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132 Cards in this Set
- Front
- Back
szczelina dodatkowa dzieląca seg górny płata górnego
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Superior accessory fissure
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częstość wystęowania dodatkowej szczeliny płata górnego
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15%- po lewej
30%- po prawej |
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Why is it important to know about this fissure's existance?
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Because consolidation in the superior segment of the upper lobe demarcated by this fissure can appear as upper lobe disease, and below the fissure can mimic lower lobe disease.
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How can disease confined to the superior lobe by a superior accessory fissure be delineated from upper lobe disease?
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1) If involvement occurs on the right, the superior vena caval margin will be visible because it is anterior while the process is posterior, in the superior segment of the upper lobe.
2) The lateral view will quickly clarify any confusion |
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DDX kardiomegalia bez obrzeku płucnego
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Pericardial effusion
Fluid overload (acute) Compensated left ventricular failure |
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What entity falls under compensated LV failure?
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Aortic regurgitation
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What suggests aortic regurgitation as the cause?
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Prematurely tortuous aorta
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Where can lesions that cause aortic regurgitation be?
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Aortic valve or aortic root
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What suggests the lesion is at the aortic root?
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Prominence of the ascending aorta
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If this finding is not present, what are the likely causes?
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Aortic valvular disease, which is typically caused by
1) Bicuspid aortic valve 2) Endocarditis 3) Rheumatic heart disease |
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In what setting is aortic regurgitation impossible to diagnose on plain film?
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In the setting of mitral heart disease
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Why?
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Because the dilated left atrium due to the mitral stenosis laterally deviates the descending aorta, making it look tortuous.
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What is the most common radiologic finding in patients with sequelae of rheumatic heart disease?
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Mitral stenosis causing mitral configuration heart
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What percent of rheumatic heart patients have involvement of the mitral valve?
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85%
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What is the most common finding in sarcoidosis?
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Bilateral symmetric hilar lymphadenopathy, with right mediastinal lymphadenopathy possibly evident
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What is the most common parenchymal appearance in sarcoidosis?
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Nodular or reticulonodular disease
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What part of lung are findings predominant?
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Upper lungs
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Why does that make sense?
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Because you know that sarcoid can cause cicatricial changes of the upper lobes just like Tb in end stage
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What do the nodules represent?
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Noncaseating granulomas, 2-3 mm large.
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Where are they seen on HRCT?
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Lymphatic distribution. SO they follow the peribronchovascular lymphatics, the interlobular septae, and the subpleural lymphatics.
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Where is lung contusion seen?
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Adjacent to area of direct blunt or penetrating trauma (so look for rib fractures or bullet fragments when you are suspecting lung contusion)
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When should contusion have completely cleared?
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1 week
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What is the other type of parenchymal lung injury that occurs in trauma?
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Pulmonary laceration (laceration, just like in liver)
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What does laceration look like?
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Usually small ovoid lucency within the area of clearing contusion.
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How else may it look?
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If may fill with blood, forming a hematoma, which can take weeks to clear
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What is pulmonary contusion?
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Hemorrhage into alveoli
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What is the most common cause of pneumomediastinum?
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Alveolar rupture into the mediastinum.
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What are the other causes of pneumomediastinum?
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Tracheal rupture
Esophageal rupture Via neck or retroperitoneum |
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What are causes of alveolar rupture?
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Either elevated intraalveolar pressure or damage to alveolar walls.
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What are causes of elevated intraalveolar pressure?
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Airway obstruction, such as from asthma or foreign body
Mechanical ventilation Blunt thoracic trauma Cough/vomiting/valsalva |
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What are the causes of alveolar wall damage that can promote pneumomediastinum?
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Pneumonia
ARDS Emphysema Interstitial fibrosis |
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How do you determine pneumomediastinum from pneumopericardium?
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Pneumopericardium will not extend superior to the great vessels, where the pericardium ends. Pneumomediastinum will often extend much further, into the neck.
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Will pneumopericardium shift in position in lateral decubitus view?
Will pneumomediastinum? |
Pneumopericardium -- yes
Pneumomediastinum -- no |
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What are 4 features of malignant pleural thickening?
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1) Greater than 1 cm thick
2) Circumferential (versus focal plaques) 3) Nodular/irregular 4) Involves mediastinal pleura as well |
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What is the differential for malignant pleural thickening?
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1) Malignant mesothelioma
2) Pleural metastases |
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Which is more common?
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Pleural metastases
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In what percent of malignant mesothelioma cases is pleural calcification seen on CT?
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only 20%
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How is it treated?
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Can be treated surgically only in limited cases: When there has been NO
Transdiaphragmatic extension Diffuse invasion of chest wall Invasion of vital mediastinal structures Vertebral body invasion Direct extension to contralateral pleura Distant mets |
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What is the most sensitive view to see pleural effusion?
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Lateral decub view
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How much fluid needed to blunt costophrenic angle on frontal view?
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200 ml
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How much needed on lateral view?
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75 ml
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How much needed on lateral decubitus view?
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5 ml
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What do you see?
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Lung floating on top of effusion, which is seen against chest wall as a dense meniscus.
Also see hyperinflation of the up lung. |
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What does subpulmonic effusion do on frontal view?
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Collects in the most dependent area of the lung, so first in posterior costophrenic angle, then causes the lung to float up on top of it, just like what happens on lateral decub view.
So you see instead of the hemidiaphragm on that side the subpulmonic fluid collection, which extends out flatter more laterally than the lung actually does. |
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How do you verify whether there is a subpulmonic effusion or not?
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Just get a lateral decub view, and it will all spill out.
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What are the most common locations for PTX on supine radiograph?
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1) Anteromedial -- makes sense, as this would be highest point in chest
2) Subpulmonic -- deep sulcus sign |
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What are the signs of a subpulmonic pneumothorax?
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Helpful to think where this air is loculated: Same place that fluid is when it is subpulmonic, except that it will tend to float anteriorly vs posteriorly in supine patients.
So, 1) Deep sulcus sign 2) Hyperlucent upper abdomen (area just below hemidiaphragm) on that side 3) Double diaphragm sign 4) Sharp margination of the hemidiaphragm |
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What is double diaphragm sign?
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Visualization of both anterior and posterior diaphragmatic surfaces
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What is radiographic evidence of anteromedial PTX?
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Sharp outline of the cardiac and mediastinal contours on that side
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What is the most helpful differentiating feature between pleural and extrapleural (chest wall) masses?
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Presence of rib destruction or remodeling. Suggests extrapleural (chest wall) disease.
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What are the two most common causes of extrapleural mass with associated rib destruction in an adult?
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Mets
Myeloma |
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What are two hypervascular mets to the chest wall that will show intense enhancement?
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Renal cell carcinoma
Thyroid |
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What are the two important descriptors for both pleural based and extrapleural chest wall masses on CXR?
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The lesions are broad-based, forming obtuse margins with the chest wall.
The lesions have incomplete borders. |
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#98
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#98
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What are 3 entities that present with peripheral consolidation?
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Eosinophilic pneumonia
Loffler's syndrome BOOP Pulm infarcts Vasculitis |
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Where does chronic eosinophilic pneumonia most prominently affect?
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Lung apices. Lung bases are less frequently involved.
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What is the differential diagnosis for a well-marginated cystic structure adjacent to the trachea near the lung apex?
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1) Paratracheal air cyst
2) Apical bullea 3) Apical lung hernia |
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What is a paratracheal air cyst?
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A tracheal diverticulum
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Where do these diverticulae occur most often?
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At the right posterolateral tracheal wall, at the level of the thoracic inlet.
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What is the finding that should make you immediately suspicious of tracheoesophageal malformation?
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Gasless abdomen
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How do you make the diagnosis?
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Put a feeding tube in and inject AIR to diagnose the esophageal atresia. Don't inject contrast unless necessary, and then only a tiny bit of BARIUM as kid can easily aspirate.
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Why is it so easy to aspirate?
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Because most esophageal atresias have associated tracheal involvement.
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What is the level of esophageal atresia usually?
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Lower cervical or upper thoracic.
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What is the level of the tracheoesophageal fistula usually?
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Usually level of carina = T4
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What are tracheoesophageal malformations associated with?
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Down's
VACTERL |
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What is the differential diagnosis for apical pleural density?
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Apical pleural cap
Tb Pancoast tumor |
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What is apical pleural cap due to?
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Old age, related to apical pleural ischemia
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When is the diagnosis of tumor suspected?
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When there is more than 5 mm asymmetry between the thickness of the caps between each side
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Where must you never forget to look on a CXR ever again?
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Look to see the normal vessels coursing through the retrocardiac shadow on ALL CASES!
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Where is intralobar sequestration usually located?
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Posterobasal segment of a lower lobe
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What is the treatment?
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Surgical excision
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What does congenital lobar emphysema do?
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Causes mass effect
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On what?
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1) mediastinum
2) Rest of ipsilateral lung, compressing it, making it look consolidated |
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What lobe is most commonly involved in CLE?
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Left upper lobe
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What lobe is second most common?
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Right middle lobe
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What is the third most common lobe?
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Right upper
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What is NOT involved
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lower lobes are not
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What is the most common cause?
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Bronchial cartilage deficiency resulting in airway collapse
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When does it present?
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1) First few days of life: CXR does not clear in that lobe, due to bronchial blockage
2) Presents symptomatically usually after neonatal period |
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How do you make the final diagnosis if CXR is not enough (should be, though)?
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CT
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why?
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To differentiate from bronchial obstruction with a check valve mechanism
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Where should tip of intraaortic balloon pump be?
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2-4 cm below SUPERIOR margin of aortic nob. Anatomically, you want it just distal to takeoff of the final branch of the arch (L subclavian usually)
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Is it OK for pacing wire to be in the coronary sinus?
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Yes. Put here for atrial pacing.
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What is the 4 chamber view of the heart an example of?
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An apical view, with transducer cutting coronally through the heart, apex first.
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So what does this mean?
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Means ventricles are always closest to transducer.
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What is the overall incidence of congenital heart disease?
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1%
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What are the two most common congenital heart abnormalities?
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Bicuspid aortic valve
Mitral valve prolapse |
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What is true about these lesions clinically?
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Usually asymptomatic
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What are the three most common symptomatic congenital heart abnormalities?
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Atrial septal defect
PDA Tetralogy of Fallot |
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What are the next three most common symptomatic ones?
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VSD
Coarctation TGA |
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When do most congenital heart lesions clinically present?
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After first month
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What is the most common lesion to present in the first month?
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Hypoplastic left heart
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What is the second most common in first month?
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TGA
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What is the third most common to present in the first month?
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Coarctation (severe)
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What is the 4th most common in 1st month?
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Severe tetralogy, or severe isolated pulm atresia
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How many things must you evaluate on the CXR for cardiac disease?
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5
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What 5 things; First?
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Pulmonary vascularity
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Second?
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Situs
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Third?
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Side of aortic arch
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Fourth?
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Chamber enlargement
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Fifth?
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Bone and soft tissue changes
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At what pressure does venous redistribution occur?
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about 15-18 mmHg
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Interstitial edema?
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18-25 mmHg
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What is a rule of thumb about the appearance of the cardiac silhouettte in cyanotic cong heart dz?
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PA segment small, concave, or not visible
Small pulmonary arteries |
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How many and what are the segments (moguls) of the right side of the heart?
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There are 3:
SVC Right atrium IVC |
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How many and what are the segments of the left side of the cardiac silhouette?
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Aortic arch
Pulm artery Left atrial appendage Left ventricle |
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przedni cień serca; boczne rtg kl.p
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Right ventricle
Main PA (short segment) Ascending aorta |
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tylny cień serca
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Left ventricle
Left atrium |
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prawa tętnica płucna na bocznym rtg kl.p.
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do przodu od cariny
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prawidłowe przyleganie prawej komory do mostka
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1/3
jeśli więcej powięszenie prawej kom. |
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Objawy radiologiczne powiąkszenia lewego przedsionka
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przemieszczenie do tyłu lewego oskrzela głównego
przemieszczenie do tyłu przełyku z barytem |
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Które wyżej: Right upper lobe bronchus or left upper lobe bronchus?
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Right
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How do you determine situs?
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1) Look for IVC = position of right atrium
2) Look at bronchi -- look for right mainstem bronchus 3) Gastric air bubble 4) Usually just obvious |
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What is incidence of congenital heart disease in situs inversus?
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5%
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What is the first step in evaluation of congenital heart disease radiographically?
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Clinical information: Is the patient cyanotic?
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What if the patient is not cyanotic. What is the first step?
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Evaluate pulmonary vascularity
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What are the options for vascularity in an acyanotic patient with suspected congenital heart disease?
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Normal or increased
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What is the reason for this?
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All acyanotic lesions are either the result of intact vascular circuitry with stenosis/interruption, OR of left to right shunting of bloodflow, back through the pulmonary circuit. The first situation results in normal vascularity. The second situation results in increased pulmonary vascularity.
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What is the pulmonary to systemic flow ratio at which a CXR will demonstrate increased pulmonary vascularity?
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2:1
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What is the next step in patient with normal vascularity?
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Render a differential.
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What is the differential?
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1) Aortic stenosis
2) Pulmonic stenosis (without intracardiac shunt) 3) Coarctation 4) Interruption of aortic arch |
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What if the acyanotic patient has increased pulmonary vascularity. What is next step?
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Evaluate for presence of left atrial enlargement.
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Why is this the next step?
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By demonstrating increased pulmonary vascular flow, you are suspicious of a shunt. Most left to right shunts cause enlargement of the left atrium, as the blood all comes back to the LA again after being shunted back through the lungs.
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What is the next step if there is no enlargement of the left atrium?
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Render a differential
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What is the differential?
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Atrial septal defect
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Why is there no left atrial dilatation?
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Because the left atrium is able to decompress through the septal defect into the right ventricle.
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What is the next step if there is left atrial enlargement?
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Look for aortic enlargement
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What is the differential if there is no aortic enlargement?
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ventricular septal defect
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Why?
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Because the aorta is not seeing increased bloodflow. The shunt is occurring into the right ventricle
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What is the differential if there is aortic enlargement?
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Patent ductus arteriosus
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What if there is cyanosis, what is the initial step?
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Same thing. Evaluate the pulmonary vascularity.
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What are the choices for pulmonary vascularity if there is cyanosis?
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Normal or decreased
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