Anwser,s 10

Wednesday, April 12, 2023

Anwser,sDr :ANAS SAHLE

1. Chest xr cases.2. Chest clinical case.

3. Chest ct cases.4. Collicum exam.

:http://www.facebook.com/dranas224

chest xr casesDr :anas sahle

http://www.facebook.com/dranas224

CXR-46

DDX :LymphomaSarcoidosis

CXR-47

Sign name is: Cannon Balls - Lung Metastasis

CXR-48

Diagnosis is : Cavitating Metastasis

CXR-49

this patient had Cancer Thyroid

Solitary pulmonary metastasis

CXR-50

Old film Diagnosis is: Lymphangitic Metastasis

Lymphangitic Metastasis Cancer Breast

•Missing right breast•Bilateral diffuse interstitial changes

CXR-51

Left Hilar and Mediastinal RadiationDiagnosis is: Radiation Pneumonitis

Bilateral Air space disease Vertical (non-segmental)

Corresponding to radiation port

CXR-52

Diagnosis is: Sarcoidosis Alveolar form

Bilateral symmetrical hilar nodes


chest clinical casesA Case of Recurrent

PneumothoracesSubmitted byJ. Shaun Smith, DOFellowPulmonary and Critical Care MedicineThe Ohio State UniversityColumbus, OhioJames N. Allen, MDProfessor of MedicineThe Ohio State UniversityColumbus, Ohio


History • A 41-year-old female presents to pulmonary outpatient clinic with a history of right-sided

pneumothorax, which had resolved. • She gives a history of several spontaneous pneumothoraces on her right side over the past 6

years.• She provides a past medical history of endometriosis and is being treated symptomatically with

occasional over-the-counter medications. • She also has a history of right-sided pleural procedure after the second pneumothorax. • However, despite this surgical intervention, she continues to have recurrence of the

pneumothorax. • Of note each pneumothorax resolved without intervention or complication.• Pulmonary function testing (PFT) was performed demonstrating a FEV1 of 86% predicted, total

lung capacity (TLC) of 112 % predicted and diffusion capacity of 93 % predicted. • There was no significant response to bronchodilator challenge. • Her remaining past medical history is significant for chronic low back pain from an L4-5 disc

herniation, now status-post discectomy, chronic knee pain from osteoarthritis, and arthroscopic anterior cruciate ligament surgery.

• Her only medications are nonprescription anti-inflammatories and a multivitamin. • She has never used tobacco or recreational drugs. • Family history is unremarkable.


cxr


Ct


Question 1• What is the most likely diagnosis?• A. Catamenial Pneumothorax• B. Lymphangioleiomyomatosis • C. Congenital bullous disease • D. Marfan’s syndrome


Question 2• Which of the following is NOT associated

with thoracic endometriosis?• A. Hemoptysis • B. Neck pain • C. Pulmonary nodules • D. Transudative effusion


discussion• Thoracic endometriosis, which is most likely cause of catamenial

pneumothorax, can present in various other forms. • Pneumothorax is the most common presentation (73%) followed by

hemothorax (14%), hemoptysis (7%), and lung nodules (6%) (6). • Interestingly, hemothorax correlated most with the presence of either pleural

or pelvic endometriosis.• Hemoptysis is caused by endobronchial or parenchymal ectopic endometrial

tissue. • During bronchoscopy, the lesions appear as purplish-red patches which bleed

easily on contact. • Cytology will show clusters of small cuboidal cells characteristic of endometrial

tissue .• Pain is also quite common, and is often due to diaphragmatic endometrial

implants. • Discomfort may be referred to the ipsilateral neck, shoulder, chest or arm.


Question 3• What is the proposed mechanism for

catamenial pneumothorax?• A. Congenital diaphragmatic fenestrations • B. Acquired diaphragmatic fenestrations from

endometrial implants • C. Metastatic spread of endometrial tissue • D. Release of dinoprost tromethamine during

menstruation • E. All of the above


discussion• The mechanism for catamenial pneumothorax is unclear. • Four possible mechanisms have been proposed. • The first potential mechanism is congenital diaphragmatic defects providing an

opening between the peritoneal cavity and the atmosphere. • When the cervical mucus plug is absent, air is allowed to migrate upward through

the peritoneal cavity into the pleural space. • The second mechanism involves necrotic endometrial implants on the

diaphragmatic surface creating a perforation in the diaphragm. • Thirdly, catamenial pneumothorax could also be caused by metastatic spread of

endometrial implants through the pelvic veins reaching systemic circulation. • This last proposed mechanism involves implants disrupting the pleural surface

during menses. • The prostaglandin dinoprost tromethamine, which is present in the plasma of some

women during menses, constricts both bronchioles and vasculature, which may result in pneumothorax when alveolar tissue is damaged and associated bronchospasm prohibits expiration .


Question 4• What is the preferred treatment of

catamenial pneumothorax?• A. Oral Contraceptives • B. Pleurodesis • C. Repair of diaphragmatic defects • D. Combined surgical intervention and

hormonal manipulation


discussion• There are several therapeutic options to treat catamenial pneumothorax. • Nonsurgical treatment includes hormonal suppression with medications, such as leuprolide, a

gonadotropin-releasing hormone, and standard oral contraceptives . • Surgical intervention includes bilateral salpingo-oophorectomy, closure of diaphragmatic

defects and pleurodesis. • Polyglactin mesh has been used to cover the diaphragm as well in an effort to occlude occult

fenestrations. This also promotes adhesion of the lung to the diaphragm . • Overall, a combined surgical approach followed by hormonal manipulation has been most

successful in preventing recurrences, with a 50% success rate .• Video-assisted thoracoscopy is the preferred method for surgical assessment and treatment

(9). • The pleural and diaphragmatic surfaces can be inspected at which time superficial endometrial

implants are vaporized using combination of hydrodissection and carbon dioxide laser. • Deeper implants, however, require sharp dissection. • With video-assisted thoracoscopy diaphragmatic defects can be resected and closed with an

endoscopic stapler device. • Standard thoracotomy may be employed when video-assisted thoracoscopy in not adequate or

prior surgical intervention has failed. • Talc pleurodesis and pleurectomy should only be considered in cases of treatment failure .


chest ct cases-9Dr :anas sahle

http://www.facebook.com/dranas224

HRCT-1

HRCT-1

• 1. Are the nodules diffuse or patchy?• Diffuse. • 2. What is their distribution?• Random.

HRCT-2

HRCT-2

• Find nodules along the inter-lobar fissure in the right lung.

• Find nodules at the peripheral pleura.• Find centrilobular nodules.• Find a nodule at the end of a vessel in the in

the left lung

HRCT-2

Gross Appearance

• The lesions in this slice of lung correspond to those shown above.

• Compare the size of the nodules in the lower lung to that in the upper lung.

• Are they larger or smaller?• SMALLER • Can you give a reason for your answer?

Histologic Findings

• Compare the amount of cytoplasm in the rounded collection of cells indicated by the thin arrows to the amount in the surrounding cells.

• Which cells have more cytoplasm? • What types of cells are in the rounded nodule?• What type of cell is indicated by the thick

arrow?• What is the histologic diagnosis?

• Which cells have more cytoplasm? • The cells delimited by arrows• What types of cells are in the rounded nodule?• Mostly epithelioid histiocytes (with prominent

cytoplasm), some lymphocytes • What type of cell is indicated by the thick arrow?• A multinucleated giant cell• What is the histologic diagnosis? • Ill-defined, non-necrotizing granuloma

Differential diagnosis of random nodules on HRCT:

• miliary tuberculous.• Fungal.• viral infections.• hematogenous metastasis (particularly from

thyroid, kidney, and breast).

Histologic differential diagnosis:

• infectious granulomas (mycobacterial and fungal).

• Sarcoidosis.• hypersensitivity pneumonia.

Diagnosis:

Miliary tuberculosis


04/12/202338

Collicum EXAMRespiratory


A1 بأسباب • يتعلق فيما $ احتماًال األقل الخيار أن أعتقد

: النتحي الجنب انصباب.AChurg-Strauss syndrome .B.Esophageal perforation العالجي المري تمزق.CSplenic abscess الطحال خراجة.DRadiation therapy. الشعاعية المعالجة.Eeosinophilic pneumonitis رئة ذات

بالحمضات .


A2يلي :• فيما الخاطئة المعلومة أن أعتقد

.A السائل ثخانة تكون عندما مسموح الجنب بزل إستطباب أنمن أكثر شعاعWيا ملم.10المثبتة

.B لديه مريض جنب سائل في البيض الكريات ترتفع عندما أنهجنبه . تقيح على دائما يدل فهذا جرثومية رئة ذات

.C الباكرة المرحلة في ترتفع أن يمكن النوي عديدات العدًالت أن. السلية الجنب لذات

.D. الرئوية الصمة عن الناجم الجنب انصباب في أن أنه يمكن. مرتفعه الجنب سائل في النوي عديدات العدًالت تكون

.E عديدات العدًالت تكون أن يمكن الحاد المعثكلة التهاب في أنه. مرتفعه الجنب سائل في النوي


A3•: يلي فيما $ احتماًال األكثر الخيار أن أعتقد

.A ينخفض الجنب تقيح .PHفي الغلوكوز من أبكر السائل

.B انخفاض يتأخر الجنب تقيح . PHفي الغلوكوز عن السائل

.C لقياس ضرورة هناك الدم PHليس غازات بجهاز السائل

.D النتعي الجنب سائل للزرع transudatفي ضرورة هناكللسائل الجرثومي

.E ناجم جنب سائل في شيوع$ا الممرضة العوامل أكثر مناللهوائيات هي بالمشفى مكتسبة رئة ذات anaerobicعن


A4مدخن 55محمد • بناء، عامل ،45: , \ الرئة وظائف أظهرت سنة . علبة•FVC 62%•FEV1 46%•FEVI/FVC 62%•TLC 92%•DLCO 44%•: مع تتوافق الوظائف هذه

.A. الشدة خفيف حاصر تناذر

.B الشدة متوسط ساد تناذر

.C. شديد ساد تناذر

.D مشترك تناذر

.E شديد حاصر تناذر


A5

•: هو المحتمل التشخيص أن أعتقد.AEmphysema رئوي نفاخ.B. رئة سرطان.CAsbestos.Dmesothelioma.E. رئة تليف


A6:18ليلي • الرئة وظائف أظهرت ، مستقرة ربوية طالبة، سنه،•FVC 70%•FEV1 80%•FEVI/FVC 110%•TLC 92%•DLCO 88%•: مع تتوافق الوظائف هذه

.A. الشدة خفيف حاصر تناذر

.B الشدة متوسط ساد تناذر


.D مشترك تناذر.E شديد حاصر تناذر


A7•: الرئة وظائف أظهرت حيث ربو بنوبة الصدرية العيادة ليلي راجعت•Pre Post Ventoline•FVC 75% 70%•FEV1 50% 70%•FEVI/FVC 60% 100%•TLC 92% 85%•DLCO 70% 80%•: مع يتوافق وهذا

.A. . الشدة خفيف حاصر تناذر

.B. الشدة متوسط ساد تناذر


.D مشترك تناذر.E شديد حاصر تناذر


A8

فيما . • صحيحة التالية المقوًالت أي Dynamic Hyperinflationيخص

.A . الشهيقية بالسعة مباشرة عالقة لهاInspiratory Capacity

.B هجمة نهاية في .COPDتزداد المزمن

.C . القصبية بالموسعات تتأثر ًال.D . باألكسجين بالمعالجة تزداد.E. القلب نتاج لزيادة تؤدي


A9مع 65باسم • الخاليا صغير قصبي سرطان له شخص سنه

كيماوي لعالج خضع ، واألضالع والجنب للمنصف انتقاًالتما ودون حرارة دون شهر من شديد سعال من يشكو

العالج شديدة، عظمية آًالم مع رئة ذات وجود على يدل: له األمثل

.A الكودئين.BIpratropium Bromide.CInhaled glucocorticoioids. .DSalbutamol.Eالهيبارين


A10منذ 16مازن • قصبي ربو له شخص معالج 4سنه سنوات

مديد قصبي موسع مع إنشاقي ستيروئيد من منخفضة بجرعةحرارة دون شهر من ليلي شديد سعال من يشكو التأثيرمزمن ليلي شخير مع رئة ذات وجود على يدل ما ودون

طبيعي / الصدر إصغاء باألنف مستمر شبه انسداد مع متقطع: له األمثل التدبير طبيعية الرئة وظائف

.A. اًالنشاقي الستيروئيد جرعة رفع

.BإضافةMontelukast

.C ليال الكودئين إعطاء

.D الفكية للجيوب صورة.EIpratropium Bromide


Health & Medicine

Anwser,s 10