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

2. 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 ?

3. 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.

5. Case 1 diagnosis Right lower lobe pneumonia

6. 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

7. 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.

9. Case 2 diagnosis Pneumomediastinum from oesophageal perforation

11. 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

12. 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

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

15. Correctly sited endotracheal tube

16. 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

17. 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.

19. Case 4 diagnosis Tension pneumothorax

20. 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.

21. 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.

23. Case 5 diagnosis Right middle and lower lobe collapse

24. 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.

25. 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.

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

28. 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)

29. 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

30. 1

32. 2

34. 3

36. 4

38. 5

40. 6

42. 7

44. 8

46. 9

48. 10

50. 11

52. 12

54. 13

56. 14

58. 15

60. 16

62. ANSWERS

64. 1 Normal

66. 2 Left lower lobe consolidation/pneumonia

68. 3 Normal right internal jugular- brachiocephalic and left subclavian- brachiocephalic vein catheters

70. 4 Normal

72. 5 Right middle lobe consolidation/pneumonia

74. 6 Left pneumothorax

77. 7 Right upper lobe collapse

79. 8 Normal

81. 9

83. 10 Right midzone consolidation/pneumonia

85. 11 Normal

87. 12 Misplaced NG tube in right main bronchus

89. 13 Normal

91. 14 Left lower lobe collapse

93. 15 Normal

95. 16 Right lower zone consolidation