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Below is a cache of http://www.capanet.org/2007ConfPresentations/10-4-1430-1745-Radiologypart2.pdf. It's a snapshot of the page taken as our search engine crawled the Web.
The web site itself may have changed. You can check the current page or check for previous versions at the Internet Archive. Yahoo! is not affiliated with the authors of this page or responsible for its content. Emphysema (COPD) 1 CHF Pearls An under penetrated CXR may appear as CHF. Use pre-test probability to help in
the diagnosis. (Beta Naturic Peptide) Be careful of the diagnosis of Bilateral pneumonia. Could this be urosepsis
putting the patient into failure? Air Spaces: Too Black? (Too black means too much air) P = Pneumothorax
E = Emphysema
P = ***Pulmonary Embolism*** Pneumothorax No Lung Markings Collaps ed Lun g Pressure Emphysema (COPD) Emphysema (Air Space Destruction) Reactive Airway Disease Chronic Bronchitis (Enlarged Goblet Cells) COPD 2 Asthma Treat them while theyre making NOISE N = Nebulizers Albuterol (B2 Agonists) Atrovent (Anticholenergic) O = Oxygen
I = IVF
S = Steroids
E = ***Epinephrine*** I:E Ratio? Inspiration to Expiration Ratio: Should be 1:2 Prolonged expiratory phase is a sensitive clinical indicator of a patients
respiratory status, especially in children How else can you tell if a child is sick? (The Look) Just TICKLE them! T = Tone (Strong or weak?)
I = Irritability
C = Consolability
K = Kry (loud and vigorous or wimpy)
L = Labor (breathing)
E = Environment (appropriately stimulated?) w/ a good Feeding history Try the Sticker on Forehead Trick Or the Hole in the Ear Trick Pulmonary Embolism: PE is the of Chest Symptoms Name That
Tune Who is Your PAPPA? How to Evaluate a CXR in terms of Chest Pain P = Pericarditis
A = Acute Coronary Syndrome
P = Pnemothorax
P = Pulmonary Embolism
A = Aortic Aneurysm (Thoracic) Pericarditis: No real radiographic help Water bottle Shape
Usually young
Positional pain Hurts supine Elevated ESR
Treatment: NSAIDS 3 Acute Coronary Syndrome No real radiographic help. Mainly used to rule out other causes of chest pain Do we need a CXR before thrombolytics? To r/o _______________________ Cardiac Risk Factors? Its a SAD case of CHF (Cardiac Risk Factors) S = Smoking
A = Age
D = Diabetes C = Cholesterol
H = Hypertension
F = Family History Who is the most accurate medical provider to diagnosis pulmonary embolism? Whats the Key to Diagnosis? High Degree of Clinical Suspicion! El Gato Seek Out Risk Factors! Virchows Triad: Hypercoagulable State High estrogen states: pregnancy/BCP
Cancer
Family History Vessel Damage
Stasis Atypical Chest/ Pulmonary Symptoms? Document on every chart: 1) Cardiac Risk Factors
2) Virchows Triad
3) Symmetrical legs Measure them!/ No Homans Sign 4 Do me a favor: Call me when This suggestion saves a Patients life, or prevents You a 7 figure law suite. 716.512.5991 That was a WHALE of a PE W= Westermark Sign
H = Hampton's Hump
A = Atelectasis
L = Lovely (Meaning perfectly normal)
E = Effusions Westermark Sign (Extremely Uncommon) Hamptons Hump Atelectasis 5 Effusion Pneumothorax Aneurysm: Dissecting Thoracic Wide Mediastinum is key radiographic feature Document Symmetrical Pulses And no Murmur Anybody with Abnormal Lung Sounds: Dont make a HORID mistake and miss something HORID (Differential diagnosis for abnormal lung sounds) H = Heart (think CHF) O = Obstruction
R = Reactive Airway Disease (COPD/ asthma) I = Infection
D = DEATH!!!! From the PE you didnt ask about Virchows Triad on, even after John warned you!!! 6 Teach This Info: Nurture The Young Great to diagnosis: Free Air
Obstruction
Metallic Foreign Body Lousy to diagnosis: Appendicitis
Gall Bladder Disease
OB/GYN Disease
AAA
Kidney Stone Abdominal Radiographs The Bottom Line: Have a Low Threshold to CT Scan the Abdomen Normal Bowel Gas Pattern Abdominal Radiographs Abdominal Series (Surgical ABD) Upright ABD most Important radiograph Left lateral decubitus
Supine
CXR Remember the importance of patient position Parachutes, Slinky or Boxing Glove (Upright Abdominal Radiograph) We are looking for Parachutes,
Slinkys or
Boxing Gloves 7 Parachutes = ileus ileus = Abnormal peristalsis. This could be from bowel irritation to early full obstruction Parachutes= ileus Parachutes= ileus Slinky = Bowel Obstruction This could be large or small bowel Two air fluid levels at different levels in the
same loop of bowel (Aka Stair Step Sign) Slinky = BO 8 BO on
Supine Film Hernia Progression of Bowel Obstruction Bloc kag e/ Ir ritat ion Air- Fluid Level Bowel Obstruction Bowel Obstruction Surgical Consultation
NG Tube
IV Fluids 3 cm 6 cm 9 cm Boxing Glove = Volvulus Volvulus = Twisting of bowel Cecal or sigmoid
Needs surgical consultation
Barium enema is usually diagnostic/ therapeutic 9 Appendicitis ABD Pain Work Up Pearls Always order a urine ABD pain with a WBC count of 20K is very different than with a WBC of 10K (order labs!) All woman are pregnant until proven otherwise Have a low threshold to do CT scan: Especially if older, on steroids or who is a diabetic Critically Important Pearl Patient with diabetes OR who are on chronic steroids, they can have peritonitis and have a benign physical exam! John Bielinski, Jr. MS, PAC Buffalo, New York 716.512.5991 Bielinsj@DYC.edu Questions? Bielinsj@DYC.edu 10
The web site itself may have changed. You can check the current page or check for previous versions at the Internet Archive. Yahoo! is not affiliated with the authors of this page or responsible for its content. Emphysema (COPD) 1 CHF Pearls An under penetrated CXR may appear as CHF. Use pre-test probability to help in
the diagnosis. (Beta Naturic Peptide) Be careful of the diagnosis of Bilateral pneumonia. Could this be urosepsis
putting the patient into failure? Air Spaces: Too Black? (Too black means too much air) P = Pneumothorax
E = Emphysema
P = ***Pulmonary Embolism*** Pneumothorax No Lung Markings Collaps ed Lun g Pressure Emphysema (COPD) Emphysema (Air Space Destruction) Reactive Airway Disease Chronic Bronchitis (Enlarged Goblet Cells) COPD 2 Asthma Treat them while theyre making NOISE N = Nebulizers Albuterol (B2 Agonists) Atrovent (Anticholenergic) O = Oxygen
I = IVF
S = Steroids
E = ***Epinephrine*** I:E Ratio? Inspiration to Expiration Ratio: Should be 1:2 Prolonged expiratory phase is a sensitive clinical indicator of a patients
respiratory status, especially in children How else can you tell if a child is sick? (The Look) Just TICKLE them! T = Tone (Strong or weak?)
I = Irritability
C = Consolability
K = Kry (loud and vigorous or wimpy)
L = Labor (breathing)
E = Environment (appropriately stimulated?) w/ a good Feeding history Try the Sticker on Forehead Trick Or the Hole in the Ear Trick Pulmonary Embolism: PE is the of Chest Symptoms Name That
Tune Who is Your PAPPA? How to Evaluate a CXR in terms of Chest Pain P = Pericarditis
A = Acute Coronary Syndrome
P = Pnemothorax
P = Pulmonary Embolism
A = Aortic Aneurysm (Thoracic) Pericarditis: No real radiographic help Water bottle Shape
Usually young
Positional pain Hurts supine Elevated ESR
Treatment: NSAIDS 3 Acute Coronary Syndrome No real radiographic help. Mainly used to rule out other causes of chest pain Do we need a CXR before thrombolytics? To r/o _______________________ Cardiac Risk Factors? Its a SAD case of CHF (Cardiac Risk Factors) S = Smoking
A = Age
D = Diabetes C = Cholesterol
H = Hypertension
F = Family History Who is the most accurate medical provider to diagnosis pulmonary embolism? Whats the Key to Diagnosis? High Degree of Clinical Suspicion! El Gato Seek Out Risk Factors! Virchows Triad: Hypercoagulable State High estrogen states: pregnancy/BCP
Cancer
Family History Vessel Damage
Stasis Atypical Chest/ Pulmonary Symptoms? Document on every chart: 1) Cardiac Risk Factors
2) Virchows Triad
3) Symmetrical legs Measure them!/ No Homans Sign 4 Do me a favor: Call me when This suggestion saves a Patients life, or prevents You a 7 figure law suite. 716.512.5991 That was a WHALE of a PE W= Westermark Sign
H = Hampton's Hump
A = Atelectasis
L = Lovely (Meaning perfectly normal)
E = Effusions Westermark Sign (Extremely Uncommon) Hamptons Hump Atelectasis 5 Effusion Pneumothorax Aneurysm: Dissecting Thoracic Wide Mediastinum is key radiographic feature Document Symmetrical Pulses And no Murmur Anybody with Abnormal Lung Sounds: Dont make a HORID mistake and miss something HORID (Differential diagnosis for abnormal lung sounds) H = Heart (think CHF) O = Obstruction
R = Reactive Airway Disease (COPD/ asthma) I = Infection
D = DEATH!!!! From the PE you didnt ask about Virchows Triad on, even after John warned you!!! 6 Teach This Info: Nurture The Young Great to diagnosis: Free Air
Obstruction
Metallic Foreign Body Lousy to diagnosis: Appendicitis
Gall Bladder Disease
OB/GYN Disease
AAA
Kidney Stone Abdominal Radiographs The Bottom Line: Have a Low Threshold to CT Scan the Abdomen Normal Bowel Gas Pattern Abdominal Radiographs Abdominal Series (Surgical ABD) Upright ABD most Important radiograph Left lateral decubitus
Supine
CXR Remember the importance of patient position Parachutes, Slinky or Boxing Glove (Upright Abdominal Radiograph) We are looking for Parachutes,
Slinkys or
Boxing Gloves 7 Parachutes = ileus ileus = Abnormal peristalsis. This could be from bowel irritation to early full obstruction Parachutes= ileus Parachutes= ileus Slinky = Bowel Obstruction This could be large or small bowel Two air fluid levels at different levels in the
same loop of bowel (Aka Stair Step Sign) Slinky = BO 8 BO on
Supine Film Hernia Progression of Bowel Obstruction Bloc kag e/ Ir ritat ion Air- Fluid Level Bowel Obstruction Bowel Obstruction Surgical Consultation
NG Tube
IV Fluids 3 cm 6 cm 9 cm Boxing Glove = Volvulus Volvulus = Twisting of bowel Cecal or sigmoid
Needs surgical consultation
Barium enema is usually diagnostic/ therapeutic 9 Appendicitis ABD Pain Work Up Pearls Always order a urine ABD pain with a WBC count of 20K is very different than with a WBC of 10K (order labs!) All woman are pregnant until proven otherwise Have a low threshold to do CT scan: Especially if older, on steroids or who is a diabetic Critically Important Pearl Patient with diabetes OR who are on chronic steroids, they can have peritonitis and have a benign physical exam! John Bielinski, Jr. MS, PAC Buffalo, New York 716.512.5991 Bielinsj@DYC.edu Questions? Bielinsj@DYC.edu 10
