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radiology > CXR II > Flashcards

CXR II Flashcards

1
Q

ddx of opacities

A

Air Space or Interstitial dz
○ Patterns overlap, can have both
○ Visible on both CXR and chest CT

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2
Q

characteristics of air-space dz

A 
Fluffy, hazy infiltrates
● Air bronchograms
● Opacities confluent (comes together), margins indistinct
● Segmental/lobar consolidation common
● “Bat wing” pattern
● Silhouette signs
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3
Q

volume loss and scaring otherwise known as

A

atelectasis

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4
Q

characteristics

A 
Discrete “particles” of Dz
● Masses, honeycombing
● No air bronchograms
● No lobar margins
● If diffuse, usually bilateral
● Areas of normal lung may be present w/
good aeration
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5
Q

another name for air disease

A

alveolar disease

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6
Q

another name for infiltrative dz

A

interstitial

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7
Q

most PNA are airspace of interstitial

A

airspace

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8
Q

three ways to describe interstitial lung dz findings on a CXR

A

Reticular​ = too many lines
○ Nodular​ = too many dots
○ Reticulonodular​ = too many lines

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9
Q

Segmental/lobar patterns tend to be airspace of interstitial dz?

A

airspace

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10
Q

Silhouette signs is indicative of airspace of interstitial dz?

A

AIRSPACE

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11
Q

– Pneumococcal PNA is seen as airspace of interstitial dz?

A

LOBAR –> airspace

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12
Q

legionella PNA is a characteristically seen as airspace of interstitial dz?

A

airspace

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13
Q

PCP PNA (late)s characteristically seen as airspace of interstitial dz?

A

airspace

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14
Q

aspirations favorite lobe

A

Aspiration – favors RLL

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15
Q

bronchograms

A

airspace dz finding due to fluid around the bronchial tubes

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16
Q

aspiration is typically seen with airspace characteristics or interstitial?

A

airspace
RLL

LL in generally but RLL if pt is supine

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17
Q

silhouette sign of ascending aorta is indicative of a dz in the

A

RUL

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18
Q

silhouette sign of right heart border is indicative of a dz in the

A

RML

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19
Q

silhouette sign of RIGHT hemidiaphragm is indicative of a dz in the

A

rll

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20
Q

silhouette sign of descending aorta is indicative of a dz in the

A

LU or LLL

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21
Q

silhouette sign of L heart border is indicative of a dz in the

A

lingula of LUL

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22
Q

silhouette sign of LEFT hemidiaphragm is indicative of a dz in the

A

LLL

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23
Q

Silhouette sign is indicative of airspace or interstitial dz?

A

airspace

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24
Q

Pulmonary alveolar​ edema – cardiac (late

CHF) or non-cardiogenic is usually seen with airspace or interstitial CXR characteristics

A

airspace

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25
Q

Most TB ari or interst?

A

air

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26
Q

Pulmonary hemorrhage air or interst?

A

air

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27
Q

ARDS air or interst?

A

air

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28
Q

a form of non-cardiogenic
pulmonary edema seen with Delayed dyspnea, hypoxia, alveolar edema

this is a fatal systemic illness

A

ARDS
(Adult Respiratory Distress
Syndrome)

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29
Q

Chronic alveolar Dz air or interst CXR

A

air

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30
Q

alveolar edema is seen in what type of dz

A

lat CHF of non-cardeogenic

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31
Q

“Bat-wing” pattern - central distribution

A

alveolar edema

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32
Q

Viral or fungal seen as interst or air CXR findings ?

A

interstitial

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33
Q

Recall that the lingula is part of the _____

A

Recall that the lingula is part of the left upper lobe.

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34
Q

Systemic Dz seen as interst or air CXR findings ?

A

Systemic Dz – sarcoid, RA, etc – affect both

lungs

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35
Q

Cancer, mets seen as interst or air CXR findings ?

A

interst

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36
Q

Pulmonary fibrosis, Pneumoconiosis

(“dusty lung”) seen as interst or air CXR findings ?

A

interst

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37
Q

○ Asbestosis, silicosis, coal worker’s

lung, etc are all air or interstitial CXR findings?

A

interst

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38
Q

TB – miliary, cavitary lesion classified as air or interstitial CXR findings

A

interstitial

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39
Q

pulmonary edema seen with early CHF air or interstitial CXR findings

A

interstitial

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40
Q

Three great pretenders

A

syphillis
TB
appendicitis

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41
Q

reactivation TB favors which lobes

A

upper

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42
Q

milliary TB is air or interstitial?

A

interstitial

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43
Q

when to suspect TB based on HX

A 
cough 
losing weight
spit up blood
short of breath
from endemic area
incarcerated 
homeless
exposure
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44
Q

fever and elevated respiratory rate

or fever and low pulse OX

A

CXR!

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45
Q

ddx of cavitary lesions

A

(Reactivation TB, Staph and Strep pneumonias, Klebsiella and Coccidiomycosis, cancer, strep PNA

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46
Q

● Differential diagnosis of consolidation:

A

Pneumonia - airways full of pus
○ Cancer - airways full of cells
○ Pulmonary hemorrhage - airways full of blood
○ Pulmonary edema - airways full of fluid

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47
Q

T or F Consolidation means there is infection.

A

false!

Consolidation does not always mean there is infection. The small airways may fill with material other than pus.

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48
Q

occupational lung dz are almost always air or interstitial?

A

interstitial

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49
Q

typically CXR finding with sarcoidosis

A

bilateral mediastinal lymphadenopathy

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50
Q

Diffuse, bilat

hilar adenopathy seen as innumerable nodules

A

miliary TB

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51
Q

cardiomegaly common is common with what CXR finding

A

CHF cardiopulmonary edema

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52
Q

non cardiogenic pulmonary edema

A

Heart +/- normal; less commonly see Kerley B, effusions

Near drowning, inhalation injury

Drug hypersensitivity, overdose (heroin)

Fluid overload - renal failure/uremia

High altitude pulmonary edema (HAPE)

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53
Q

cardiogeni pulmonary edema is characterized by

A

● Fluid in fissures (major and minor)
● Kerley B lines (Kerley A lines too)
● Pleural effusions
● Peribronchial cuffing

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54
Q

pleural based straight lines coming right off of the edge

A

kerley B’s

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55
Q

what is peribronchial cuffing

A

bronchus on end seen b/c of fluid aroudn the bronchus like in CHF

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56
Q

Incomplete aeration/expansion of the lung – no air there

A

Atelectasis

incomplete aeration or expansion of the lung because there is no air there

the lung collapses

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57
Q

why does atelectasis appear white

A

because collapsed lung is denser

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58
Q

Causes of atelectasis

A

obstructing neoplasm such as a bronchogenic carcinoma, asthma mucus plugs, aspirated FB

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59
Q

what do we see in with structures and fissures

A

sructures shift to SAME side (being PULLED), fissures displaced

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60
Q

what do we see in the unaffected lung with at atelectasis

A

○ Compensatory overinflation of thasis e unaffected ipsilateral lobes or the contralateral lung

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61
Q

Lobar collapse d/t occluding lesion of the bronchial tree

A

obstuctive lobar atelect

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62
Q

diaphragm on obstructure atelectasis

A

elevated (being pulled)

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63
Q

Tracheal deviation, mediastinal deviation, elevated hemidiaphragm (tenting), upward bowing of
fissures, hyperinflation remaining lung on same side, rib cage narrowing

all common findings with

A

obstructive atelectasis

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64
Q

common causes of obstructive atelectasis

A

Tumors – includes bronchogenic carcinoma (especially squamous cell), endobronchial
metastases, carcinoid tumors
● Mucus plug – esp in bedridden, post-op, asthma or cystic fibrosis patients
● FB aspiration – esp peanuts, toys, or following a traumatic intubation
● Inflammation – as in scarring caused by TB

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65
Q

Normal or increased volume
No shift
Air space disease
No apex

all classic CXR findings for

A

PNA

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66
Q

key to pleural effusions on CXR

A

meniscus sign​ or blunting of costophrenic angles

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67
Q

you can see small effusions better on what type of CXR

A

lateral

68
Q

Meniscus sign

A

upward sloping of fluid in cfa

69
Q

○ The beam must be _______ to fluid to see meniscus or fluid level

A

○ The beam must be horizontal to fluid to see meniscus or fluid level

70
Q

Plural effusion _____things away and atelectasis ____

A

pleural effusions pushes

atelectasis pulls

71
Q

causes of plural effusions

A

: infection, malignancy (chest or abdominal), CHF, trauma/toxic, renal failure, chronic lung disease

72
Q

effusions in the lung can be foun

A

fluid in thorax, around the lung; in the potential space between the visceral and parietal pleura

73
Q

fissure finding with effusions

A

Look for “opacified” fissures – effusion fluid likes to collect here

74
Q

It takes _____ of fluid to opacify an entire hemithorax

A

It takes 2 liters of fluid to opacify an entire hemithorax

75
Q

– easy to mistake for a mass/infiltrate; btw layers of fissure; will disappear with tx

A

Round effusion​ –

76
Q

luid collects beneath the lung, between the hemidiaphragm and the lung base
→ elevated hemidiaphragm, no meniscus on PA, lateral is the money shot, silhouettes the diaphragm

A

Subpulmonic effusion

77
Q

both air and fluid in pleural space; produces an air-fluid level w/ horizontal beam

A

Hydropneumothorax​

78
Q

Blunting of costophrenic angle – seen earliest on lateral (___ necessary to see it)

A

Blunting of costophrenic angle – seen earliest on lateral (75ml necessary to see it)

79
Q

blunting of costophrenic angle can be seen with ____ml of fluid on PA

A

200-300

80
Q

if plural effusion does not layer out

A

If it does not “layer out” on lateral decubitus film – it is loculated and cannot be tapped simply

81
Q

Failure of an effusion to change location with changes in the patient’s position is a clue that the
effusion is unable to flow freely or is __________

A

Failure of an effusion to change location with changes in the patient’s position is a clue that the
effusion is unable to flow freely or is loculated

82
Q

On CT – effusions settle _______-

A

On CT – effusions settle posteriorly as pt is supine

83
Q

how to differentiate opacified hemithorax from PNA or pneumonectomy

A

no deviation of structures

exam your effin pt if they don’t have a lung you should know (or their ribs are missing)

84
Q

what should we be able to see with a pneumothorax that you can’t see normally

A

Visceral pleura line must be visible

○ *The pleura only become visible when there is an abnormality present.

85
Q

MCC of pneumothorax

A

MCC is trauma, with laceration of the visceral pleura by a fractured rib

86
Q

what film finding would you see with a subtle pneumothorax

A

Expiratory upright film or Lateral decub film if subtle

Inspiratory film expands your lungs vs. expiratory film makes them smaller!
○ Lateral decubitus film b/c air rises!

87
Q

what film finding would you see with a subtle pneumothorax

why?

A

Expiratory upright film or Lateral decub film if subtle

Inspiratory film expands your lungs vs. expiratory film makes them smaller!
○ Lateral decubitus film b/c air rises!

88
Q

● Deep sulcus sign is seen in ______ or ______- with pntx

A

● Deep sulcus sign in supine pt or tension pntx

89
Q

Deep sulcus sign

A

used to recognizing pneumothorax in the supine pt. The air of a pneumothorax will collect
anteriorly and inferiorly, displacing the costophrenic angle inferiorly. The angle becomes “deeper” and
more lucent

90
Q

Tension pneumothorax

A

​ is a clinical Dx, usually after trauma. Sudden tachycardia/hypotension/hypoxia,
pain, resp distress, agitation, tracheal deviation AWAY from affected side, distended neck veins, absent lung sounds, pntx on ultrasound. Immediate lung re-expansion is life-saving – no time for a chest X-ray.

91
Q

“Free Air” under the diaphragm is called_____ usually from

A

Pneumoperitoneum

perforated viscous (hole in the bowel), trauma, post-surgical, post-procedural

92
Q

best film for recognizing a pneumoperitoneum

A

Lateral CXR good for small perfs – see air under diaphragms

○ Really small crescent of air seen separating the liver and diaphragm

93
Q

tomach slides upward through diaphragmatic hiatus (opening in diaphragm for the esophagus).

A

● Diaphragmatic/Hiatal Hernia

History/patient presentation is key – may be completely asymptomatic (painless!)

○ Air-fluid level in stomach commonly seen through heart – straight lines are abnormal…

94
Q

“Free air” around the mediastinum; seen as area of lucency around the heart and great vessels

A

Pneumomediastinum

95
Q

Pneumomediastinum . caused by

A

Pulmonary interstitial emphysema is caused by rupture of an alveolus (d/t increased alveolar pressure)

Mechanical ventilation can also cause pneumomediastinum, as can ruptured bleb (COPD) or barotrauma

96
Q

Air dissecting into the neck and chest wall can produce subcutaneous emphysema. Air dissecting along
muscle bundles produces a characteristic comblike, striated appearance that superimposes on the
underlying lung, often making it difficult to evaluate the lungs by CXR.

A

● Subcutaneous Emphysema

97
Q 
Hyperinflation
○ Flat diaphragms
○ Narrow cardiac silhouette
○ Increased retrosternal space on lateral - “barrel chest”
○ +/- blunting of costophrenic angle

all findings seen with

A

Emphysema

98
Q

why do we see barrel chest on CXR of pt with COPD

A

increased retristernal air

99
Q

what are Bullae on CT chest

A

Bullae​ measure more than 1 cm in size. They are usually associated with emphysema. They
occur in the lung parenchyma and have a very thin wall (<1 mm) that is frequently only partially
visible on CXR but well seen on CT.

100
Q

what are the characteristics of bullae

A

Characteristically, they contain no blood vessels, but there
may be septae that appear to traverse the bulla. On conventional radiographs their presence is
often inferred by a localized paucity of lung markings.

101
Q

CXR findings of lung cancer

A

○ Pulmonary nodule or mass
○ Mediastinal mass/hilar enlargement
○ Lobar atelectasis, obstructive pneumonia, malignant effusions, chest wall mass, metastases

102
Q

CXR can mirror

A

effusions or PNA

103
Q

– central, obstructive – rapid progression lung cancer

A

Squamous cell

104
Q

peripheral, solitary – slow growing

A

Adenocarcinoma

105
Q

central, Cushing’s, SIADH – fastest

A

Small cell/oat cell​

106
Q

– peripheral, dx of exclusion – fast

A

Large cell

107
Q

Diagnostic tool you want to do first if suspecting lung cancer and why?

A
  • low sensitivity; fast, inexpensive, low radiati
108
Q

if you find something on your CXR what would you do next?

A

CT

evaluate CXR abnormalities; staging, screening

109
Q

when would you use MRI for cancer?

A

MRI- not common for lung itself; good for cancer involving spinal cord, soft tissue of neck

probably use it more in the future

110
Q

tests you would do after CT

A

PET scan - staging, diagnosis

○ Fluoroscopy- biopsy, diagnosis, staging of lesion

111
Q

shoulder pain + older + smoker

typical presentation of

A

pancoast tumor

112
Q

Typically destroy adjacent ribs

○ Usually squamous cell carcinoma or adenocarcinoma

A

pancoast tumor

113
Q

Can invade the brachial plexus or cause a Horner’s syndrome on the affected side
○ On the right side, they can also lead to _____-through obstruction of the ____

A

pancoast tumor

Can invade the brachial plexus or cause a Horner’s syndrome on the affected side

○ On the right side, they can also lead to superior vena cava syndrome through obstruction of the SVC

114
Q

Solitary Pulmonary Nodules

what size would indicate benign

A

<3cm

115
Q

what age and risk factor would indicate a malignant pulmonary nodule

A

> 30 smoker

116
Q

Poorly defined edges or “spiculated”
Asymmetric or no calcification
Cavitary

usually indicative or benign or malignant?

A

malignant nodule

117
Q

Well-defined edges
No growth in 2 years
Central calcification

usually indicative or benign or malignant?

A

benign

118
Q

Work-up for benign pulmonary nodule

A

Repeat CXR q3 mos for 1st year,

then q6 mos in 2nd year

119
Q

what would you want to do if you see what you suspect malignant pulmonary nodule

A

CT, PET scan, biopsy

120
Q

★★★Wide Mediastinum DDx: anterior

A

Anterior (retrosternal): “4 T’s”​ – Thyroid, (Terrible) Lymphoma, Thymoma, Teratoma

121
Q

★ Wide Mediastinum DDx: middle

A

Middle: Lymphadenopathy, Cancers, Aortic Aneurysm

122
Q

★ Wide Mediastinum DDx: posterior

A

Posterior: Aortic Aneurysm, Neurogenic tumors

123
Q

spiculation

A

starburst border incredibly suspicious of cancer

124
Q

hallmark of mediastinal mass

A

● Hallmark = wide appearing mediastinum

125
Q

Chest, back pain

○ Risks, presentation

A

high suspicion

Thoracic Aortic Aneurysm

126
Q

● CXR suspicious: of Thoracic Aortic Aneurysm

A

○ Wide mediastinum
○ Tortuous aorta :doesn’t do the arch thing
○ Left pleural effusion common

127
Q

what is the difference b/w a aortic dissection and aortic anuerysm

A

intima (part of the lining of the vessel ) tears apart and away, blood will dissect down

viewed as little black line in an axial view

usually v painful

128
Q

CXR in PE

A

CXR first in all for alternate Dx (but NOT diagnostic!!!)

○ Atelectasis, effusion, elevated hemidiaphragm

almost always normal

129
Q

hamptons hump

A

: late finding (develops in 3-4 days), ipsilateral pleural-based infiltrate

130
Q

Westermark sign​:

A

late; oliguria (decreased vascular markings) distal to site of embolic blockage

131
Q

if you want to RULE OUT a PE

A

CT scan with IV contrast​ – PE protocol

132
Q

if you can not use a CT to dx because of renal failure or pregnancy

A

V/Q scan – if cannot use contrast, consider if pregnan

133
Q

when would we use pulmonary angiogram to rule out a PE

A

probably never

would inject dye this would see westermark

Oligemia distal to the affected segment on pulmonary angiography

○ Used to be gold standard 6-8 yrs ago, but now rarely used

134
Q

oliguria

A

decreased vascular markings

135
Q

what can you see with US following trauma

A

Pneumothorax

  • Fluid in chest (blood)
  • Rib Fracture
136
Q

indications for ULS

A
  • Pulmonary Edema (CHF)
  • Pulmonary Effusions
  • Pneumonia
137
Q

B LINES on ULS

A

obliterate A-lines

can dx pulmonary edema DONE

normally you would see acoustic shadow of the ribs and then A lines. B lines look like little sunshine rays coming down everywhere

138
Q

besides pulmonary edema what else would cause B lines?

A

PNA but not throughout

only in pulmonary edema would we see B lines everywhere

139
Q

fluid is what color on ULS

A

BLACK

allows you do dx plural effusion by looking at the costophrenic angel

in trauma you send this pt to the ER because that is blood

140
Q

if you have an absence of Pleural Sliding WITH ULS

-No comet tail artifact

A

Pneumothorax

141
Q

M-Mode to confirm PNX seen as

A

waves with no beach

aka barcode PNX

142
Q

lung-point

A

Spot where lung moves in one area, not in adjacent area:

100% sensitive

143
Q

infant normal variants on a CXR

A

Thymus

Cardiomegaly - in infants, cardiothoracic ratio can be up to 65% (not 50% as in adults)

144
Q

CXR in peds are helpful for dx

A

Congenital heart disease
Infections
Foreign bodies

145
Q

Tetrology of Fallot

A

cardiac defect that allows for dx w/ CXR in peds

146
Q

steeple sign on CXR is indicative of

A

Croup – “steeple sign”

147
Q

most common cause of a mediastinal mass overall.

A

Lymphadenopathy

148
Q

__________ frequently presents with a border that is lobulated or polycyclic in contour owing to the conglomeration of multiple enlarged nodes.

A

Lymphadenopathy frequently presents with a border that is lobulated or polycyclic in contour owing to the conglomeration of multiple enlarged nodes.

149
Q

_______is most common in Hodgkin’s Disease, especially the nodular sclerosing variety, which was this patient’s diagnosis.

A

Anterior mediastinal lymphadenopathy is most common in Hodgkin’s Disease, especially the nodular sclerosing variety, which was this patient’s diagnosis.

150
Q

aneurysms are defined as enlargement of a vessel greater than ____- of its original size.

A

aneurysms are defined as enlargement of a vessel greater than 50% of its original size.

151
Q

_____ is the most common cause of a thoracic aortic aneurysm. Most patients are asymptomatic and the aneurysm is discovered serendipitously.

A

Atherosclerosis is the most common cause of a thoracic aortic aneurysm. Most patients are also hypertensive. Most patients are asymptomatic and the aneurysm is discovered serendipitously.

152
Q

a thick-walled cavity (dotted line) with a nodular inner margin (white arrow) characteristic of a _

A

a thick-walled cavity (dotted line) with a nodular inner margin (white arrow) characteristic of a cavitating bronchogenic carcinoma,

153
Q

Solitary pulmonary nodules that are found on mass screenings of asymptomatic patients prove to be cancer less ____ of the time.

A

Solitary pulmonary nodules that are found on mass screenings of asymptomatic patients prove to be cancer less than 5% of the time.

154
Q

Masses larger than 5 cm have a ___ chance of malignancy.

A

Masses larger than 5 cm have a 95% chance of malignancy.

155
Q

_______is the most important determinant in distinguishing benign from malignant.

A

Calcification is the most important determinant in distinguishing benign from malignant. The presence of calcification is usually determined by CT.

156
Q

Squamous cell carcinomas of the lung are primarily _____in location.

A

Squamous cell carcinomas of the lung are primarily central in location.

157
Q

why would we want to do a left decubitus xray in a pt withe pleural effusion

A

(1) to establish if the fluid is free-flowing in the pleural space (which has implications for its successful drainage), or, on occasion
(2) to visualize the underlying lung if the patient lies on the side opposite from the pleural fluid for the radiograph.

158
Q

acute airspace disease

A

Pneumonia

Pulmonary alveolar edema

Hemorrhage

Aspiration

Near-drowning

159
Q

chronic airspace disease

A

Bronchoalveolar cell carcinoma

Alveolar cell proteinosis

Sarcoidosis

Lymphoma

160
Q

reticular interstitial disease

A

Pulmonary interstitial edema

Interstitial pneumonia

Scleroderma

Sarcoid

161
Q

nodular interstitial diseae

A

Bronchogenic carcinoma

Metastases

Silicosis

Miliary tuberculosis

Sarcoid

162
Q

why don’t you see air bronchograms in pulmonary alveolar edema?

A

because fluid fills the lungs AND the airways themselves

163
Q

what makes up the lung’s interstitium

A

The lung’s interstitium consists of connective tissue, lymphatics, blood vessels, and bronchi.

164
Q

where does atelectasis most frequently occur in a critically ill patient

A

In the critically ill patient, atelectasis occurs most frequently in the left lower lobe.

165
Q

only a pneumonia in this portion of the lung can be seen to extend above and below the minor fissue

A

but only a pneumonia in the superior segment of the LOWER LOBE can seem to extend both above and below the minor fissure

radiology (13 decks)

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