Clinical questions - chest Flashcards
Left upper lobe collapse signs?
as the lobe collapses, it appears as a veil like shadow over the left hemi-thorax, there may be associated hyper-expansion of the superior segment of the left lower lobe = The lateral border of the aortic arch is well defined by air (Luftsichel sign). there is tenting of the hemidiaphragm. There is loss of the left superior mediastinal and left heart border interfaces (silhouette sign). Can do a lateral CXR to see the oblique fissure pushed anteriorly and the superior segment of the left lower lobe hyperinflated.
elevation of the hemidiaphragm
‘peaked’ or ‘tented’ hemidiaphragm: juxtaphrenic peak sign
crowding of the left sided ribs
shift of the mediastinum to the lef
What are the parts of the cardiac silhouette?
Recognition of this sign is useful in localising areas of airspace opacities, atelectasis or mass within the lung, with the loss of these normal silhouettes on frontal chest radiographs being generally indicative of the site of pathology 3, 4:
right paratracheal stripe: right upper lobe
right heart border: right middle lobe or medial right lower lobe
right hemidiaphragm: right lower lobe
aortic knuckle: left upper lobe
left heart border: lingula segments of the left upper lobe
left hemidiaphragm or descending aorta: left lower lobe
Sites of silhouette sign on the lateral chest radiograph include 3:
posterior border of the heart +/- posterior left hemidiaphragm: left lower lobe
anterior right hemidiaphragm: right middle lobe
posterior right hemidiaphragm: right lower lobe
The silhouette sign forms the basis of the hilum overlay sign, cervicothoracic sign and thoracoabdominal sign 2
right upper lobe collapse
volume loss with raised horizontal fissure, rib-space narrowing and a raised hilum
a Golden S sign indicates the central mass causing obstruction and distal collapse. The mass may be in the hilum due to pulmonary lung cancer or metastases. There is increased opacification in the right upper zone with associated volume loss - rib spacing is reduced, midline structures displaced to the right and the right hilum and right hemi-diaphragm are elevated.
There is increased density at the right hilum consistent with a mass causing upper lobe collapse. Review of the lung fields and bones is normal. The costophrenic angle is crisp and there is no suggestion of pleural fluid on either side.
left lower lobe collapse
look for retrocardiac density and loss of the medial hemidiaphragm there may be a classic sail sign, but don’t count on it. Sail sign = anterior fat pad
pulmonary oedema
look for associated features including pulmonary plethora (increased pulmonary perfusion), Kerley lines, effusions and cardiomegaly.
Pulmonary hemmorage
Goodpasture’s syndrome: history of renal disease
Wegener granulomatosis: history of nasal symptoms/sinus disease
Blood in the alveolar, clears up faster than pneumonia.
Congestive heart failure
Cardiomegaly (greater than the width of one hemithorax)
Upper lobe venous diversion
Kerley-B lines
Bat’s wing hilar oedema
Bilateral effusions. Pleural fluid seen on the left side.
Pulmonary vessels are somewhat more prominent compared to the old film.
What are the consequences of pneumonia?
Pleural effusion
Empyema
Hyponatremia
Abscess in the lungs
Sarcoidosis
reticulonodular opacities bilateral and symmetric. Bilateral symmetrical hilar enlargement + paratracheal enlargement = Garland triad, lung parynchemal shadowing, mediastinal nodal enlargement, possibly pulmonary effusion. Can get a galaxy sign in alveolar sarcoidosis. In end stage sarcoidosis you get coarse linear opacities in upper and middle zones.
TB
Widespread ill-defined densities, which are probably small consolidations.
Cavity
atelectasis
minimal fibrosis
basal atelectasis
severe collapse of the alveoli, raising the diaphram
MI
batwing/ butterfly appearance
Cardiomegaly
enlarged aorta and double heart border lines
Pericardial effusion
cephalisation of blood vessels
Right atrial enlargement
Lost heart definition maybe due to tricuspid stenosis
Mitral valve replacement
enlarged left side
Left atrial enlargement
double density sign/ double buble
increased atrial diameter
increased subcarinal angle
ASD (Atrial septal defect)
Convex bump
No double sign therefore it’s an atrial atrial enlargement – hole between the right and left atrial septum. This is where blood clots may occur.
Mitral stenosis
cardiomegaly
double left heart border (enlarged left atrium and normal right atrium)
prominent left atrial appendage
splaying of the subcarinal angle (>120 degrees)
Pulmonary hypertension
High blood pressure results in high back pressure therefore all the vessels in the hilum get enlarged. BP of systolic greater than 120
Tetralogy of Fallot
Great vessels connect to the wrong part of the heart and the blood flow is different. Bulge of the atrium with a sharp angle.
Golf club
VSD
ventricular enlargment
TAPVR
x
CHF
Cephalisation of pulmonary veins, double buuble
When do you know there is a LL pneumonia?
Left lobe : cannot distinguish between the borders of the left lobe and the heart silhouette = silhouette sign.
Some kind of pneumonia (LL) because you can’t see the lower lobe and you can’t distinguish the heart size.
COPD or emphysema
Bullae = blowouts alveolar blowouts
decreased peripheral vessels (arteries),
vascular markings are decreased in peripheral lung fields,
Look how high the clavicles are
12 posterior ribs
Elevated hilum
If the left lung looks white, what are the possible causes for it?
Right lung removed Hemothorax Atelectasis Pleural effusion Empyema – pus filled lung Lung full of blood. Pneumonia to the whole of the lung
ABCDE checking full form
Apices - Pneumothorax? Bones/soft-tissues - Fractures/density? Cardiac shadow- Consolidation/mass? Diaphragm - Pneumoperitoneum? Edge of the image - Unexpected findings?
Pleural effusion
- homogenous opacification
- > 400ml fluid
- loss or blunting of costophrenic angle
- possible mediastinal shift
lateral image =
- superimposed costo angles
Pulmonary embolus
more localised opacities extending to the pleura and indistinguishable between small areas of inflammation and/or collapse
Collapse and linear atelectasis Raised hemidiaphragm - hampton's hump Pleural effusion Wedge shaped shadowing reduced vascular markings, This is ‘Westermark’s sign
primary TB
Enlargement of the right hilar lymph nodes
Plueral effusion
Homogeneous, well-defined consolidation of the lung parenchyma
Healing TB
healing occurs scaring leaves calcium deposits
inflammatory cells are killed, and a cavity forms. cavities come together to form a large cavity,
Air-space pneumonia
air-bronchogram signs
Aspiration Pneumonia
stomach and oesophagus contents get into lung
Lower lobes affected
consolidation
Bronchopneumonia
An inflammation that originates in the airway s and spreads to adjacent alveoli. Radiographically appears as PATCHY areas of consolidation within the lung
Interstitial pneumonia
An inflammation that predominately involves the walls of the alveoli, and obviously the interstitium. Radiographically, the appearance is a LINEAR, or RETICULAR pattern.
Pneumoconiosis
Prolonged occupational exposure to certain irritating dusts.
Radiographic appearance is one of nodular shadows scattered throughout the lung. These nodules may become calcified
Asbestosis
plueral thickening with calcific plaques
heart contours ill-defined and shaggy
Shrinkage of the lung starts in the lower portions = first sign
mesothelioma = result
Pericardial Mesothelioma
affects the lining of the heart
cystic fibrosis
diffuse interstitial disease with bronchiectasis and nodular densities of mucoid impaction
Appears as pulmonary oedema
ARDS - two general way of occurring
Direct and indirect lung injury
Hyaline membrane disease (RDS) *
decreased surfactant therefore called newborn or glass lung. Increased air bronchograms and hypoaeration
Consolidation with atelectasis.
Increased opacity seen behind the left heart with loss of the left hemi diaphragm centrally, suggestive of progressive consolidation/atelectasis. Bilateral pleural effusions are still seen
Bronchiectasis
honeycomb lung appearance
Pneumothorax
- visceral pleural white line
- Absence of lung markings distal or peripheral to the visceral pleural white line
- Displacement of mediastinum
- Deep sulcus sign
Tension Pneumothorax
Increasing pressure forces complete collapse of the lung on the affected side and a flattening hemidiaphragm
Mediastinal shift away from the pneumothorax
Reexpansion Pulmonary Oedema
the re expansion treatment occurs too rapidly
Surgical Emphysema
Mediastinal Emphysema
= Air pushes mediastinal pleura laterally
Subcutaneous Emphysema = Streaks of lucency outline muscle boundaries of chest
Miliary Metastases
Wide spread nodules throughout both lungs (usually secondaries from highly vascular tumors)
Non-Hodgkin’s lymphoma of mediastinum
Large soft tissue anterior mediastinal mass with significant neovascularity. Substantial posterior mass effect on mediastinal structures with some vascular attenuation. Pericardial and L pleural effusion.
