Lecture 16 - Chest x-rays

Question 1

What is indicative of a pneumoperitoneum on a chest x-ray?

Answer 1

Dark stripe under the diaphragm

Question 2

What is the approach used to assess a chest x-ray?

Answer 2

ABCDE

Question 3

What do you have to assess before you even start using the ABCDE approach to a chest x-ray?

Answer 3

Confirm the patient details

Question 4

What is the A in ABCDE to chest x-ray assessment?

Answer 4

Airways

Is trachea central (thyroid goitre)

Question 5

What is the B in ABCDE to chest x-ray assessment?

Answer 5

Breathing

Any lung changes?

Question 6

What is the C in ABCDE to chest x-ray assessment?

Answer 6

Circulation (Heart size)

Question 7

What is the D in ABCDE to chest x-ray assessment?

Answer 7

Disability/densities

So bones
Any fractures

Question 8

What is the E in ABCDE to chest x-ray assessment?

Answer 8

Everything else

Soft tissues

Question 9

What size should the heart be relative to the thorax?

Answer 9

Longest transverse diameter of the heart shouldn’t be more than 50% of the transverse diameter of the thorax

Question 10

Where do rib fractures often occur?

Answer 10

Lateral edges

Question 11

What diagnosis should you consider:

20yr old
1wk of lethargy, myalgia, fever and cough with brown sputum?

Answer 11

Pneumonia

Question 12

What signs on a chest x-ray can be seen with pneumonia?

Answer 12

Air space narrowing
Air bronchograms (lines running in the fluffy white area)

Bulging/thickenign of fissures of lung

Question 13

What diagnosis should you consider:

65yr female
Cough
Haemoptysis
Weight loss

Answer 13

Lung cancer

Question 14

What signs on a chest x-ray can be seen with lung cancer?

Answer 14

Rounded opacity
Possible pleural effusion
Possible lymphadenopathy

Question 15

What diagnosis would you consider:

60yr male
1 day of increasing SOB
Frothy white sputum

Answer 15

Likely pulmonary oedema due to heart failure

Question 16

What are Kerley B lines?

Answer 16

Short sharp horizontal lines from the edge of lungs indicating theres fluid in the interstitium of the lung (pulmonary oedema)

Question 17

What signs on a chest x-ray can be seen with pulmonary oedema?

Answer 17

Bat wings (perihilar shadowing)
Peripheral lines (Kerley b lines from interstital fluid)
Pleural effusions

Question 18

What should you’re first thought be if sputum is brown/green?

What should you’re first thought be if sputum is red/haemoptysis?

What should you’re first thought be if sputum is frothy white?

Answer 18

Brown green = pneumonia
Red = lung cancer
White frothy = cardiac failure (pulmonary oedma)

Question 19

What is dextrocardia?

Answer 19

When the heart sits/faces the right side instead of the left side

Question 20

What is situs inversus totalis?

Answer 20

When all of the organs in the abdomen/thorax are on the wrong side

Question 21

What is the point of changing window width and level on CTs?

Answer 21

Can see different structures/details

Question 22

What are the signs of COVID infection on a chest x-ray?

On CT?

Answer 22

Multi focal peripheral opacities

Get ground like glass/opacities on CT

Question 23

What is the first thoughts on diagnosis:

25yr F
Known chronic lung disease
Cough + Increased sputum production

Answer 23

Bronchiectasis/CF

Question 24

What are the signs of cycstic fibrosis on chest x-ray?

What is the sign seen on CT called?

Answer 24

Bronchiectasis
Thickened parallel bronchial airways that aren’t normally visible

Airway plugging
Can have a venous Catheter

Signet ring sign

Question 25

What imaging presentation can a pulmonary embolism have?

Answer 25

Normal CXR Peripheral opacity due to infarction CTPA: filling defect Straightening of interventricular septum since inc RV pressure

Question 26

What is a saddle embolus?

Answer 26

Embolus that spans the width of teh pulmoary artery affecting the 2 main branches

Question 27

What diagnosis would you consider: 20yr M Retching followed by sudden onset sharp central chest pain

Answer 27

Likely tear of lower oesophagus causing Pneumomediastium

Question 28

How does a pneumomediastium present on a CXR?

Answer 28

Streaky lines parallel to mediastinum Gas in neck and Axillae Boerhaave syndrome

Question 29

What is boerhaave syndrome?

Answer 29

Oesophageal tear

Question 30

How do you normally treat pneumomediastium?

Answer 30

Treat nil by mouth to allow oesophagus to heal

Question 31

What diagnosis should you consider: 70yr M Retired factory worker Intermittent SOB Why do you consider this?

Answer 31

Pleural plaques Likely exposed to asbestos which has this affect

Question 32

What are some signs of pleural plaques on CXR?

Answer 32

Calcified plaques Normally very visible on diaphragm surface

Question 33

What diagnosis do you consider in this patient: 70yr M Retired factory worker Worsening SOB Weight loss Fatigue Why?

Answer 33

Mesothelioma Red flags for cancer Likely exposed to asbestos so mesothelioma is caused my asbestos

Question 34

What is mesothelioma?

Answer 34

Malignancy of the lung pleura Usually due to asbestos exposure

Question 35

Why can mesothelioma present with chest wall pain?

Answer 35

Malignancy compresses chest wall nerves

Question 36

What is a sign of mesothelioma on CXR?

Answer 36

Lung encased by ring of tissue Associated within asbestos exposure

Question 37

Go to the last slide and look at CXR 1: 20yr old 1wk of lethargy, myalgia, fever and cough with brown sputum What is your diagnosis? What signs support this?

Answer 37

Pneumonia Airspace shadowing Air bronchograms (can see lines runnngi in white fluffy areas) Well defined bulging fissures

Question 38

Go to the last slide and look at CXR 2: 65yr old F Cough, Haemoptysis and weight loss What is your diagnosis? What signs support this?

Answer 38

Lung cancer Rounded opacity Pleural effusion (lost of sharp costophrenic angles)

Question 39

Go to the last slide and look at CXR 3: 60yr old M 1 day of increasing SOB and frothy white sputum What is your diagnosis? What signs support this?

Answer 39

Pulmonary oedema secondary to heart failure Perihilar shadowing/bats wings X-ay is an AP from resus so patient likely very unwell Kerley b lines

Question 40

Go to the last slide and look at CXR 4: 25yr old M Fit and well, CXR for immigration purposes What is your diagnosis? What signs support this?

Answer 40

Situs inversus totalis Dextrocardia Stomach on right (gastric bubbles) Aortic knuckle on right

Question 41

Go to the last slide and look at CXR 5: 50yr old F 3 day dry cough, malaise and fever What is your diagnosis? What signs support this?

Answer 41

COVID Multifical peripheral opacities

Question 42

Go to the last slide and look at CXR 6: 25yr old F Known chronic lung disease, cough and inc sputum production What is your diagnosis? What signs support this?

Answer 42

Cystic fibrosis Bronchiectasis Thickened parallel airway (indicate inflammation) Airway plugging

Question 43

Go to the last slide and look at CXR 7: 85yr old M Syncope, postural dizziness, hypoxia and tachycardia What is your diagnosis? What signs support this?

Answer 43

Pulmonary embolism Hazy right lower lobe Lost right sharp costophrenic angle

Question 44

Go to the last slide and look at CXR 8: 20yr old M Retching followed by sudden onset sharp central chest pain What is your diagnosis? What signs support this?

Answer 44

Pneumomediastium Branching dark lines of gas parallel to oesophagus/mediastium

Question 45

Go to the last slide and look at CXR 9: 70yr old M Retired factory worker, intermittent SOB What is your diagnosis? What signs support this?

Answer 45

Pleural plaques Exposed to asbestos likely Plaques visible on Left lung Can see dense calcified plaque on diaphragm surface

Question 46

Go to the last slide and look at CXR 10: 70yr old M Retired factory worker, worsening SOB, weight loss and fatigue What is your diagnosis? What signs support this?

Answer 46

Mesothelioma Asbestos exposure likely Lung encase by rind of tissue Cancer red flags