Respiratory: CXRs Flashcards
Explain what is depicted in this CXR [1]
Atelectasis (collapse / closure of the lung) in left lower lobe:
- Loss of left diaphragm silhouette
- Blunting of costophreninc angle
- Left main bronchus pulled down
In this case: obstructive lesion on the bronchus - causes no ventilation in lobe beyond obstruction. Gradually the air gets absorbed by pulmonary circulation and the lobe is devoid of air and becomes atelectatic
What pathology is depicted? [1]
Describe what is depicted in this CXR:
- Important positives? [4]
- Important negatives? [2]
Pneumonia:
- Consolidation of right upper lobe
- lobar density
- loss of ascending aorta silhoutte
- Air-bronchograms (gas-filled bronchi surrounded by alveoli filled with fluid, pus or other material)
Negatives:
- No shift of mediastinum
- Transverse fissure not significantly shifted
Describe what is occuring in this CXR [1]
Bilateral pleural effusion:
- blunting of costophrenic edges
Describe what is occuring in this CXR [1]
Pneumothorax: air in pleural space, lung margin
What are the two basic types of pulmonary oedema? [2]
Cardiogenic pulmonary oedema: caused by increased hydrostatic pulmonary capillary pressure
Non-cardiogenic pulmonary oedema: caused by either altered capillary membrane perm. or decreased plasma oncotic pressure
State the pathology [1]
Describe what is depicted in this CXR [2]
Emphysema:
- hyperlucent lung fields with multiple blebs
- Avascular zones with prominant pulmonary arteries
- Also common to see bullae: (lucent, air containing spaces that no vessels and therefore not perfused)
Is this emphysema more likely to be from smoking or alpha-1anti-trypsin defieciency? [1]
How can you tell? [1]
Smoking:
- Marked upper lobe emphysema
Pulmonary emphysema defines permanent dilatation of airspaces due to destruction of alveolar walls. It is one end of the spectrum of COPD, resulting from the smoking of tobacco.
Is this emphysema more likely to be from smoking or alpha-1anti-trypsin defieciency? [1]
How can you tell? [1]
Alpha-1 anti trypsin: lower lobes affectd
Describe how lung masses typically present on an CXR? [3]
Sharp margins
Round or oval
Homogenous appearance
Desribe the common featuers observed on a chest radiograph of someone who has heart failure [5]
ABCDE
A: Alveolar oedema
B: Kerley B lines
C: Cardiomegaly
D: Dilated pulmonary vessels & cephalisation (upper zones veins dilate and equal size)
E Pleural Effusion
Describe this CXR [1]
What pathology is likely? [1]
Batwing pattern: CHF
What method should you use when interpreting a CXR?
DRSABCDEFGHI
- Details: patient name and DOB; PA or AP film; erect or supine; date and time of study
- RIP: Rotation - medial clavicle ends equidistant from spinous process; Inspiration - is there 5/6 anterior ribs in mid clavicular line or 8-1- posterior ribs above diaphragm. Pentration / exposure
- Soft tissue: symmetry, swelling, loss of tissue planes, subcut air, masses, calcification
- Airway: trachea central, mediastinal width < 8cm on PA film, aortic knob
- Bones: ribs, sternum, spine, clavicles, symmetry, fractures, dislocations, density
- Cardiac silhouette: heart position, size (CT ratio normal < 0.5), shape, aortic stripe.
- Diaphragm: hemi diaphragm levels - right lung should be higher than left lung; cardiophrenic and costophrenic angles; pneumoperitoneum
What pathology this CXR depict?
Pneumonia
TB
Pneumothorax
Emphysema
Mesothelioma
What pathology this CXR depict?
Pneumonia
TB
Pneumothorax
Mesothelioma
Why does this CXR depict COPD? [2]
This chest x-ray demonstrates hyperexpanded lung fields with a flattened diaphragm.
More than 6 anterior or 10 posterior ribs above the diaphragm level on the midclavicular line is indicative of hyper expansion
How would an aspiration pneumonia show on an CXR? [1]
right lower lobe is most frequently involved.
What pathology does this CXR depict?
Pneumonia
TB
Pneumothorax
Emphysema
Mesothelioma
TB
This chest X-ray shows extensive bilateral reticulo-nodular infiltrates in keeping with miliary tuberculosis.
What pathology this CXR depict?
Pneumonia
TB
Pneumothorax
Emphysema
Mesothelioma
This chest X-ray shows a round opacity in the right upper lobe. This is the typical location for a primary infection with tuberculosis.
What is the most likely secondary infection in this case of TB? [1]
This round opacity is surrounded by a halo of air. It indicates a secondary infection with Aspergillus.
What is the name for this sign? [1]
What is the cause of this sign histopathologically? [1]
What is the most likely infective agent? [1]
Histopathologically, it represents a focus of pulmonary infarction surrounded by alveolar haemorrhage.
It is typically seen in angioinvasive aspergillosis.
This chest x-ray shows diffuse bilateral and symmetric coalescent air space opacities which are slightly less severe at the lung apices.
What pathology does this therefore suggest? [1]
acute respiratory distress syndrome.
Which of the following descriptions of benign or malignant focal lung opacities is correct?
benign: much wider than tall, with scalloped margins
benign: taller than wide, with rounded margins
malignant: microlobulated margins, with sparse, angulated radiations
malignant: polygonal margins, with indrawing of the fissure
Which of the following descriptions of benign or malignant focal lung opacities is correct?
benign: much wider than tall, with scalloped margins
benign: taller than wide, with rounded margins
malignant: microlobulated margins, with sparse, angulated radiations
malignant: polygonal margins, with indrawing of the fissure
What is the name for this sign depicted in this CXR? [1]
What pathology does it indicate? [1]
Sail sign: a loss of volume of the left lung with a double left heart border (the ‘sail sign’) with an absence of the usual outline of the left hemi-diaphragm
Indicating left lower lobe collapse.
What criteria can be used to help determine the source of this pathology? [1]
Lights criteria: used to classify pleural effusion; work out if is an exudate or transudate source
Describe the finding on this CXR [1]
Suggest a cause of this [1]
pleural plaque: small areas of thickened tissue in the lung lining, or pleura.
non-malignant manifestation of asbestos exposure, 20/30 years after exposure
Name the most common cause of this pathology? [1]
This chest X-ray demonstrates right middle and lower lobe consolidation. The most common cause is streptococcus pneumonia.
What pathology this CXR depict?
Pneumonia
TB
Pneumothorax
Emphysema
Mesothelioma
What pathology this CXR depict?
Pneumonia
TB
Pneumothorax
Emphysema
Mesothelioma
This chest X-ray demonstrates tracheal deviation and a large area with no lung markings on the left side. This indicates a left sided tension pneumothorax.
What pathology this CXR depict?
Pneumonia
TB
Pneumothorax
Emphysema
Mesothelioma
What pathology this CXR depict?
Pneumothorax
This chest x-ray demonstrates an absence of lung markings at the left apex with a rim of lung markings.
There is no tracheal deviation.
This is in keeping with a non-tension pneumothorax.
What pathology is depcited here? [1]
There is a globular shaped heart consistent with a pericardial effusion.
Describe what you can see in this CXR [1]
Give three differentials [3]
bilateral perihilar lymphadenopathy
What CXR findings would indicate MR? [2]
Left atrial and ventricular enlargement
Acute MR: pulmonary oedema (due to increased back pressure)
Dilated left atrium and left ventricle in a patient with chronic MR
What is a tell tale sign of left atrial enlargement? [1]
double-density sign, also known as the double right heart border
Normally the left atrium is located posteriorly and only the atrial appendage component is visible. **But left atria becomes englarged enlarged, the right aspect may become visible as an extra shadow next to the right atria **
If the double density sign is present on a CXR, what measurement can be taken to confirm left atrial enlargement? [1]
Olbique left atrial measurement: outer edge of atrium to midpoint of left main bronchus: > 7 cm = LA enlargement
A 75-year-old man is admitted to the Emergency Department with dyspnoea. A chest x-ray is performed upon arrival:
What is the main finding on the film?
Bronchiectasis
Right sided pleural effusion
Right upper lobe consolidation
Pulmonary oedema
Right middle lobe collapse
Right upper lobe consolidation
What is the most likely diagnosis?
Pleural effusion
Pneumonia
Pneumonectomy
Diaphragmatic hernia
Mesothelioma
Pneumonectomy
The x-ray shows an opacified left hemithorax with mediastinal and tracheal shift towards the affected side. Crowding of the ribs over the affected side with compensatory overinflation of normal lung is also seen.
A 60-year-old man presents to his GP with a 6-month history of a dry cough with associated diffuse chest pain. On questioning, he also has symptoms of fatigue and dyspnoea on exertion. An X-ray is performed before a secondary care appointment and appears as below:
He has no relevant medical history but has had several occupations during his life, including in labouring professions such as construction, shipbuilding and farming.
Is it:
Pleural plaques
Mesothelioma
Mesothelioma
This image shows pleural thickening indicative of mesothelioma on the right, almost certainly due to asbestos exposure during his shipbuilding or construction work. As a rule of thumb, the pleurae should only be the thickness of a pencil line on a radiograph, whereas here on the right it is diffusely thickened. There is also decreased volume of the right lung as a result, causing dyspnoe
Pleural plaques are asymptomatic
What would be the management of this CXR? [1]
Pleural plaques are benign and do not undergo malignant change. They, therefore don’t require any follow-up. They
This 55-year-old male attended the Emergency Department with a short history of shortness of breath and chest pain. He has a history of hypertension. Computed tomography (CT) of the chest was performed.
What is the cause of the shortness of breath?
Bronchial carcinoma
Aortic dissection
Pneumothorax
Pulmonary embolus
Myocardial infarction
Pulmonary embolus
This computed tomography pulmonary angiogram (CTPA) image shows a large embolus in the right pulmonary artery. The pulmonary vasculature appears white due to contrast, and the embolus appears as a grey ‘filling defect’.
What does this CXR show? [1]
Pneumoperitoneum
This chest X-ray shows subdiaphragmatic gas, confirming the presence of air within the peritoneal cavity.
A 50-year-old man presents with a 2-month history of worsening shortness of breath. Based on the chest x-ray appearance, what is the most likely reason for the patient’s dyspnoea?
atelectasis
pleural effusion
pneumonia
prior pneumonectomy
atelectasis
The mediastinum is deviated to the right: atelectasis is the only option that will pull the mediastinum towards the side of the “total white-out”.
Describe what is happening here [1]
Clinical information:
* Joint pain
* Erythema nodosum
Sarcoidosis
This patient had a history of intravenous drug abuse and presented with a high fever
Septic embolus
Bullous Emphysema
Arrows point to walls of blebs. Note mutiple thin walled cavities. Bulla is one of the differential for thin walled cavities.
Aspergillosis / Angioinvasive / Lung Ball
Shortness of breath, weight loss and clinically suspected underlying malignancy
Pulmonary metastases
Shortness of breath and right-sided chest pain
Biopsy results showed this to be a mesothelioma - a malignancy of the pleura caused by exposure to asbestos
Clinical information:
* Chronic mild shortness of breath
* Retired dock worker with history of multiple exposures to asbestos
Bilateral calcified asbestos related pleural plaques
Clinical information:
Smoker
Progressive shortness of breath and cough
Right upper lobe collapse
Bronchoscopy revealed a lung cancer causing obstruction to the right upper lobe bronchus
History of severe chest trauma
Diagnosis
Left hemi-diaphragmatic rupture with herniation of bowel into the left-hemithorax
Clinical information:
* Known inoperable lung cancer
* Rapid worsening of shortness of breath
Left phrenic nerve palsy due to direct invasion of the nerve - causing Raised left hemidiaphragm (red to blue lines)
Label the different signs of HF
Upper zone vessel enlargement (1) – a sign of pulmonary venous hypertension
Septal (Kerley B) lines (2) – a sign of interstitial oedema – see next picture
Airspace shadowing (3) – due to alveolar oedema – acutely in a peri-hilar (bat’s wing) distribution
Blunt costophrenic angles (4) – due to pleural effusions
What sign can be seen in this CXR? [1]
Clinical information:
Previous myocardial infarction
Left ventricular aneurysm - an uncommon complication of myocardial infarction
State what this CXR shows (and which vein its inserted via)
Jugular line (for chemotherapy)
A tunnelled line is inserted via the internal jugular vein. Its tip (arrow) lies at the cavoatrial junction - the junction of the superior vena cava and the right atrium.
State what this CXR shows (and which vein its inserted via)
This cancer patient has another type of tunnelled line which has been placed via the left subclavian route.
What can be seen in the midline of this CXR? [1]
What pathology might this indicate? [1]
Sternotomy wires - previous coronary artery bypass graft CABG
What does the arrowhead show? [1]
Aortic valve replacement (arrowhead)
Which valve has been replaced based off this chest CT?
Aortic
Pulmonary
Tricuspid
Mitral
Which valve has been replaced based off this chest CT?
Aortic
Pulmonary
Tricuspid
Mitral
This CXR indicates:
- Pneumonectomy
- Pleural effusion
- Left lower lobe collapse
- Right lower lobe collapse
- Phrenic nerve palsy
This CXR indicates:
- Pneumonectomy
- Pleural effusion
- Left lower lobe collapse
- Right lower lobe collapse
- Phrenic nerve palsy
This CXR indicates:
- Pneumonectomy
- Pleural effusion
- Left lower lobe collapse
- Right lower lobe collapse
- Phrenic nerve palsy
This CXR indicates:
- Pneumonectomy
- Pleural effusion
- Left lower lobe collapse
- Right lower lobe collapse
- Phrenic nerve palsy
This CXR indicates:
- Pneumonectomy
- Pleural effusion
- Left lower lobe collapse
- Right lower lobe collapse
- Phrenic nerve palsy
Pneumonectomy
Describe the findings in this CXR [3]
1 - Carina splayed to >90°
2 - Double right heart border
3 - Left atrial appendage bulging the left heart border
Describe the findings in this CXR [4]
Pericardial effusion
Describe the findings in this CXR [2]
Malignant pericardial effusion
This shows calfication of which valve
Mitral
Atrial
Pulmonary
Tricuspid
This shows calfication of which valve
Mitral
Atrial
Pulmonary
Tricuspid
What is outlined in this CXR [1]
Tracheostomy
