Notes

X-Ray OSPE
Answer to the Question No. 01
a. Findings:
Chest X-ray PA view showing:
i. Dense homogeneous opacity occupying lower and mid zones of the lung field with concave upper margin/curvilinear line
ii. Blunt costophrenic and cardiophrenic angles
iii. Trachea shifted to opposite side
iv. Heart slightly shifted to opposite side
So, my diagnosis is Massive unilateral pleural effusion

b. Common causes:
i. Pneumonia causing para-pneumonic effusion
ii. TB
iii. Bronchial carcinoma
iv. Lymphoma
v. Connective tissue disorder: eg. SLE, RA
vi. Liver abscess
vii. Pulmonary infarction
viii. Pancreatitis

Clinical Features:
Symptoms:
i. Chest pain or heaviness of the affected side
ii. Respiratory difficulty
iii. Fever, Cough, Haemoptysis
Signs:
i. On inspection:
- Restricted chest movement in affected side
ii. On palpation:
- Trachea and apex beat are shifted to opposite side
- Vocal fremitus is reduced or absent in affected side
iii. On percussion:
- Stony dull in affected side
iv. On auscultation:
- Breath sound diminished or absent in affected side
- Vocal resonance diminishes or absent in affected side

c. Treatment:
i. Therapeutic aspiration: not more than 1.5 L at a time
ii. Treatment of underlying causes.

Complications:
i. Lung scarring
ii. Pneumothorax
iii. Empyema
iv. Sepsis

Answer to the Question No. 02
a. This is X-ray chest P/A view showing :
* low flat diaphragm
* widening of intercostal space
* tubular heart shadow
* hypertranslucency of lung field
So radiological diagnosis is 'chronic obstructive pulmonary disease'

B. Common causes of COPD:
Exposure to:
-Smoking (the most common)—active or passive
-Indoor and outdoor air pollution
-Occupation exposure to dust, fumes, smokes, chemicals, etc. (e.g. coal miners and those who work with cadmium)
-Urban dweller
-Low socioeconomic status
-Low birth weight
-Poor lung growth which may be due to childhood infections or maternal smoking Infections recurrent lung infection, persistent adenovirus in lung tissue, HIV infection is
associated with emphysema.
-Cannabis smoking
Host factors:
-Genetic factors-a antitrypsin deficiency
-Airway hyperreactivity
-More in male and Caucasians
-Biofuel mass.

Clinical features:
*Usually the patient is above 40 years, male and smoker.
There is:
*Chronic cough and sputum production, which is progressively increasing.
*Progressively increasing breathlessness. *There may be hemoptysis, edema and morning headache (due to hypercapnia).
*Muscular weakness, peripheral edema due to impaired salt and water excretion, weight loss due to altered fat metabolism, increased osteoporosis, increased circulating inflammatory markers.

c. Treatment :
1. Smoking must be stopped.
2. Avoidance of dust, fume, smoke etc
3. Drug therapy according to the stage:
★Mild:
*Avold of risk factors, influenza vaccination. *Short acting inhaled bronchodilator : (salbutamol, terbutaline) or anticholinergic (ipratropium) when needed.
★ Moderate :
*Above treatment plus:
*Regular treatment with one or more long acting bronchodilator like B2 agonist (eg. salmeterol, formeterol) or anticholinergic (tiotropium) when needed.
* Rehabilitation
★ Severe :
*Above treatment plus
*Inhaled steroid (fluticasone)
★ Very severe :
*Above treatment plus:
*Long-term oxygen, if chronic respiratory failure.
*Surgical treatment, if needed
4. Other therapy:
*Oxygen, if needed
*Mucolytic (acetylcysteine)
*Antibiotic (if infection)
*Diuretic (if edema)
*Pulmonary rehabilitation
*Pneumococcal vaccination.
*Reduction of obesity.
5. Surgical intervention:
•Bullectomy: If young patient, large bullae compressing surrounding lung tissue, no generalized emphysema
•Lung volume reduction surgery (LVRS): Predominant upper lobe emphysema, preserved gas transfer, no evidence of pulmonary hypertension.
•Lung transplantation.

Complications :
* Pulmonary hypertension
* Cor pulmonale
* Respiratory failure
* Secondary infection
* Polycythemia

Answer to the Question No. 03
a. Findings:
Chest X-ray P/A view showing:
i. Large area of consolidation in the middle lobe
ii. Volume loss of the affected side
iii. Cavitation of the consolidated area
So my Diagnosis is lung consolidation most probably Pneumonia .


b. Common causes:
i. Bacterial causes:
-Streptococcus pneumoniae
-Mycoplasma pneumoniae
-Chlamydia pneumoniae
-Haemophylous influenzae etc
ii. Viral causes:
-Influenza, Parainfluenza
-Coronavirus
-Measles
-Herpes simplex
-Varicella
-Adenovirus etc

Clinical features:
Symptoms:
i. Fever
ii. Cough
iii. Rusty sputum
iv. Chest pain
v. Haemoptysis
Signs:
i. General findings:
-Toxic look
-Raised temperature
-Increased respiratory rate
-Tachycardia
ii. Respiratory System Findings:

On inspection:
-Increased Respiratory rate
-Central cyanosis
On palpation:
-Reduced chest expansion on opposite side
-Increased vocal fremitus
-Raised temperature
On Percussion:
-Dull over affected area
On auscultation:
-Bronchial breath sound
-Increased vocal resonance over affected area
-Pleural rub

c. Treatment:
i. Amoxicillin 500 mg 8 hourly oral
ii. If allergic to penicillin then Clarithromycin 500 mg 12 hourly oral
iii. If Staph suspected
Flucoxacillin 1-2 gm 6 hourly IV+Clarithromycin 500 mg 12 hourly IV
iv. If Mycoplasma suspected: Erythromycin 500mg 6 hourly oral or iv+Rifampin 600mg 12 hourly iv

Complications:
i. Para pneumonic effusion
ii. Empyema
iii. Retention of sputum causing lobar collapse
iv. DVT and pulmonary embolism
v. ARDS, renal failure
vi. Suppurative pneumonia
vii. Pneumothorax
viii. Pyrexia


Answer to the Question No. 04
Diagnostic feature :
It is a chest x-ray PA view showing a cavity with air - fluid level in the right upper and part of the mid – zone.
So, my diagnosis is right sided lung abscess

Causes of lung abscess :
1. Aspiration of infected material - Vomiting, anaesthesia, tooth extraction, tonsillectomy and nasal operation, unconscious patient (CVA), alchoholism, achalasia cardia, reflux oesophagitis and neurological problem.
2. Specific Infection – Streptococcus pneumonia type 3, Staphylococcus aureus, Klebsiella pneumonia and fungal infection. In HIV. Pneumocystitis carinii, Cryptococcus neoformans and Rhodococcus equi.
3. Bronchial Obstruction – by foreign body, enlatrged lymph node, bronchial carcinoma and adenoma.
4. Infection in pulmonmary infarction – by Streptococcus pneumonia, Staphylococcus aureus and Hemophilus influenza.
5. Local spread from liver abscess, subphrenic abscess – due to transdiaphragmatic spread.
6. Hematogenous from other sites of infection of septic emboli from pelvic abscess, salpingitis, appenditis, pyemia or septicemia.

Treatment :
A: Sputum is sent for C/S and broad spectrum antibiotic should be started.
Amoxicillin or co-amoxiclav or erythromycin plus metronidazole or cefuroxime 1gm IV 6 hourly plus metronidazole 500 mg IV 8 hourly for 5 days, followed by cefaclor plus metronidazole. If the condition improves. continue as above. If no response, antibiotic is given according to culture and sen sitivity. Treatment to be continued for 4-6 weeks. If no response to medical therapy (occurs in 1-10% cases), percutaneous aspiration (USG or CT guided) is done. Sometimes surgery (lobectomy) may also be done.
Postural drainage and chest physiotherapy.
Treatment of primary cause.

Complications:
Pleurisy.
Empyema.
Bronchiectasis.
Cerebral abscess.
Amyloidosis (rare, seen in chronic cases).

Answer to the Question No. 05
CXR PA view showing multiple miliary mottling involving all zones of both lung fields.
So my diagnosis is Miliary Tuberculosis.

Causes :
1. M. tuberculosis
2. Atypical mycobacteria

Clinical Feature:
1.Fever,drenching night sweat,weight loss
2. PUO
3.Hepatosplenomegaly
4. Headache,drowsiness,confusion

Complications :
1.Tubercular meningitis
2. Addisonian crisis

Treatment :
1.Anti TB drugs
First 4 months 4 FDCs
Next 4 month 2FDC (rifampicin and isoniazide)
Ist localized lymphnode is involved excision is better.


Answer to the Question No. 06
a. Chest Xray P/A view showing flask-shaped, enlarged cardiomegaly, cardiac silhouette present.
So my diagnosis is Pericarditis with Pericardial effusion.

b. Causes of pericarditis:
1) Viral infection: e.g. Coxsackie B, echo virus.
2) Tuberculosis.
3) Connective tissue disease e.g. SLE, RA.
4) Malignancy: Metastasis from lung cancer, lymphoma.
5) Uraemia.
6) Acute MI.
7) Trauma.
8)Acute rheumatic fever.
9) Hypothyroidism
10) Sarcoidosis.
11) Drug-induced: e.g., procainamide, hydralazine, phenytoin, isoniazid
methysergide.
12) Radiotherapy

C/F:
Symptoms :
1) fever
2) chest pain
3) breathlessness
4) palpitation
Sign :
1) Rapid or irregular pulse
2) Coarse Pericardial friction rub

c. Treatment:
1) The pain is usually relieved by aspirin (600 mg 4-hourly), but a more potent anti-inflammatory agent such as Indomethacin (25 mg 8-hourly) may be required.
2) Corticosteroids may suppress symptoms but there is no evidence that they accelerate cure.
3) In viral pericarditis, recovery usually occurs within a few days or weeks, but there may be
recurrences (chronic relapsing pericarditis).
4) Purulent pericarditis requires treatment with antimicrobial therapy, paracentesis and, if necessary,
surgical drainage.
5) Ultrasound-guided pericardiocentesis, a safe and effective procedure to remove excess fluid from the pericardium. This is most common followed by fluoroscopy for Pericardial effusion.
6) Diuretics therapy for PE.

Complication:
1) Cardiac temponade
2) chronic constrictive pericarditis
3) Recurrence pericarditis


Answer to the Question No. 07
a. CXR PA view showing heart is enlarged in transverse diameter with straightnening of left heart border, fullness of pulmonary conus and double right heart border
So, my diagnosis is Mitral Stenosis

b. Common Cause :
Chronic Rheumatic heart disease [Commonest cause]
In 50% cases there may be rheumatic fever and rheumatic chorea

Clinical Features
Pulse – normal, low volume, normal in rhythm and character, no radio-radial or radio-femoral delay.
JVP – normal
BP – low
On inspection –
Visible cardiac impulse in mitral area
On palpation –
Apex beat – tapping in nature
Thrill – present in yhe apical area
On auscultation –
1st heart sound – loud in all area
2nd heart sound – normal but in Pulmonary HTN P2 is loud
Mid Diastolic murmur – in mitral area, low pitched localized, rough, rambling, best heard with stethoscope bell, in lateral position with breathing hold after expiration. It may be associated with presystolic accentuation which is absent in AF.

c. Treatment :
1. Restrictive activity
2. anticoagulant to reduce the risk of embolism
3. if AF – digoxin, beta blocker, rate limiting calcium antagonist e.g verapamil, diltiazem
4. if CCF – diuretics, digoxin
5.infective endocarditis is very rare here. Routine prophylaxis with antibiotic is not recommended.

Complications :
1. Atrial Fibrilation
2. Pulmonary oedema
3. PH LEADING TO CCF
4. Pulmonary infarction
5. Systemic embolysm
6. Haemoptysis
7. Ortner’s syndrome
8. Dysphagia due to enlarged left atrium


Answer to the Question No. 08
CXR PA view showing:
🔸heart is enlarged in transverse diameter
🔸Fullness of pulmonary conus
🔸straight left heart border
🔸double contour of right heart border
🔸 Fluffy or woolly opacities. spreading from both hilar region, giving butterfly or bat's wing appearance, relatively less in periphery.
Diagnosis: Mitral Stenosis with MR (predominan) with Pulmonary oedema.

Cause:
🔸Chronic Rheumatic Heart disease
🔸mitral valve prolapse
🔸 papillary muscle dysfunction
🔸 Rupture of chordae tendinae
🔸RA,SLE

Clinical features:
symptoms:
🔸 Dyspnoea
🔸 Palpitation
🔸 Weakness, Fatigue
🔸 Swollen feet and ankles

Signs:
On examination:
• Pulse: normal in rate, volume, rhythm and character.
• JVP: Normal.
• BP: normal usually

On inspection:
• Visible cardiac impulse in mitral area.
On palpation:
• Apex beat is diffuse, thrusting in character.
Systolic thrill maybe present
On auscultation:
• First heart sound: Soft in mitral area, normal in other areas.
• Second heart sound normal
(third heart sound: may be present)
• There is a PSM present in mitral area , which radiates to the left axilla (PSM is reduced on inspiration and more in expiration)
MDM may also be present

Treatment:
Mild to moderate case
- symptomatic rx👉 diuretic,vasodilators (ACEI), follow up every 6 months by echocardiogram
Severe case
Valve replacement required.
Complications:
🔸acute LVF
🔸CCF
🔸AF
🔸infective endocarditis
🔸systemic embolism

Answer to the Question No. 9
a. CXR PA view showing hypertranslucency with collapsed lung margin on the right side
So, my diagnosis is right sided Pneumothorax.

b. Common causes –
1. Spontaneous –
Primary
i. Rupture of apical subpleural bleb due to congenital defect in connective tissues of alveolar walls
ii. Rupture of emphysematous bullae or pulmonary end of pleural adhesion
Secondary
Due to pre existing lung disease Causes are:
i. Commonly COPD and tuberculosis
Others: Lung abscess, acute severe asthma, bronchial carcinoma, pulmunary infection, fibrotic and cystic lung disease, Marfan syndrome. Ehlers-Danton syndrome and eosinophilic granuloma
2. Traumatic
i. Iatrogenic - aspiration of pleural fluid, thoracic surgery, Iung biopsy or plural biopsy,
positive pressure ventilation thoracocentesis and subclavian vein catheterization
ii. Chest wall injury

Clinical Feature
On inspection
i. Restricted movement
ii. intercostal spaces may appear full
On palpation:
1. Trachea and apex beat – shifted to the left
2. Vocal fremitus reduced in right side, normal in left side
3. Chest expansion reduced on the right side
On percussion: Hyperresonance in right side but normal in left side
On auscultation
Breath sound diminished or absent in right side but vesicular in left side
Vocal resonance diminished or absent in right side but normal in left side

c. Treatment
Depending on whether it is primary or secondary, open, closed or tension or presence of symptoms.
1. in primary pneumothorax – in small, closed pneumothorax without significant breathlessness – observation of the case. The patient may be dischareged with early out patient riview. Advice the patient to return if there is breathlessness.
2. in secondary pneumothorax –
i. all patient should be hospitalized for observation
ii. in small or isolated apical pneumothorax in asymptomatic patient, observation
iii. if age is less than 50 then asymptomatic or small pneumothorax – simple aspiration. If successful, 24 hr observation prior to discharge. If unsuccessful intercoastal drain tube should be inserted.
iv. if age is greatefr than 50 years then symptomatic or large pneumlothorax, intercoastal drainage tube should be inserted.

3. open pneumothorax - surgery
4. tension pneumpothorax –
i. stop smoking
ii. avoid air travel for weeks
iii. diving should be permanently avoided

Complications :
Respiratory failure
Shock
Recurrent pneumothorax


Answer to the Question No. 10
a. Diagnostic features :
This is the chest x-ray PA view showing -
Homogenous opacity involving the right hemithorax with shifting of trachea to the right side
Right dome of diaphragm, right Costophrenic & cardiophrenic angle
Left lung field shows compensatory hypertranslucency.
So, my diagnosis is collapse of whole right lung.
b. Causes :
Bronchial obstruction due to any cause namely
*Bronchial carcinoma
* Bronchial adenoma
* Foreign body
* Mucus plug
*pressure on bronchus from outside ( enlarged lymph node)

Clinical features :
* Difficulty in breathing
* Rapid & shallow breathing
* Wheezing
* Cough
c. Treatment :
1) Oxygen inhalation.
2) Management of shock.
3)Percutaneous needle aspiration:
*Immediate aspiration is done in the 2nd intercostal space anteriorly in the mid-clavicular line using a wide bore needle (16 F canula).
*Discontinue if resistance is felt, the patient coughs excessively, or > 2.5 litres of air are
removed.
4) Water-sealed intercostal drainage: In the 4h, 5th or 6h intercostal space in the mid-axillary line.
5)Treatment of the underlying cause.

Complications :
• Acute pneumonia
• Bronchiectasis
• Hypoxemia and respiratory failure
• Postobstructive drowning of the lung
• Sepsis
• Pleural effusion and empyema