S10) Radiology of the Chest

Question 1

Penetration refers to the degree to which the x-rays have passed through the body.

What indicates adequate penetration in a normal CXR?

Answer 1

• Vertebrae just visible through heart
• Complete left hemidiaphragm is visible

Question 2

Identify 5 external/iatrogenic material which obstructs the view in a CXR

Answer 2

• Clothes
• Buttons
• Hair
• Surgical/vascular lines
• Pacemaker

Question 3

Identify the structures 1-5 in the CXR below:

Answer 3

1. Trachea
2. Hila
3. Lungs
4. Diaphragm
5. Heart

Question 4

Identify the structures 6-10 in the CXR below:

Answer 4

6. Aortic knuckle
7. Ribs
8. Scapulae
9. Breasts
10. Bowel gas

Question 5

Identify the lung zones in the CXR below:

Answer 5

Question 6

Identify the pleura in the CXR below:

Answer 6

Question 7

Identify the costophrenic angles in the CXR below:

Answer 7

Question 8

Identify the cardiophrenic angles in the CXR below:

Answer 8

Question 9

Identify the cardiac contours in the CXR below:

Answer 9

Question 10

Outline the systematic ABC approach used to evaluate a CXR

Answer 10

• Patient demographics
• Projection
• Adequacy
• ABCDE (airway, breathing, circulation, diaphragm, dem bones)
• Review areas

Question 11

What does one look for in the ‘adequacy’ component of the CXR evaluation?

Answer 11

• Rotation – alignment of spinous processes and clavicles
• Inspiratory volume – look for diaphragm between 5th and 7th ribs, incomplete inspiration, hyperinflation, costo-phrenic recesses and angles, flat diaphragm
• Penetration – vertebrae just visible through the heart, complete left hemidiaphragm visible

Question 12

What does one look for in the ‘airway’ component of the CXR evaluation?

Answer 12

• Trachea
• Bronchi (hila)

Question 13

What does one look for in the ‘breathing’ component of the CXR evaluation?

Answer 13

• Lungs
• Pleural spaces
• Lung interfaces

Question 14

What does one look for in the ‘circulation’ component of the CXR evaluation?

Answer 14

• Aortic arch
• Pulmonary vessels (hila)
• Right heart border: right atrium, middle lobe interface
• Left heart border: left ventricle, lingula interface

Question 15

What does one look for in the ‘diaphragm’ component of the CXR evaluation?

Answer 15

• Free gas
• Nodules
• Fracture/dislocation
• Mass

Question 16

Identify the 8 review areas in a CXR evaluation as well as the abnormalities one looks for

Answer 16

• Apices – pneumothorax
• Thoracic inlet – mass
• Paratracheal stripe – mass/lymph nodes
• AP window – lymph nodes
• Hila – mass/collapse
• Behind heart – mass
• Below diaphragm – pneumoperitoneum/mass
• Bones – fracture/mass/missing

Question 17

What abnormality can one observe in the following CXR?

Answer 17

Pneumothorax

Question 18

Describe 4 radiological findings observed in a pneumothorax

Answer 18

• Tracheal/mediastinal shift away from the pneumothorax (if tension)
• Depressed hemidiaphragm
• Visible pleural edge

- Radiolucent field around collapsed lung

Question 19

What abnormality can one observe in the following CXR?

Answer 19

Pleural effusion

Question 20

Describe 4 radiological findings observed in a pleural effusion

Answer 20

• Uniform white area
• Loss of costophrenic angle
• Hemidiaphragm obscured
• Meniscus at upper border

Question 21

What abnormality can one observe in the following CXR?

Answer 21

Lobar lung collapse

Question 22

Describe 4 radiological findings observed in a lobar lung collapse

Answer 22

• Elevation of the ipsilateral hemidiaphragm
• Crowding of the ipsilateral ribs
• Mediastinal shift towards the side of atelectasis
• Crowding of pulmonary vessels

Question 23

Consolidation is the filling of small airways/alveoli various substances.

Identify 4 possible substances as well as their associated conditions

Answer 23

• Pus – pneumonia
• Blood – haemorrhage
• Fluid – oedema
• Cells – cancer

Question 24

What abnormality can one observe in the following CXR?

Answer 24

Lung consolidation

Question 25

Describe 3 radiological findings observed in a lung consolidation

Answer 25

- Dense **opacification** - **Volume** preserved ± increased - Air **bronchogram**

Question 26

What abnormality is observed in the following CXR?

Answer 26

Space occupying lesion

Question 27

What are the two different kinds of space occupying lesions (single/multiple)?

Answer 27

- **Nodule** \< 3 cm - **Mass** \> 3 cm

Question 28

What abnormality is observed in the following CXR?

Answer 28

Cardiac enlargement

Question 29

What is the cardiothoracic ratio?

Answer 29

- **CTR,** measured on a PA chest x-ray, is the ratio of maximal horizontal cardiac diameter to maximal horizontal thoracic diameter - A normal measurement should be \<0.5

Question 30

What abnormality is observed in the following CXR?

Answer 30

Pulmonary cavitation

Question 31

What is cavitation in a CXR?

Answer 31

A **pulmonary cavity** is a gas-filled area of the lung in the centre of a nodule or area of consolidation due to infectious and non-infectious diseases

Question 32

Mike, 60 years old, came into A&E with a 3-day history of fever, cough with greenish sputum and pleuritic chest pain. Referring to the CXR below, answer the following questions: - CXR abnormalities? - Right side percussion? - Right side breath sounds? - Diagnosis?

Answer 32

- **CXR abnormalities:** right-sided opacity in middle zone - **Right side percussion:** dull - **Right side breath sounds:** crepitus & bronchial breathing - **Diagnosis**: pneumonia

Question 33

John, 55 years old presents to his GP with worsening breathlessness of 4 weeks in duration Referring to the CXR below, answer the following questions: - CXR abnormalities? - Right side percussion? - Right side breath sounds? - Diagnosis?

Answer 33

- **CXR abnormalities:** loss of right heart border & right costophrenic angle - **Right side percussion:** stony dull - **Right side breath sounds:** absent/diminished - **Diagnosis**: pleural effusion

Question 34

Darren, 22 years old, develops sudden onset, sharp right sided chest pain while jogging. This worsens on inspiration and is associated with SOB Referring to the CXR below, answer the following questions: - CXR abnormalities? - Right side percussion? - Right side breath sounds? - Diagnosis?

Answer 34

- **CXR abnormalities:** right lung collapse, artefact (ECG tag) - **Right side percussion:** hyperresonance (more air) - **Right side breath sounds:** absent/diminised - **Diagnosis**: Spontaneous right-sided pneumothorax

Question 35

Mr Singh, 50 years old, presents with a cough of 3 months in duration, recent haemoptysis, weight loss, night sweats and low grade fever in the evenings. Referring to the CXR below, answer the following questions: - CXR abnormalities? - Abnormality at arrow? - Diagnosis?

Answer 35

- **CXR abnormalities:** bilateral consolidation, patchy distribution in left upper and middle zones, slightly obscured left heart border - **Abnormality at arrow:** cavitating lesion - **Diagnosis**: tuberculosis

Question 36

Joseph, 64 years old, increasing SOB for 2 years, chronic cough with productive mucoid sputum, 40 pack year history of smoking. Referring to the CXR below, answer the following questions: - CXR abnormalities? - Right side percussion? - Auscultation? - Diagnosis? - Complications?

Answer 36

- **CXR abnormalities:** flattened diaphragm, hyperinflated lung fields, two ECG tags - **Right side percussion:** diffused hyperresonance - **Auscultation**: wheezing, stridor - **Diagnosis**: COPD - **Complications**: pneumonia, pneumothorax

Question 37

Stephen, 50 years old, presents with dry cough of 3 months duration, recent haemoptysis, 30 pack year history of smoking and finger clubbing. Referring to the CXR below, answer the following questions: - CXR abnormalities? - Diagnosis? - Other investigations? - Complications?

Answer 37

- **CXR abnormalities:** irregular dense opacity in upper left lobe - **Diagnosis**: lung cancer - **Other investigations:** tumour markers, lung biopsy - **Complications**: compression of left phrenic nerve by lung tumour (elevation of left hemidiaphragm, left mediastinal shift)

Question 38

Michael, 70 years old, presents with loss of appetite, weight loss of 1 month duration, looks emaciated and unwell. Referring to the CXR below, answer the following questions: - CXR abnormalities? - Diagnosis? - Origin? - Investigations?

Answer 38

- **CXR abnormalities:** obscured right cardiophrenic angle, slightly obscured heart borders, wide bilateral soft tissue nodules (irregular edges, size varies) - **Diagnosis**: multiple lung metastases (cannonball metastases) - **Origin**: primary renal cancer - **Investigations**: full body CT, FBC, tumour biopsy

Question 39

George, 75 years old, presents with increasing SOB for 2 months duration on minimal exertion, SOB at night, previous AMI at 69 years old, past smoker (gave up after heart attack). Referring to the CXR below, answer the following questions: - CXR abnormalities? - Apex beat change? - Auscultation? - Diagnosis? - Accumulation of fluid?

Answer 39

- **CXR abnormalities:** bilateral hilar shadowing, loss of left costophrenic angle, slightly enlarged heart - **Apex beat change:** laterally shifted apex beat - **Auscultation**: fine crackles - **Diagnosis**: heart failure - **Accumulation of fluid:** pulmonary, saccral and peripheral oedema