Vincent Chou, Pulmonology W2D1-2

During my first two days in pulmonology, I have likely seen more CXR's than all of last school year. Dr. Huang presented to us the basics and step-wise fashion of CXR interpretation. Many things were (much needed) review, but certain details were new. 

• use of lordotic view for improved view of lesions in apex
• four bumps in mediastinum and heart: aortic arch, pulmonary trunk, left atrium, left ventricle
• enlarged pulmonary trunk indicates pulmonary hypertension--in one case we've seen one so large that it protruded out the right side and was mistaken for a tumor
• four cancers common in mediastinum are the 3 T's and 1 L: thyroid, thymoma, teratoma, and lymphoma
• there are more lung markings in the lower right lobe because of the inferior PA
• fully inspired breath, lung field should encompass 6 ribs anteriorly and 10 ribs posteriorly
• heart width is measured in PA view; width is larger in AP view
• memorizing bronchus number and associated lobe is useful for endoscopy
• RUL: RB 1-3, RML: RB 4-5, RLL: RB 6-10
• LUL: LB 1-3, Lingula: LB 4-5, LLL: LB 6, 8, 9, 10

Dr. Yiu also showed us films of some fascinating cases he's seen in the past few years (which he can conveniently pull up on any computer using the patient number). He also a number of topics as well as each of his cases in depth.

• The new GOLD's criteria of grading COPD. Previously grouped into numerical 1,2,3, or 4 based on percent of ideal FEV1. Currently, it is grouped A B C or D based on lung fuction, frequency of acute exacerbation, and presence of dyspnea. Dr. Yiu suggests that in the future it will become more phenotypic grouping. An example of a phenotypic groupic would be frequent acute exacerbators, and their associated treatment would primarily include anti-inflammatory drugs, such as steroids, PDE-4 inhibitors (roflumilast), macrolides (for immunomodulatory effects), and acetyl cysteine (mucolytic and antioxidant effects). On the other hand, another phenotypic group would be emphysema, which would require predominately bronchodilators, etc.
• Most common cause of chest pain in young adults is mitral valve prolapse. It is a localized pain that can also be migrating and intermittent. Breathlessness is not related to exercise. Patients usually have a history of palpitations. Most often it is related to stress, and the most effective treatments are beta blockers and to decrease life stressors.