Respiratory: CXRs Flashcards by patrick ellis

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

Describe what is occuring in this CXR [1]

Bilateral pleural effusion:
- blunting of costophrenic edges

How well did you know this?

Not at all

Perfectly

Describe what is occuring in this CXR [1]

Pneumothorax: air in pleural space, lung margin

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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)

How well did you know this?

Not at all

Perfectly

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.

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

Describe how lung masses typically present on an CXR? [3]

Sharp margins
Round or oval
Homogenous appearance

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

Describe this CXR [1]
What pathology is likely? [1]

Batwing pattern: CHF

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

How well did you know this?

Not at all

Perfectly

What pathology this CXR depict?

Pneumonia
TB
Pneumothorax
Emphysema
Mesothelioma

What pathology this CXR depict?

Pneumonia
TB
Pneumothorax
Mesothelioma

How well did you know this?

Not at all

Perfectly

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 well did you know this?

Not at all

Perfectly

How would an aspiration pneumonia show on an CXR? [1]

right lower lobe is most frequently involved.

How well did you know this?

Not at all

Perfectly

What pathology does this CXR depict?

Pneumonia
TB
Pneumothorax
Emphysema
Mesothelioma

This chest X-ray shows extensive bilateral reticulo-nodular infiltrates in keeping with miliary tuberculosis.

How well did you know this?

Not at all

Perfectly

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.

How well did you know this?

Not at all

Perfectly

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.

How well did you know this?

Not at all

Perfectly

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.

How well did you know this?

Not at all

Perfectly

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.

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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.

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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 ## Footnote 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"**.

When discussing rotation - what do you exactly look for? [1]

The **medial aspect** of **each clavicle** should be equidistant from the **spinous processes.**

Describe what is happening here [1]

Clinical information: * Joint pain * Erythema nodosum

Sarcoidosis

Differential diagnosis of consolidation? [4]

**Pneumonia** - airways full of pus **Cancer** - airways full of cells **Pulmonary** **haemorrhage** - airways full of blood **Pulmonary** **oedema** - airways full of fluid

This patient had a history of intravenous drug abuse and presented with a high fever

**Septic embolus**

Name 5 differential diagnosis of lung cavities [5]

**Lung abscess** - TB, Klebsiella or Staph aureus **Lung cancer** **Septic embolus** - infected thrombus **Fungal infection** - if immunocompromised **Granulomatosis with polyangiitis**

**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

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**