  Expense  Travel ______ Time including absence from work or school  Outcomes ______

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______Slide 4 ______So how do we decide….

4  Know the limits of the test  Signs and symptoms ______ Risk factors  Pathophysiology  Step 1: Screening tests  Step 2: Secondary tests ______ Remember the individual patient!  Basic decision trees will not work for all patients ______

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Slide 5 ______EXAMPLE

5  35 yo female presents to office c/o “difficulty breathing” and some hemoptysis. ______1. Initial survey:  Onset?  URI symptoms?  Fever? ______2. Check out risk factors:  Recent surgery  Leg, pelvic pain  Immobility ______

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Slide 6 ______Plain Radiograph v. V/Q v. CT w/ Contrast

6 CHEST X-RAY V-Q LUNG SCAN ______ Usually normal  Used most frequently  Hampton’s Hump  Noninvasive  Westermark’s sign  Normal ______ Fleischner’s sign  High probability  Necessary for correct  Low probability V-Q interpretation ______

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______Slide 7 ______Pulmonary C-T w/ Contrast

7  Increasingly replacing V-Q scanning  Positive scan ______ Complete obstruction of a pulmonary vessel  A filling defect within the pulmonary artery  Limitations:  Relatively high false-positive rate ______ Difficulty detecting lesions in the lung periphery ______

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Slide 8 ______

Imaging Modalities ______8

BASIC INFORMATION FOR THE RADIOLOGIC INSECURE ______

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Slide 9 ______Ultrasound

9  High-frequency sound waves capture images in real- time ______ Types: 1. Conventional 1. 3-D 2. 4-D ______2. Doppler 1. Color doppler 2. Power doppler 3. Spectral doppler ______

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______Slide 10 ______USN: Risks vs. Benefits

10 BENEFITS RISKS ______1. Noninvasive  No real risks but this is 2. Widely available a technician dependant modality 3. Less expensive ______4. No ionizing radiation 5. Clear pictures of soft tissues ______

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Slide 11 ______USN: Limitations and Indications

11 Limitations: 1. Disrupted by gas or air ______2. Limited by patient body habitus 3. Doesn’t penetrate bone. Indications: 1. Heart and blood vessels ______2. Internal organs including: 1. Thyroid and parathyroid 2. Liver, pancreas, and gallbladder 3. Kidneys, bladder, uterus, ovaries, scrotum ______3. Guided biopsies

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Slide 12 ______Preferred Approach

12  Endometrium (transvaginal)  Pelvic pain ______ Prostate screening (transrectal)  Testis  Palpable breast mass ______ Parathyroid  Carotid bruit  Peripheral vasular disease; peripheral aneurysm  Renals (secondary HTN etiology) ______

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Slide 15 ______CT Scanning

15  Obtains views from multiple angles giving cross- sectional images of soft tissue and bone. ______ 360 degree beam and computer produced images  Ordered with or without contrast material  Water –soluble contrast media increases contrast resolution.  Can indicate increased or decreased vascularity in an ______abnormal area.

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______Slide 16 ______Computed Tomography

 Role of CT ______ Main further investigation for most CXR abnormality (eg nodule/mass) or to exclude disease with normal CXR ______ Main investigation for certain scenarios (PE, dissection, trauma) ______

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Slide 17 ______Radiation Dose

 Compare dose to normal background radiation (3mSv/year) ______ CXR PA view :3 days  CXR PA Lat :18 days  Low Dose CT :0.5 year ______ HRCT :1 year  Helical CT :2-3 years ______

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Slide 18 ______Use CT for….

1. Sinus studies 2. Abdomen ______3. Detecting loculated fluid collections, abscesses, strangulating obstructions. 4. Chest ______5. Brain

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______Slide 19 ______CT Contrast: How and When

19  4 methods of administration: 1. IV ______2. PO 3. PR 4. Inhalation ______

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Slide 20 ______CT: Risks and Benefits

20 BENEFITS RISKS ______ Painless, noninvasive,  Radiation exposure accurate  Contrast reaction  Fast, simple real time  Relatively high cost images of bones, ______tissues, vessels all at the same time  Diagnostic ______ Cost effective

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Slide 21 ______CT: Limitations and Indications

21  Limitations:  Patient size ______ Pregnancy  MRI superior for some soft tissue details  Indications: ______

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Slide 24 ______MRI

24  Uses a powerful magnetic field, radio pulses, computer ______ Works by inducing transitions between energy states  Certain hydrogen atoms within a powerful static magnetic field absorb energy and transfer that energy when impacted by a specific frequency radio ______pulse.  Computer translates measures of time required to return to relaxation time to visual images. ______

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______Slide 25 ______MRI Images

25  T1-weighted imaging  Bright signal intensity ______ Fat, highly proteinaceous material, subacute hemorrhage, slow- moving blood  On T1 water appears dark and soft tissue has intermediate intensity  T2-weighted imaging ______ Bright signal intensity  Water  Soft tissue, muscle, fat appear dark ______

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Slide 26 ______MRI: Risks and Benefits

26 BENEFITS RISKS ______1. No ionizing radiation  Less effect on 2. Images directly in specificity multiple planes  High cost ______3. Less operator  Claustrophobia dependant than USN  Metal 4. Higher soft tissue contrast resolution ______than CT

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Slide 27 ______MRI: Indications

27  Imaging of choice for CNS  Brain and spinal cord ______ Imaging of choice for musculoskeletal system  Spine and joints  Equivalent to contrast CT for:  Splenic and pancreatic disorders ______ Renal disorders  Lymphadeopathy  Focal hepatic disease ______

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______Slide 28 ______Case Example

28  14-year-old male presents with his father. He is crutch walking and tells you he can’t straighten his ______knee and when he tries to stand his knee “buckles and gives way.”  Hint: he’s a catcher for a baseball team ______ Diagnosis?  Imaging? ______

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Slide 29 ______

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Lateral view: intact patellar tendon Lateral view: ruptured patellar tendon ______

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Slide 30 ______MRI Indications

1. Meniscus tear, cruciate or multi ligament injury with pain and instability evidenced by: ______1. Pivot shift test 2. McMurray’s sign (meniscus injury) 3. Lachman’s sign (ACL) 2. A suspected ligament injury or meniscus tear ______without instability AND non responsive to 4 weeks of PT and conservative therapy 3. Avascular necrosis AFTER standard x-rays 4. Baker’s cyst IF USN is non-diagnostic ______

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Slide 32 ______Case Example

32  19 yo female presents with lower abdominal pain and tenderness and fever. She also relates “pain during ______sex” and vaginal discharge.  Diagnosis?  What imaging modality is preferred as #1? ______

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Slide 33 ______1.

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2. ______

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______Slide 34 ______Case Example

34  36 year old female presents with c/o being “bloated.”  She relates having vague abdominal pressure and ______“gaining weight” over the past 3-4 months. She now “feels run down” and states “I look pregnant.”  Diagnosis? ______ Imaging?

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Slide 36 ______Case Example

36  A neonate is brought in for exam 2 days after hospital discharge. You palpate what feels like an ______abdominal mass during exam.  Suspected origin?  Preferred initial imaging? ______

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______Slide 37 37 ______

Neonatal Obstruction Meconium plug. Film ______done with contrast enema shows colon dilated proximally to the plug. ______

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Slide 38 ______Case Example

38  56 y0 male presents to your office with a diffusely enlarged abdomen. He tells you he has had no ______medical care “since high school” but made this appointment because “ I can’t button my pants and I feel lousy.”  Differential diagnosis? ______ Imaging technique? ______

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Slide 39 39 ______

USN Irregular contour of the ______left lobe

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______Slide 40 40 ______

Cirrhosis ______Ascites (A)

Irregular, atrophic liver

Splenomegaly Increased collaterals ______within the omentum

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Cirrhosis. Taylor, C.R., Yale University School of Medicine

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Slide 41 ______Case example

41  16-year-old male presenting with right lower quadrant pain and fever. ______ + guarding on palpation  Differential diagnosis?  Imaging? ______

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______Slide 43 ______Case Example

43  6-week-old female brought in by mom because of persistent vomiting. She tells you that a previous ______provider told her “not to worry” that she was “feeding to fast and not burping correctly.”  On questioning, vomiting is described as projectile, non-bilious. Baby cries as if hungry “all the time.” ______ Diagnosis?  Imaging? ______

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Slide 44 ______

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Slide 45 ______

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Dahnert W. Radiology Review Manuel, 5th ed.,Lippincott, Williams & Watkins, 45 2003 ______

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______Slide 46 ______Plain Radiography

46  Least expensive choice  #1 order for most musculoskeletal problems ______including:  Gout  OA and RA ______ Neuropathic arthropathy  Hip and pelvic fractures  Stress fractures  Osgood-Schlatter disease ______

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Tibial plateau fx ______

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______Slide 52 ______Chest X-Ray: Basic Interpretation ______52

CAREFUL OBSERVATION AND SYSTEMATIC REVIEW ______

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Slide 53 ______Note the Basics

53  Right patient  Right date ______ Position markers  Upright  Right vs. left ______ Patient position  Technical quality ______

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Slide 54 ______General to Specific

54  Male vs. female  General body habitus ______ Age  Infant  Child  Adult ______ Elderly  Foreign objects  Medical and non-medical ______

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______Slide 55 ______Chest X-Ray: Approach

BE SYSTEMATIC  Bone and Soft Tissue including abdomen ______ Heart  Mediastinum-aorta, trachea  Hila ______ Pulmonary Vasculature  Lungs  Pleura ______

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Slide 56 Chest X-Rays: Know the View ______

 PA (posterior to anterior) and Lateral (left)  Minimizes magnification of heart (heart closest to film)  Portable (nearly always AP) ______ Supine or Erect  Specialized Views  Lordotic  Lateral decubitus (for effusions, pneumothorax) ______

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Slide 57 ______

Normal Anatomy ______

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______Slide 58 ______Comparison

Anatomical Radiographic ______PA View ______

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Slide 59 ______Bone Anatomy

______Sternum

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Slide 60 ______Heart Size

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______Slide 61 Lateral view ______

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Slide 62 62 ______

Frontal: Heart 1 = edge of SV ______2 = RA

3 =Aortic arch

4 = edge, main PA 5 = L atrial appendage ______6 = LV

______http://rad.usuhs.mil/rad/chest_review/index.html

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Slide 63 63 ______

Lateral: Heart 1 = Trachea ______2 = R Ventricle

3 = Left Ventricle

4 = Left Atrium 5 = Right P A ______

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http://rad.usuhs.mil/rad/chest_review/index.html

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______Slide 64 ______Cardiac Anatomy: Right Sided

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Slide 65 ______Cardiac Anatomy: Left Sided

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Slide 66 ______Airway Anatomy

 Trachea  Cartilage ______ Membranous posteriorly  Carina  Bifurcation  Bronchus ______ Left and right  Lobar (RUL,RML,LUL,LLL)  Segmental (8 left, 10 right) ______

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______Slide 67 ______Airway Anatomy

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Slide 68 ______Lung Anatomy

 Lobes are separated by fissures  Right ______ Upper Lobe  Middle Lobe  Lower Lobe  Left ______ Upper Lobe (includes lingula)  Lower Lobe ______

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Slide 74 ______Pleura and Fissures

 Pleura ______ Lubricates and prevents friction during respiration  Potential Space  Parietal pleura  Lines chest wall, mediastinal and diaphragmatic surfaces ______ Visceral pleura  Lines lungs, fissures ______

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Slide 75 ______Pleura

AP LATERAL ______

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Slide 77 ______

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Slide 78 Clavicles ______

Spinous Process ______

Vertebral Body Visible ______6

7 10 ______Counting anterior 11 ribs Counting posterior ribs

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______Slide 79 ______Inspiration/Expiration Images

______ Expiration  Heart size appear larger  Mediastinum is wider  Pulmonary vasculature indistinct ______

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Slide 80 ______

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4th Anterior ______

8th Posterior ______

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Slide 81 ______Comparison Views

EXPIRATION INSPIRATION ______

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______Slide 82 ______Abnormal Cases  Bone  Cardiovascular ______ Airspace Disease including Silhouette Sign  Interstitial Disease and Pulmonary Edema  Atelectasis  Pulmonary Nodule ______ Pleura and Diaphragm  Mediastinal Mass ______

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Slide 83 ______Bone and Soft Tissues

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Slide 84 ______Focus! Soft Tissue and Bones

 Soft tissue ______ Calcifications  Abnormal air (subcutaneous emphysema)  Any obvious mass effect  Bones ______ Size, shape, contour  Mineralization  Fractures or erosions  Lytic or blastic regions ______

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______Slide 85 Concentrate on the bones. ______Alignment Symmetry Density ______

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Soft tissues Subcutaneous emphysema Calcifications Tracheal position, size C-spine: ______Alignment Congenital abnormalities 85 ______

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Slide 86 ______

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Slide 87 Lordotic View ______

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Slide 89 Cardiovascular ______

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Slide 90 Increased Cardiac Size: Cardiac or ______Pericardial

Dilated Cardiomyopathy Pericardial Effusion ______

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______Slide 91 ______Left Ventricular Enlargement

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IVC ______Left Ventricle

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Slide 92 ______

Airspace Disease ______

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Slide 93 ______Airspace Disease

 Filling in of acini (air space)  Air space (acinar) nodules ______ Coalesce to consolidation  Air bronchograms  Silhouette Sign ______

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______Slide 94 ______

Bronchopneumonia ______

Airspace Nodules ______

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Slide 95 ______Air Bronchogram

 Airways ______ Not normally seen in a normal chest radiograph  Aerated lung opacification allows visualization of the bronchi due to surrounding contrast effect ______

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Slide 96 ______

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______Slide 97 Where is the Pneumonia? ______

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Slide 98 ______

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Slide 99 ______Right Lower Lobe Pneumonia

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______Right: Partially seen Left ______

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______Slide 100 ______Left Lower Lobe Pneumonia

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Slide 101 Where is the pneumonia? ______

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Slide 102 ______

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Horizontal (minor fissure) ______Oblique(major) fissure ______

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Slide 104 ______Right Middle Lobe Pneumonia

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Slide 105 ______

Interstitial Disease ______

PULMONARY FIBROSIS PULMONARY EDEMA ______

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Interstitial Disease: Pulmonary Fibrosis

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Slide 107 ______Interstitial Disease

 Reticular  net-like ______ Nodular  Reticulonodular:  Combination of the two patterns ______

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Slide 108 ______Reticular Pattern

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______Reticular Pattern

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Slide 110 ______Pulmonary Edema

 Pleural Effusions/Cardiomegaly  Vascular Redistribution / Enlargement ______ Interstitial Changes  Indistinct pulmonary vasculature  Kerly lines  Fissural Thickening ______ Bronchial Cuffing  Alveolar Edema  Perihilar air space disease  “Batwing” or “butterfly” appearance ______

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Slide 111 ______Normal Bronchus ______

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Slide 114 ______

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Kerly B Lines

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Atelectasis ______

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Slide 117 Left lower lobe collapse ______

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______Slide 118 ______Pulmonary Nodule

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Slide 119 ______Multiple Nodules

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Slide 120 ______Pleura and Diaphragm

 Pleural Effusion  Lateral decubitus>Lateral>PA in sensitivity ______ Pneumothorax  Upright  Deep sulcus sign in supine ______

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______Slide 121 Small Pleural Effusion ______

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Slide 122 Large Pleural Effusion ______

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Slide 123 Lateral Decubitus ______

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Pleural Effusion in Supine Patient ______Effusion layers posteriorly

Diffuse increase in density ______

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Mediastinum: Overview ______

CLASSIFICATION OF MEDIASTINUM MEDIASTINAL MASSES ______

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Slide 128 ______Classification of Mediastinum  Anatomic  Superior: above sternal angle  Anterior ______ Anterior to the heart and great vessels  Middle: heart and pericardium  Contains heart, great vessels, lymph nodes  Posterior ______ Contains descending aorta, esophagus, thoracic duct, lymph nodes ______

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Slide 129 ______

1 ______

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______Slide 130 ______Anterior Mediastinal Mass

 The 4 T’s  Thyroid ______ Thymus (Thymoma)  Teratoma  Tumor (Lymphoma ) ______

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Slide 131 ______

Thyroid Goiter Most common superior ______mediastinal mass extending to thoracic inlet ______

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Slide 132 ______

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Slide 134 ______Hiatus hernia

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Slide 135 ______Lymphadenopathy

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______Slide 136 ______Lymphadenopathy

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Slide 137 ______

Cases ______

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Slide 138 ______

? ______

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______Slide 139 ______59 year old female w/ s.o.b

PATIENT NORMAL ______

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Slide 141 ______

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______Slide 142 ? ______40 year old female w/ fever, cough

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Slide 143 ______

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Slide 144 ______

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______Post Chest Tube Insertion Large Pleural Effusion

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Slide 146 ______Atelectasis ETT Pulled Back

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Slide 147 ______THANKS FOR LISTENING… HEADACHE ______

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______Slide 148 ______THE END

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