Chest/Pulmonary Student Handout 1
Student Handout – IPC Block 5
Diagnostic Testing and Medical Decision Making
Week 6: Chest/Pulmonary
Note to students:
Recommended reading from Mettler Radiology text, “Essentials of Radiology”:
Chapter 1: Introduction to Radiology (if not already read)
Chapter 2: Chest
Please review the cases below and prepare the answers for small group discussion.
Images are available for review on Blackboard prior to the sessions. (Note: Some images
on Blackboard will not be included in your questions, and will be used for further
discussions during small group sessions.)
Additional resources: Medical Imaging by Peter Scally (1999). (On reserve in the library and on PBL shelves.)
A wife brings her 66-year-old husband to clinic because she is worried about possible weight loss and
decreased level of activity over the last few months. He says that he feels fine, although he acknowledges
his appetite is a little decreased, and a recent 5-day history of mild shortness of breath and minimal
hemoptysis. His wife was recently treated as an outpatient for bronchitis that seemed to resolve. His past
medical history is significant for gastro-esophageal reflux disease and mild osteoarthritis. He takes an
ASA 325mg per day and ranitidine 150 mg BID.
1. What other information would you like to know?
Do you have a family history of cancer?
Have you been around anybody with TB?
Do you smoke?
Nature of dyspnea? Onset of dyspnea (exertional or at rest)? What makes it better or worse?
Have you had any cough, atelectasis, postobstructive pneumonia, or wheezing?
Do you take any illicit drugs (crack cocaine can cause hemoptysis)?
social hx; occupation; vitals; physical; other sick contacts; nature of hemoptysis (color of blood – dark or
bright); other GI issues
VS: Wt=172 lbs P = 78 bpm R=22/m BP=135/72 T=99.2 (Wt at clinic visit 3 months ago: 177
General: Well appearing male
HEENT: PERRL, EOMI, TM: clear, OP: clear, pale. No icterus
Neck: supple, no anterior or posterior cervical lymphadenopathy
Chest: Clear to auscultation and percussion; no wheezes, rales, or rhonchi.
Heart: Normal S1 and S2, no murmurs, rubs, gallops
Abdomen: Soft/nontender/nondistended. No hepatosplenomegaly.
Rectal: Heme negative stool. No masses. Non-tender.
Extremities: No C/C/E
Chest/Pulmonary Student Handout 2
2. What is your initial differential diagnosis for this patient’s concerns?
Malignancy (Bronchogenic carcinoma, Leukemia)
Autoimmune (Goodpasture‘s syndrome, Wegener‘s granulomatosis, SLE Parasites, eg, paragonimiasis, ascariasis, hookworm, strongyloidiasis
GI-related something (GERD, ulcer)
3. What initial tests would you order and why? (Prioritize these diagnostic tests.)
CXR => Since he may have lung cancer
PPD => Since he may have TB
UA (GI issues)
4. What is the differential diagnosis for the finding on Case 1 CXR 1 (PA view)?
See solitary pulmonary nodule in left upper lobe. Could also say ―opacification‖ in left upper lobe.
―Masses‖ tend to be bigger (>3 cm), so this probably isn‘t a ―mass‖. ―Nodules‖ are <3 cm.
Collection of lymph nodes
Fungal Infection (e.g. Aspergillosis)
Atelctasis (rarely looks like a nodule)
Histoplasmosis or any other granuloma
5. What would be your next step to evaluate the finding on the chest x-ray?
CT of chest. With contrast. (Chest CT‘s are almost ALWAYS with constrast)
Review Case 1 CT scan 1 (Image 1A-D) and CT scan 2. (Be able to identify normal of the CT scan, including the following structures.)
a) Heart f) Descending aorta b) Sternum g) Pulmonary vessels c) Left lung h) Liver d) Trachea i) Superior vena cava e) Arch of the aorta
Bone-Soft Tissue Window CTs
CT 1A: See 2-3cm nodule in posterior portion of upper left lobe in pictures 4-6.
Chest/Pulmonary Student Handout 3
CT 1B: Another mass in left lung (middle, near heart)
CT 1C: See the mass again in 3-6.
Lung Window CT 2: See mass in 9-11 in same place as 1A.
6. What are your findings on Case 1: CT scan 1 and 2? What is the appropriate next step to
establish a definitive diagnosis for this patient?
Dude got lung cancer
CT-guided transthoracic needle Biopsy
Review Case 1 CXR 2 which was taken next. What are your findings?
They‘re checking for a pneumothorax (not use of expiratory film).
7. In contrast to the patient initially reviewed in case 1, review the images of another patient--
Images Case 1: CXR 4A-B (PA and lateral) and Case 1: CT scan 3A-B. What are the major
CXR 3A: Hyperinflation of the lungs. Pneumothorax in top right. White things to either side are
scapulas. Can get spontaneous, iatrogenic, or tension pneumothorax.
CXR 3B: Hyperinflation.
CXR 4A: Nodule in left lower lobe lung near heart apex. Nodule in right middle lobe. See nodule in
paraspinous area posterior to the heart. See central line portacath (implanted central line) -> Used for
CXR 4B: See mass again
CT 3A: See 3 masses in anterior portion of right lung.
CT 3B: See 3 masses in anterior portion of right lung.
8. What is your differential diagnosis for the finding on CXR 4?
DDX for multiple pulmonary nodules Metastatic osteosarcoma in a teenager is what we have
Miliary TB (usually 100s of little nodules)
***Other images for Case 1 available on Blackboard will be discussed during small group sessions.
A 28 year old woman presents to your clinic with concerns of fatigue and swollen ‗glands‘ for the last 2 weeks. She is an established patient in your practice and she does not have any chronic medical problems.
She reports some ‗wheezing‘ when she exercises. Her exercise tolerance has dropped notably and she
reports difficulty keeping up with her 2 year old son. She reports night sweats on occasion and has had
subjective fevers over the last few days. Other past medical, family and social history are negative.
On examination, she has normal vital signs. Weight 65 kg (unchanged from her well woman exam 6
month prior to this visit). She has shotty cervical and inguinal adenopathy. No hepatosplenomegaly is
appreciated. Her chest is clear, and her cardiac examination is normal.
Chest/Pulmonary Student Handout 4
1. Develop a differential diagnosis.
Cancer (lymphoma, Hodgkin‘s Disease) Pneumonia
Some sort of infection
Exercised induced asthma
2. What tests would you order next? (include review of Image: Case 2 CXR 1A-B.)
Blood Cultures (if she has fever)
PFT or Albuterol challenge without PFTs
CXR 1A: Marked widening of the middle and superior mediastinum.
CXR 1B: Filling in of the retrosternal space by an ill-defined anterior mediastinal mass.
Next ? order Spiral Chest CT with contrast ? Biopsy
3. What diseases typically present as masses in a) the anterior mediastinum, b) the middle
mediastinum and c) the posterior mediastinum?
A: T-Cell Lymphoma, Thymoma, Teratoma, Thyroid tumor
B: Thoracic aortic aneurysms, hematomas, neoplasms, adenopathy, esophageal lesions, diaphragmatic
hernias, and duplication cysts
C: Neuroblastomas, neurofibromas, schwannomas, ganglioneuromas, hernias, neoplasms, hematomas, or
Need to next do a CT then biopsy => She has nodular sclerosing Hodgkin‘s disease.
4. What is the next step in the evaluation of this patient?
(Review the Image Case 2: CT scan 2A-C.) CT scan and excisional biopsy
CT 2A: Middle right does not look normal. See a mass of coalescing lymph nodes. Right paratracheal
nodes were really big (6 cm)
CT 2B: See some more lymph nodes and some lymph nodes around the spleen.
A 22 year old G1P1 female presents to her family practitioner with a new onset chest pain. She reports
sharp substernal chest pain of 1 day duration which is exacerbated by deep breaths. She is also reports intermittent mild shortness of breath. The pain is described as ―stabbing‖ and 6-7/10 on a pain scale.
It is non-radiating. She reports one ―temperature‖ of 100 F. She also describes an occasional non-
productive cough. She has no history of similar events or ill contacts. She had been feeling well since
her discharge from the hospital three weeks ago following the delivery of a healthy daughter. The vaginal
delivery was uncomplicated and she was discharged home approximately 2 days later. Pregnancy was
Chest/Pulmonary Student Handout 5
Past Medical Hx: Bilateral ovarian cysts removed 3 years ago. Mild asthma—no treatment in last 4
Family Hx: Father has Type II DM and HTN. Maternal grandfather died of stroke and ―clots.‖
Social Hx: Smoked 1 pack/week before pregnancy—none since. Denies drug or alcohol use. Married. Stays at home with her daughter.
ROS: Positive for mild dyspnea on exertion. Denies nausea/vomiting/diarrhea. She feels a little down
about being away from her daughter. Denies anxiety, guilt, difficulty with concentration, or changes in
appetite. Sleep is variable.
PE: Temperature: 37.0 Heart rate: 105 RR: 22 BP 110/55 Pulse oximetry 90% on room air.
General: Awake, alert, non-toxic appearing female. Is mildly dyspneic but able to converse without
Lungs: Clear to auscultation bilaterally. No wheezes, rales, rhonchi. No dullness to percussion. Mild
pain on palpation of the sternum.
Heart: Normal S1 and S2. No murmurs.
Abdomen: soft, nontender, nondistended, NABS
Ext: no edema
1. Develop a differential diagnosis for this patient.
PE (she is hypercoagulable – one of leading causes of peripartum mortality)
2. How would you initially evaluate this patient and why? Prioritize your initial laboratory or
imaging requests. (Include review of Image Case 3: CXR 1A-B (PA and lateral).)
CT to rule out PE
ABG (debatable if you need this)
CXR 1A: normal.
CXR 1B: normal
3. What are the next options for imaging and the advantages and disadvantages of each?
(Include review of Image Case 3: CT scan 1A-B—soft tissue windows and lung windows)
CT with contrast. Could have alternatively done V/Q scan to look for PE (good if patient has contrast
allergy or renal disease).
CT 1A: Big embolus in left main pulmonary artery. See a filling defect (contrast isn‘t there).
Risk factors for DVT
Smoking + Estrogen Therapy
Chest/Pulmonary Student Handout 6
4. Would your work-up have changed if this episode of shortness of breath occurred during the
Yes. Would have shielded the baby if you had to do a CT or could do a V/Q scan possibly. Case 4 Mild shortness of breath is common as pregnancy progresses. A 32 year old male was seen by his primary care provider for a 2-3 week history of fever (Tmax 102 F), chills, and cough productive with green sputum. He was diagnosed empirically with community acquired pneumonia and placed on Azithromycin. He did not improve after 48 hours of therapy. He presented to
the emergency department with worsening of symptoms.
ROS: positive for night sweats; right sided pleuritic chest pain; fatigue, malaise, and decreased
PMHx: No surgeries or chronic health problems.
Family history: unavailable.
Social history: 6 cigarettes/day; 12 pack of beer/weekend. Originally from Honduras. Has lived in the
U.S. for 10 years. Lives with his wife and 11 month old son.
VS: T = 99, P = 86, R = 18, BP = 126/84; pulse oximetry 91% Gen: Appears comfortable at rest, no distress.
HEENT: PERRL, EOMI, oropharynx—moist mucous membranes; no tonsillar hypertrophy or exudate Lungs: Rales in left lung field. Decreased breath sounds over left lower lung field. No wheezes.
Heart: RRR without murmur
Abdomen: Soft, nontender, no palpable organomegaly.
Extremities: Without clubbing, cyanosis or edema. No calf swelling or tenderness.
1. What is your differential diagnosis?
Pneumonia (that didn't respond to azithromycin) – either resistant or viral Fungal Lung Infection
TB ? Since from Honduras (could be latent infection)
Aspiration Pneumonia (likes to drink)
Bacterial URI (that didn't respond to azithromycin)
2. What initial labs and imaging study would you order and why?
(Include review of Image Case 4: CXR 1(PA and lateral)):
CXR => He has rales and decreased breath sound in his left lung. He has also described right sided
pleuritic chest pain. These respiratory symptoms along with his fever point towards a lung infection of
Sputum Culture => To see if anything grows.
Case 4 CXR 1A: Good inspiratory effort (I count 10 ribs on the right). Heart size looks to be within
normal limits. Right lung looks normal with a good diaphragmatic border and a sharp costophrenic angle.
There appears to be some infiltrate in the left lung. The diaphragmatic border isn't as sharp and the costophrenic angle appears to filled with something (meniscus sign in costophrenic angle). He has a
possible pleural effusion. Patchy infiltrate of apex of right upper lobe. He definitely has a pneumonia.
3. What diagnostic study would you like to perform next?
Chest/Pulmonary Student Handout 7
AFB stain => for TB
4. How do you determine if pleural fluid is a transudate or an exudate?
Light's Criteria (Pleural Fluid LDH level / Serum LDH level) >0.6
(Pleural Fluid Protein level / Serum Protein level) > 0.5
Pleural Fluid LDH greater than 2/3 upper limit of normal serum level
5. What are common causes of transudative effusion? Common causes of exudative effusion?
Congestive heart failure
Cirrhosis (hepatic hydrothorax)
Atelectasis (which may be due to malignancy or pulmonary embolism)
Malignancy (carcinoma, lymphoma, mesothelioma)
Collagen-vascular (rheumatoid arthritis, lupus)
Postcardiac injury syndrome
Yellow nail syndrome
Review Case 4 CXR 2A-B taken during the patient’s treatment.
Case 4 CXR 2A: Left lung appears ―less hazy‖. The left costophrenic angle still isn't really sharp, but it
is much more normal looking than before.
Case 4 CXR 2B: Posterior costophrenic angle still looks like it might have some fluid in it.
Patient had TB.
Review Case 5 CXR 1 and CT scan 1A-C.
What are your findings and likely diagnosis?
Chest/Pulmonary Student Handout 8
CXR 1A: Bilateral infiltrates. Bases more affected than uppers. Increased pulmonary markings
CT 1A: Diffuse alveolar infiltrates. More central than peripheral. Cardiomegaly. Huge pleural effusion on posterior right lung.
CT 1B: same
CT 1C: same
CHF with Pulmonary edema
Both CXR and CT = CHF
What type of clinical presentation (i.e. symptoms, physical examination findings, and past medical
history) might be expected for a patient with these images?
– Exertional dyspnea progressing to orthopnea and then dyspnea at rest ? Fatigue and exercise intolerance – Paroxysmal nocturnal dyspnea – Chronic nonproductive cough (often worse in recumbency) RV CHF – Nocturia – Anorexia
– Right upper quadrant pain due to chronic passive congestion of the liver and gut
? Tachycardia, hypotension, reduced pulse pressure, cold extremities, and diaphoresis
? Long-standing severe CHF: cachexia or cyanosis
Physical examination findings in LV CHF
– Crackles at lung bases, pleural effusions and basilar dullness to percussion, expiratory wheezing, and rhonchi
– Parasternal lift, an enlarged and sustained LV impulse, a diminished first heart sound
– S3 gallop
– S4 gallop in diastolic dysfunction
Physical examination findings in RV CHF
– Elevated jugular venous pressure, abnormal pulsations, such as regurgitant v waves
– Tender or nontender hepatic enlargement, heptojugular reflux, and ascites
– Peripheral pitting edema sometimes extending to the thighs and abdominal wall