Goldshmidt: Imaging of the chest, CT scans and MRIs

Question 1

What needs to be visible for an x-ray to be considered to have an adequate breath?

Answer 1

10-11 visible ribs

Question 2

What is the most common rib lesion?

Answer 2

Callous due to a healing fracture

Question 3

What rib lesions are common in older age groups?

Answer 3

Metastatic lesion

Question 4

What two things accentuate heart size?

Answer 4

Supine pictures

AP films

Question 5

What causes an enlarged heart?

Answer 5

1. Hypertrophy due to overuse
2. Cardiomyopathy- CV disease, drugs, infectious
3. Fluid around the heart

Question 6

What will you see with mitral stenosis?

Answer 6

Massive left atrial enlargement

Question 7

What can cause an abnormal aorta?

Answer 7

Aneurysm
Aortic Dissection
Post traumatic injury with hematoma

Question 8

What do you see on an xray of someone with diaphragm paralysis?

Answer 8

You lose your sharp borders and you can’t see the costophrenic angles

Question 9

How do you evaluate diaphragm paralysis?

Answer 9

1. inspiration and expiration films

2. Fluoroscopic evaluation (Sniff test)

Question 10

What does an x-ray of someone with COPD look like?

Answer 10

1. A lot of air is trapped so the lungs look black (radiolucent)
2. Hyper-expanded lungs
3. Barrel chest
4. Flat diaphragms

Question 11

What do you see on a lateral view xray of a pt with COPD?

Answer 11

Diaphragm looks straight rather than curved.

Question 12

What is a common cause of tracheal deviation?

Answer 12

Enlarged thyroid

Question 13

Do you usually see LNs on an xray?

Answer 13

No, if you do, they look like soft fluffy circles in the hilum of the lungs.

Question 14

What causes LN enlargement?

Answer 14

Metastatic disease
Lymphoma
Reactive nodes related to infection (TB)
Granulomatous disease (sarcoid)

Question 15

How many lobes does the right side have vs teh left?

Answer 15

RUL, RML,RLL

LUL, LLL, BUT don’t forget the lingula!!

Question 16

What affects the sihouette sign?

Answer 16

Any process that replaces air in the lung!

Question 17

Pneumonia that obscures the left heart border is….

Answer 17

Lingula pneumonia

Question 18

Pneumonia that obscures the left diaphragm is…

Answer 18

LLL

Question 19

Pneumonia that obscures the right diaphragm is…

Answer 19

RLL pneumonia

Question 20

Pneumonia that obscures the right atrium is….

Answer 20

RML

Question 21

Pneumonia that obscures the SVC is….

Answer 21

RUL

Question 22

Pneumonia that obscures the Aortic knob is…

Answer 22

LUL

Question 23

What does RML pneumonia look like?

Answer 23

Right side of the heart is obscured so you know it’s RML

Question 24

What are air bronchograms?

Answer 24

air filled bronchi and bronchioles outlined by disease in the adjacent aveoli

Question 25

What do interstitial infiltrates look like and what diseases cause them?

Answer 25

Lacy, reticular pattern on CXR

Atypical pneumonia, early CHF, fibrosis

(disease in the interstitium between the alveoli)

Question 26

What are alveolar infiltrates and what diseases cause them?

Answer 26

Disease within the alveoli themselves.

Fluffy, ocnsolidating pattern w/ air bronchograms present.

Bacterial pneumonia, late CHF, ARDS

Question 27

What is commonly seen with CHF?

Answer 27

Early pulmonary edema is interstitial
Late pulmonary edema is alveolar
Pleural effusions are common
CArdiomegaly is often seen
Kerley's B lines  are strongly suggestive

Question 28

What does a pleural effusion look like on a CXR?

Answer 28

Fluid build up in the lungs. Has a meniscus appearance, or may blunt the costophrenic angle. If you lay the person down you may see it more clearly.

Question 29

What is hte DDx for multiple nodules?

Answer 29

Metastatic Disease
Infection
Granulomatous Disease

Question 30

What is hte DDx for a solitary nodule?

Answer 30

Lung cancer
Abscess
Infeciton
Benign granuloma
AV malformation
Granulomatous disease

Question 31

What is the first thing that you suspect if a pt presents to the ER with Chest pain and what do you do?

Answer 31

Acute Coronary Syndrome
-MI, Angina

Get EKG and check enzymes

Question 32

What is the second cause of chest pain?

Answer 32

PTX

Question 33

What is a PTX

Answer 33

Air between parietal and visceral pleura. Seen in 30-40% of pts with blunt chest trauma, usually associated with rib fx

(It can also be spontaneous or iatrogenic)

Question 34

What is a tension PTX?

Answer 34

Life threatening

Air accumulates d/t one way valve mechanism causing increased pressure with vena cava compression and impaired venous return

Question 35

What does a tension PTX look like on a CXR?

Answer 35

Sharp line= visceral pleura, no lung markings lateral (can push heart/trachea laterally)

Mimics: lg bullae, skin folds, bedding, tubes

Question 36

What is the third primary cause of chest pain?

Answer 36

Pulmonary embolis

Question 37

What is a PE?

Answer 37

Clot in the pulmonary artery
3rd most common cause of DV death. Only 30% are diagnosed prior to death, but less than 35% of pts with suspected PE actually have PE

Question 38

What does a PE look like on a CXR?

Answer 38

NON SPECIFIC

Hampton’s Hump: wedge shaped opacity corresponding to lung infarct

Question 39

What is a VQ scan?

Answer 39

Nuclear medicine scan with ventilation and perfusion components. Pts w/ PE have normal ventilation and abnormal perfusion.

Question 40

What is the 4th primary cause of chest pain?

Answer 40

Aortic dissection–requires immediate surgery

Question 41

What is an aortic dissection?

Answer 41

Tear in the intimal layer of vessel separating intima from media or adventia, causing a false channel.

Question 42

How does aortic dissection present clinically?

Answer 42

Severe pain with tearing or ripping quality

RFs: HTN, Marfans/ehlerdanlos, cocain use, pregnancy

Question 43

What does a CXR of a dissection look like?

Answer 43

Wide mediastinum
Abnormal arch configuration
L>R pleural effusion