Chest X-Ray

Question 1

What is the suggest approach to examining a chest Xray?

Answer 1

1. Projection: (AP/PA)
2. Patient details (consider Hx)
3. Technical Quality (RIP)
4. Obvious abnormality (which lung, which zone, size, shape, density)
5. Systematic Review: ABCDD
   A: Airway (trachea)
   B: Breathing (apices, hila. mediastinum, costophrenic angles, edges of lung fields for pneumothoraces)
   C: Cardio (cardiomegaly, heart boarders, behind the heart)
   D: Diaphragm (costophrenic angles)
   D: Delicates (bones)
6. Summary

Question 2

Pneumonia

Answer 2

Dense/patchy consolidation.
Diaphragms: L and R lower lobes
R heart border: right middle lobe

Question 3

Pleural effusion

Answer 3

Loss of costophrenic angle, homogenous opacification and fluid level (meniscus).
Bilateral or lateral?
Pleural aspiration helps identify cause.

Question 4

How much protein is in an exudate pleural effusion?
Are they normally uni or bi lateral?
What are the main causes?

Answer 4

>30g/l protein
Unilateral
Infection: pneumonia, TB
PE
Malignancy: mets, bronchial, mesothelioma
RA, LUPUS
pancreatitis
Trauma/surgery

Question 5

How much protein is in an transudate pleural effusion?
Are they normally uni or bi lateral?
What are the main causes?

Question 6

If the cause of the transudate is heart failure how does the CXR appear?

Answer 6

ABCDEF
Alveolar shadowing 
Kerley B lines (horizontal dashes in lateral lower edges)
Cardiomegaly (ratio greater than 50%)
Upper lobe blood diversion
Effusions
Fluid in the horizontal fissure

Question 7

Pneumothorax on CXR

Answer 7

Loss of lung markings in peripheral lung field.
Discrete lung edge
If tension (should have been diagnosed clinically): tracheal/mediastinal shift deviation away from the pneumothorax and flattening of diaphragm.

Question 8

Causes of pneumothorax

Answer 8

Spontaneous
Iatrogenic 
Obstructive lung disease 
Infection
Connective tissue disorder

Question 9

Lobar collapse on CRX.

What would you see for Left upper lobe?

Answer 9

Look for loss of volume: narrowing of space between the ribs, a raised hemidiaphragm, tracheal and mediastinal shift towards the collapsed.

Left upper lobe: Veil sign: the whole lung field looks like it’s covered by a veil.

Question 10

Left lower lobar collapse?

Answer 10

Left lower lobe: Sail sign- sharp line like the edge of a sail at the same angle as the heart border

Question 11

Right upper lobe collapse on CXR

Answer 11

Right upper lobe: hazy RUL, with raised horizontal fissure and the abnormality well demarcated by fissure.

Question 12

Right middle lobe collapse on CXR

Answer 12

Loss of right heart boarder (can be difficult to distinguish between consolidation)

Question 13

Right lower lobe collapse on CXR

Answer 13

Hard to differentiate from effusion. Normally complete loss of costophrenic border die to haziness while the right heart border is normally clear.

Question 14

Causes of single coin lesion on CXR.

Names and cause of multiple coin lesions

Answer 14

Malignant tumour: bronchial, single pulmonary metastasis
Infection: pneumonia, abscess, TB, cysts
Infarction
Rheumatoid nodule

Cannonball metastasis. Often from Kidney.

Question 15

Causes of unilateral hilar lymphadenopathy

Answer 15

Neoplastic: spread of bronchial carcinoma, lymphoma
Infective: TB

Question 16

Causes of bilateral hilar enlargement

Answer 16

Sarcoid
Tumours: lymphoma, bronchial carcinoma, metastases
Infection: TB, recurrent chest infections, AIDS

Question 17

Causes of cavitating lung lesion

Answer 17

Abscess (Staph, Klebsiella)
Neoplasm (usually squamous cell)
Cavitation (around puemonia, TB)
Infarct

Question 18

Examples of how you would present your findings to a consultant:

Answer 18

1. This is an AP radiograph. Identity patient details and date it was taken.
2. It is a technically adequate film: adequate penetration, good inspiratory effort, and no important areas are cut of by the film edge.
3. The most striking abnormality is…. in the RU zone….
4. Review film: trachea is central. Comparing R and L lines I can not see any other obvious abnormalities in the lung fields. The heart is not enlarged, heart borders are clear as are the costophrenic angles. There is no abnormality behind the heart. The diaphragms look normal, no air. There is no evidence of fractures.
5. In summary this shows a right upper lobe collapse with associated right hilar enlargement.
6. The most likely DD are…..

Question 19

How do you treat DVT in cancer patients?

Answer 19

LMWH for 16 months and monitor kidney function.

Not warfarin

Question 20

What are the main causes of pleuritic rub?

Answer 20

Pneumonia, pleuritic rub, pleurisy.