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VAQ 3

VAQ 3. Helen Parker & James Taylor Sandringham Hospital 2014. VAQ 3 An 80 year old lady from high level care presents with shortness of breath. Her observations are as follows: Temp 38.2 PR 120 BP 110/70 RR 30 Sats 92% on 10L O2 Describe and interpret her CXR (100%).

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VAQ 3

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  1. VAQ 3 Helen Parker & James Taylor Sandringham Hospital 2014

  2. VAQ 3 • An 80 year old lady from high level care presents with shortness of breath. Her observations are as follows: • Temp 38.2 • PR 120 • BP 110/70 • RR 30 • Sats 92% on 10L O2 • Describe and interpret her CXR (100%)

  3. Positive findings on CXR • RUL consolidation/collapse- extensive • - some air bronchograms • - upward bowing of fissure • RLL consolidation medially • RML sparing- R heart border preserved • LLL – some incr markings. Left heart border indistinct – lingular lobe. • LU zone relatively clear

  4. Positive findings continued.. • Likely/possible cardiomegaly (even allowing for AP view) • Likely/possible LVF – prominent upper lobe vessels, possible small effusions as blunted costophrenic angles

  5. Relevant negatives…. • No evidence cavitation/ abscess radiographically • No large effusion/ empyema • No pneumothorax

  6. Interpretation • Elderly HLC nursing home pt with significant hypoxia and septic clinical picture • Multilobar pneumonia • Aetiol: bacterial • Consider aspiration as RUL/RLL • Concurrent LVF • HIGH MORTALITY RATE • NOT a candidate for aggressive resuscitation/ intubation/inotropic support

  7. Interpretation continued.. • Consider any advanced care directives • Involve NOK in end-of-life care discussion • May be appropriate to treat with antibiotics but likely terminal illness regardless • Palliation/ comfort measures only , a reasonable option

  8. Pitfalls in answers • Lack of knowledge of normal CXR anatomy!! • (R heart border is visible= RML spared) • - not pass/fail point but diminished overall mark

  9. Right heart border

  10. If RML consolidation present- lose R heart border as solid:solid interface rather than air:solid interface

  11. Pitfalls in answers cont’d…. • Over-calling/ over-analyzing • Eg tracheal deviation to R plus RUL mass plus prominent hilar region ?LN’s

  12. Unfolded aorta displacing trachea

  13. Pitfalls • Failure to comment on severity of illness and high mortality • Failure to consider option of comfort/ palliation measures • Failure to consider treatment limits/ advanced care directives

  14. Suggested method(s) to improve interpretation • Look at the stem (in this case an elderly lady with significant hypoxia/ sepsis), then examine the prop (the xray) and ask yourself “how does this CXR support what is going on clinically?” • (and is there anything which is at odds with the clinical picture?)

  15. Suggested method(s) to improve interpretation • Try changing the age group of the patient to see if it changes your “take” on the situation – for example – change the patient to a 40 yo female and imagine yr interpretation– now, how does your answer change given its an 80 yo from HLC??

  16. Make the negatives RELEVANT • Clinical picture and xray suggest PNEUMONIA • So, look for common complications of pneumonia • Empyema • Abscess • Pneumothorax

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