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LIs 1) Can you put in tabular form the physical findings which distinguish a pneumothorax from a hemothorax and

atelectasis? a. A collapsed lung (pneumothorax) is due to an air leak from the inside of the lung through the covering of the lung, out into the space between the lung and the ribs. The site of the leak has some damage, which heals itself later. With a hemothorax, it is not air that is filling the chest cavity between the lung and the rib cage, but it is blood (the blood can come from any broken vein or artery. b. Atelectasis is a partial collapse of the lung caused by failure of the parenchymal (functional) lung tissue due to disease (i.e., COPD). Pneumothorax is the collapse of the lung due to mechanical causes (i.e., traumatic injury, violent coughing). 2) Pathophysiology of narcolepsy in relation to obesity a. Narcolepsy i. Other features Additional findings that are common among patients with narcolepsy include fragmented sleep, other sleep disorders, depression, and obesity ii. Narcolepsy is a clinical syndrome of chronic daytime sleepiness, cataplexy (Cataplexy is a sudden and transient episode of loss of muscle tone, often triggered by emotions such as laughing, crying, terror, etc.), hypnagogic hallucinations, and sleep paralysis 3) Significance of enlarged neck circumference / crowded oro-pharynx a. Daytime sleepiness is a common feature of OSA Obstructive sleep apnea b. Careful questioning of the patient typically reveals a pattern of feeling sleepy or falling asleep in boring, passive, or monotonous situations. As an example, the patient may admit to consistently falling asleep while reading, watching television, or even while operating a motor vehicle c. Physical examination OSA is most common among males who are 18 to 60 years old, although it is also common at other ages and in women. The physical exam is frequently normal, except for obesity (body mass index >30 kg/m2) and a crowded oropharyngeal airway. The obesity may be only moderate, since up to 40 percent of patients are less than 20 percent above their ideal body weight. Additional physical findings that are common among patients with OSA include the following: i. Narrow airway Numerous conditions can narrow the upper airway. These include retrognathia, micrognathia, lateral peritonsillar narrowing, macroglossia, tonsillar hypertrophy, an elongated or enlarged uvula, a high arched or narrow palate, nasal septal deviation, and nasal polyps. ii. Large neck and/or waist circumference OSA is more strongly correlated with an increased neck size or waist circumference than general obesity. OSA is particularly prominent among men who have a collar size greater than 17 inches and women who have a collar size greater than 16 inches. iii. Elevated blood pressure Approximately 50 percent of patients with OSA have coexisting hypertension, which is often most elevated in the morning. iv. Signs of pulmonary hypertension or cor pulmonale (eg, peripheral edema, jugular venous distension) Pulmonary hypertension and cor pulmonale are common sequelae when OSA coexists with either obesity hypoventilation syndrome or an alternative cause of daytime hypoxemia (eg, chronic lung disease) 4) What are the differences between collapsed / obstructed lungs in CXR? a. The main feature of a pneumothorax on a chest radiograph is a white visceral pleural line, which is separated from the parietal pleura by a collection of gas. In most cases, no pulmonary vessels are visible beyond the visceral pleural line (the collection of pleural gas is avascular).

b. TYPES OF PNEUMOTHORAX Imaging may provide important clues about the type of pneumothorax that exists. However, imaging alone is seldom sufficient to determine the type of pneumothorax. The clinical context always needs to be considered along with the imaging findings. i. Simple pneumothorax With a simple pneumothorax, the pleural pressure in the affected hemithorax remains subatmospheric and is only slightly more positive than the pleural pressure in the contralateral hemithorax. A simple pneumothorax usually has only modest repercussions unless the patient has limited respiratory reserve or is being mechanically ventilated. Radiographically, simple pneumothoraces tend to be small and without mediastinal shift to the contralateral side. ii. Tension pneumothorax With a tension pneumothorax, the pleural pressure in the affected hemithorax exceeds atmospheric pressure, particularly during expiration. This is frequently the result of a "check valve" mechanism that facilitates the ingress of gas into the pleural space during inspiration, but blocks the egress of gas from the pleural space during expiration. The results are the accumulation of gas, the build-up of pressure within the pleural space, and eventually respiratory failure from compression of the contralateral normal lung. Radiographically, tension pneumothorax shows a distinct shift of the mediastinum to the contralateral side and flattening or inversion of the ipsilateral hemidiaphragm. iii. Open pneumothorax Open pneumothorax occurs when a traumatic chest wall defect persists, through which ambient air enters the pleural space during inspiration (ie, a "sucking wound"). As a result, the mediastinum shifts toward the normal hemithorax and the lung within the injured hemithorax remains collapsed. During expiration, air exits the pleural space through the chest wall defect and the mediastinum swings back toward the injured hemithorax. Expiratory air from the normal lung (ie, pendulum air) fills the collapsed lung. The mediastinal flutter" may cause respiratory failure. Radiographically, an open pneumothorax is characterized by a visible chest wall defect and by massive expiratory mediastinal shift towards the injured side: this mediastinal behavior is different from tension pneumothorax where the expiratory shift of the mediastinum occurs towards the normal lung, resulting from air-trapping in the affected pleural space. iv. Pneumothorax ex vacuo This rare type of pneumothorax forms adjacent to an atelectatic lobe. It is seen preferentially with atelectasis of the right upper lobe and is the result of rapid atelectasis producing an abrupt decrease in the intrapleural pressure with subsequent release of nitrogen from pleural capillaries. Treatment consists of bronchoscopy rather than chest tube drainage. Radiographically, pneumothorax ex vacuo is suggested when an atelectatic lobe or lung, particularly right upper lobe atelectasis, is surrounded by a focal pneumothorax. A similar presentation can occur in patients with visceral pleural thickening and a "trapped lung" following drainage of an effusion. v. Bilateral postoperative pneumothorax Bilateral pneumothoraces have been described after cardiac surgery, particularly in recipients of heartlung transplants. They are a consequence of extensive mediastinal dissection disrupting the anterior junction line, allowing a unilateral pneumothorax to propagate to the contralateral hemithorax. A single thoracostomy tube is able to evacuate both pleural cavities. This type of pneumothorax has been dubbed buffalo chest, since these animals have pleural spaces that communicate anteriorly and, as a result, they are susceptible to bilateral pneumothorax