Clinical cases A chance to apply some of your new knowledge to real clinical scenarios

Case 1 A 60 year old non-smoking woman complained of cough, dyspnoea and right sided pleuritic chest pain for 3 days. She was pyrexial (39.3 C) and a pleural rub was audible at the right lung base. Her white cell count was raised. What are the notable observations ?

Case 1 A 60 year old non-smoking woman complained of cough, dyspnoea and right sided pleuritic chest pain for 3 days. She was pyrexial (39.3 C) and a pleural rub was audible at the right lung base. Her white cell count was raised.

Case 1 diagnosis Right lower lobe pneumonia

Case 2 This 25 year old woman, visiting Scotland on a hen weekend, was admitted with central chest pain which began during an episode of vomiting. She complained that her neck had become swollen. On examination he had a tachycardia and mild pyrexia (38.1 C). Palpation of her neck and chest wall gave rise to a ‘crackling’ sensation

Case 2 This 25 year old woman, visiting Scotland on a hen weekend, was admitted with central chest pain which began during an episode of vomiting. She complained that her neck had become swollen. On examination he had a tachycardia and mild pyrexia (38.1 C). Palpation of her neck and chest wall gave rise to a ‘crackling’ sensation.

Case 2 diagnosis Pneumomediastinum from oesophageal perforation

Case 3 This 55 year old man collapsed whilst out shopping with his wife. The paramedics noted his breathing to be laboured and intubated him at the scene. This CXR was obtained on admission to hospital

Case 3 This 55 year old man collapsed whilst out shopping with his wife. The paramedics noted his breathing to be laboured and intubated him at the scene. This CXR was obtained on admission to hospital

Case 3 diagnosis Endotracheal tube inserted too far into right main bronchus.

Correctly sited endotracheal tube

Case 4 This 22 year old woman complained of sudden onset right sided chest pain, followed by progressive dyspnoea. By admission, she was in distress and appeared cyanosed. Her pulse was 140, with respiratory rate 40. On chest auscultation, breath sounds were noted to be quiet, especially on the right

Case 4 This 22 year old woman complained of sudden onset right sided chest pain, followed by progressive dyspnoea. By admission, she was in distress and appeared cyanosed. Her pulse was 140, with respiratory rate 40. On chest auscultation, breath sounds were noted to be quiet, especially on the right.

Case 4 diagnosis Tension pneumothorax

Case 5 This 67 year old man, a lifelong smoker, complained of several weeks of reduced exercise tolerance due to dyspnoea. He had a chronic cough productive of white sputum but recently it had been blood stained. He had lost 10kg in weight.

Case 5 This 67 year old man, a lifelong smoker, complained of several weeks of reduced exercise tolerance due to dyspnoea. He had a chronic cough productive of white sputum but recently it had been blood stained. He had lost 10kg in weight.

Case 5 diagnosis Right middle and lower lobe collapse

Case 6 This 68 year old man was admitted with a myocardial infarct 5 days ago. He became acutely breathless at 3am. On examination he was sitting up in bed and sweating. His respiratory rate was 40 and pulse 130. His chest was dull to percussion at the bases and crackles were heard there on auscultation.

Case 6 This 68 year old man was admitted with a myocardial infarct 5 days ago. He became acutely breathless at 3am. On examination he was sitting up in bed and sweating. His respiratory rate was 40 and pulse 130. His chest was dull to percussion at the bases and crackles were heard there on auscultation.

Case 6 diagnosis Acute pulmonary oedema due to congestive cardiac failure.

QUIZ TIME Is this CXR normal or abnormal ? (correct answer = 1 point) If you think it is abnormal, what is the diagnosis ? (correct answer = 1 bonus point)

QUIZ TIME This is a chance to see if you’ve acquired any CXR interpretation skills 8 normal CXR (correctly sited lines = normal) 8 abnormal CXR maximum score = 24 points additional points may be given for entertaining incorrect answers, at the discretion of the moderator

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ANSWERS

1 Normal

2 Left lower lobe consolidation/pneumonia

3 Normal right internal jugular- brachiocephalic and left subclavian- brachiocephalic vein catheters

4 Normal

5 Right middle lobe consolidation/pneumonia

6 Left pneumothorax

7 Right upper lobe collapse

8 Normal

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10 Right midzone consolidation/pneumonia

11 Normal

12 Misplaced NG tube in right main bronchus

13 Normal

14 Left lower lobe collapse

15 Normal

16 Right lower zone consolidation