case book for the medical students guide to the plain chest film

Handout for VMS II Course:Disease, Diagnosis and Therapeutics

Case Book for

The Medical Student's Guideto the

Plain Chest Film

Edwin F. Donnelly, M.D., Ph.D.

Associate Professor of Radiology and Radiological SciencesVanderbilt University Medical Center

2009 Version

This version of the document has been optimized for viewing on thecomputer, not printing. The image resolution has been lowered to keepthe filesize down. These images will not appear correct if printed.

Contents

Contents i

Preface iii

1 White Belt Cases 1

2 Yellow Belt Cases 23

3 Orange Belt Cases 43

4 Purple Belt Cases 63

5 Blue Belt Cases 87

6 Green Belt Cases 107

7 Brown Belt Cases 129

8 Black Belt Cases 153

i

Preface

This collection of cases is designed to be a companion to the new (2009)edition of my Medical Student’s Guide to the Plain Chest Film. TheGuide instructs the student on the systematic evaluation of the plainchest film using the clavicle method. I have collected here a series ofgraduated plain frontal chest films for the student to not only practicehis or her chest film interpretation skills, but also to improve.

How not To Use These CasesThere is one way that you can spend a lot of time with these casesand really not improve your chest film interpretation skills at all. Thatway is to casually look at each film and then go right away to the textdescribing the case. The overwhelming majority of your learning comesat the exact point where you force yourself to make a decision aboutwhat you think is going on in the film. By just casually looking atthe film, not thinking too much about, not forcing yourself to makea conclusion, and then just reading my description, you will deludeyourself into thinking that you are progressing when in fact you aremaking no progress at all.

How To Learn To Read Chest FilmsIf your goal is to improve your skills at reading chest films, you arein luck because, if you utilize these cases properly, you become muchbetter. The first thing you should do is come up with a systematicmethod for evaluating a plain chest film. For a long time I told students

iii

that it doesn’t matter what method they use, as long as it is systematic.I still feel that is true, but so many students have requested that Ijust tell them a method that I have finally given in and developed theclavicle system. Whether you use that method or some other, yourshould first read my Medical Student’s Guide to the Plain Chest Filmbecause it not only describes the clavicle method in great detail, butit also goes through all of the major categories of abnormalities thatyou will find on these films. Once you have been through the Guide,then you should look at these cases.

The best way to use these cases is to treat each one as if it is a filmon one of your patients and it is your responsibility to extract as muchinformation as possible from the film. Look at the film and analyze itwith your systematic method. Then consider all of the findings thatyou have found, and decide what problems are present. Remember,there may be multiple problems present and there may be findingsthat, while “abnormal,” are not really significant. Once you have madea firm commitment to what you think is going on in the film, then youshould read my description. I go through every step of the claviclesystem for each film and then I summarize the major abnormalities andtheir significance at the end of the discussion.

The cases gradually get more difficult as you progress through thecolored belt system. For each of the eight belt levels there are eightrelated cases, for a total of 64 cases in all. This collection is not meantbe comprehensive — that is, it is not designed to cover all of the ab-normalities you will encounter on your patients’ films, but rather it isintended to give you practice and experience in a variety of increasingly-difficult types of cases. By the time you finish the Guide and all of thesecases, you will have developed a strong foundation upon which you willcontinue build for the rest of your career.

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Group 1

White Belt Cases

White Belt Cases

The cases here are designed to be extremely easy and to illustratesome basic concepts in the interpretation of plain chest films. You

should use a systematic approach to analyze each of these films. Whenyou look at these, imagine that each film corresponds to a patientof yours and think about what the findings of that chest film wouldmean for your patient. Is further imaging required? Is a diagnostic ortherapeutic procedure indicated? Is the film normal?

1

2 1 White Belt Cases

Case 1

history: 24 year-old presents to the emergency department with acough.

3

Case 1

Correct — You would verify that it is the correct patient and film.

Life Support — No devices.

Anatomy:

Airways — Airways normal, minor fissure not well seen.

Bones — All appear normal.

Contours — All appear normal.

Vascular — Heart, vascular pedicle and vasculature appear normal.

Interfaces — All interfaces are well-preserved.

Categorize — No abnormal patterns.

Limitations — None, excellent quality film.

Extra Look — Trachea, hila and “hidden areas” all appear normal.Notice that a normal trachea does deviate slightly to the rightwhen it goes by the aortic arch.

This is a normal PA chest radiograph. As you encounter abnormalcases in the book, it may be useful to refer back to this image to remindyou of what “normal” looks like.


Case 2

history: 54 year-old presents to the emergency department withchest pain.

5

Case 2



Anatomy:








Extra Look — Trachea, hila and “hidden areas” all appear normal.

This is a normal portable, AP chest radiograph. Because the film istaken with a shorter source-to-object distance and because the heart isfarther from the detector on a AP film, there may be some magnificationof the heart and vascular pedicle, but often, as in this case, there’s stillno question that everything is normal.


Case 3

history: 44 year-old presents to the emergency department with afever.

7

Case 3



Anatomy:





Interfaces — The right heart border shows a silhouette sign.

Categorize — There is a subtle but real increased, “fluffy” opacityin the right mid to lower lung field. The appearance is that ofalveolar flooding.



The combination of an alveolar flooding pattern with that of a sil-houette sign along the right heart border indicates that there is some-thing filling the alveolar spaces in the right middle lobe. The simpledifferential diagnosis is blood, pus, water or cells. We would think abouthemorrhage (blood) if there were something in the patient’s medical his-tory that would suggest a tendency towards bleeding in general (throm-bocytopenia, etc.) or towards pulmonary hemorrhage specifically (suchas Goodpasture’s, Wegener’s, Lupus, etc.). We would generally thinkabout pulmonary edema (water) if the pattern were symmetrical andperihilar and if there were an appropriate history. Edema often, but


not always, also has enlargement of the heart and vascular pedicle.We would think about tumor (cells) such as bronchoalveolar cell car-cinoma or lymphoma if the pattern were persistent despite treatmentwith antibiotics. In this case, even without the history of fever, themost likely (and, incidentally, correct) conclusion is that the patienthas a pneumonia in the right middle lobe.

9

Case 4

history: 45 year-old found down, brought by ems to the emergencydepartment and admitted to the icu where several life support

devices were placed.


Case 4


Life Support — There are four specific hardware devices that havebeen placed. Make sure you at least see all of them before readingfurther. (1) There is an endotracheal tube in place with its tipbelow the level of the clavicular heads. Without a referencescale, you cannot make an actual measurement from the picturegiven here, but if you could you would find that it is 3 cm abovethe carina. Ideally it should be between 4 and 5 cm, so it couldbe pulled back slightly. (2) There is a nasogastric tube, andthough its tip goes just off the bottom of the film, the side-portmarker is well-seen and is clearly below the diaphragm, so it isfine. (3) There is a pulmonary artery catheter (dashed line inthe figure) which has been placed from a femoral approach. Itstip is just at the right hilum and is fine. (4) There is an intra-aortic counter-pulsation balloon. Only its tip (white line in thefigure) is visible on the film, but the balloon itself (white dashes)extends well into the abdomen. The tip of the balloon pumpneeds to be distal to the origin of the left subclavian artery,or else the balloon may obstruct the left subclavian artery (andthus, the vertebral artery). The tip of this balloon is a little lowerthan normal. Overlying ekg leads and the external portions oftubes are generally not even worth mentioning unless they mightbe mistaken for an internal hardware device.

Anatomy:

Airways — The airways appear normal. The minor fis-sure is much more prominent than normal.


Contours — See below.

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Case 4 — Zoom to illustrate hardware. A. Original image. B. The blackdashes overlie the femoral pulmonary artery catheter, the short whiteline overlies the tip of the intra-aortic balloon pump. The white dashesshow the course of the balloon pump, even though it is not visible onthe image.


Vascular — The heart and the vascular pedicle appear slightly largerthan normal, though neither is definitely abnormal. It is diffi-cult to find an airway/artery pair because of the parenchymalopacities.

Interfaces — The central hilar vessels show a silhouette sign. Theother interfaces are well-preserved.

Categorize — There is a fluffy, bilateral, symmetrical and centralparenchymal pattern. It is the pattern of the alveolar flooding.


Extra Look — Trachea, hila and “hidden areas” all appear normal.The hilar vessels are obscured by the parenchymal opacities.

Again we are faced with an alveolar pattern, but this time we seethat it is easy to conclude that what we are seeing is alveolar pulmonaryedema. First, the pattern itself is symmetric and perihilar. In addition,the heart and vascular pedicle appear subjectively larger than normal.The reason the minor fissure is seen so well is that there is fluid within it(pleural fluid) and adjacent to it (subpleural fluid). The clinical historyas well as the fact that the patient needed both the pulmonary arterycatheter and the intra-aortic balloon pump support the diagnosis ofalveolar pulmonary edema from congestive heart failure.

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Case 5

history: 58 year-old smoker with hemoptysis.


Case 5



Anatomy:


Bones — There is orthopedic hardware seen over the leftshoulder, but it is not all within the field of view. Thereare also old, healed rib fractures seen bilaterally.



Interfaces — All interfaces are well-preserved except for the areasobscured by the large white opacity near the right hilum.

Categorize — There is a large, solid white opacity which falls intothe “nodule” category, but would be classified officially as a massbecause of its size (greater than 3 cm in diameter). The mass isnot a perfect sphere, being somewhat lobulated in shape. Thereis also a small round lucency seen near the center which couldrepresent some cavitation.


Extra Look — Trachea, left hilum and “hidden areas” all appearnormal. The right hilum is obscured by the large mass.

This is a large lung cancer. Other entities, including some infectionsand abscesses can have this kind of appearance, but the general thoughtis that any mass (i.e., bigger than 3cm) is cancer until proven otherwise.In this case, lung biopsy for tissue diagnosis was obtained, and ct andpet scans were also obtained to aid in staging.

15

Case 6

history: 37 year-old who comes to the emergency departmentacutely short of breath.


Case 6



Anatomy:

Airways — The trachea shifts slightly to the left. Theminor fissure is not seen at all (nor is the right lung, forthat matter).

Bones — The ribs on the right side appear more “spreadout” than those on the left.

Contours — The heart is shifted to the left and the rightdiaphragm is displaced downward slightly.

Vascular — Heart and vascular pedicle are normal in size. Novessels are seen on the right.

Interfaces — The right heart border is completely obscured.

Categorize — There is a large right-sided pneumothorax (must-know pattern).


Extra Look — The amount of tracheal shift is similar to that ofthe rest of the mediastinum. The right hilum cannot be seen atall. No abnormalities are seen in the “hidden areas.”

This patient has a large right pneumothorax. The other findings sug-gest that this may be a tension pneumothorax. Of particular concernare the complete collapse of the right lung, the shift of the mediastinum,the inferior displacement of the right hemidiaphragm and the spreading

17

of the ribs on the right side. This is the kind of finding that needs to beseen right away, and it is because of findings like this that you shouldalways make sure you look at any film you order. Imagine what wouldhappen if this film got lost in the radiology department for several days.


Case 7

history: 85 year-old with long-standing pulmonary symptoms.

19

Case 7



Anatomy:

Airways — Airways normal, minor fissure not displaced.


Contours — Central pulmonary arteries appear too large,peripheral vessels are diminished.

Vascular — The heart and vascular pedicle are normal, but thecentral pulmonary arteries are enlarged. The peripheral vesselsare diminished.


Categorize — The lungs are hyperinflated in the emphysema pattern(must-know pattern). There are some areas of vascular crowdingin the lung bases (atelectasis pattern) as well.


Extra Look — Trachea and “hidden areas” all appear normal.The hila appear too large, but this is because of the enlargedpulmonary arteries.

This is a patient with severe centrilobular emphysema. This patientis markedly hyperinflated. The atelectasis in the lung bases representsmore “normal” lung parenchyma which is actually being compressed bythe more-severely emphysematous lung tissue above it. The enlarge-ment of the pulmonary arteries is quite common and is a manifestationof secondary pulmonary hypertension related to the emphysema.


Case 8

history: 45 year-old patient in the hospital recovering from recentabdominal surgery.

21

Case 8



Anatomy:



Contours — Both hemi-diaphragms are partially obscuredand the costophrenic angles are blunted.


Interfaces — There are new soft-tissue interfaces seen laterally inboth lungs near the costophrenic angles. In addition, the normalinterface between the hemidiaphragms and the lung are gone.

Categorize — The is a homogeneous white pattern seen laterallyover the lung bases. This represents fluid in the pleural space(must-know pattern).


Extra Look — Trachea, hila and “hidden areas” all appear normal,though it is difficult to see “through” the diaphragm in this casebecause of the fluid.

There are bilateral pleural effusions with associated volume loss inthe lung bases. Pleural effusions are common, especially in hospital-ized patients. Sometimes portable films such as this one can under-estimate the size of the effusions, since fluid does not always go to thecostophrenic angles as it does in this case.

Group 2

Yellow Belt Cases

Yellow Belt Cases

For these cases, imagine that you are an intern covering hospitalpatients at night. Part of your duty is to check on the chest films of

those patients who had life support devices placed earlier in the evening,but the films didn’t get taken until after everyone else (including all theradiologists!) left. Unfortunately, the resident checking the patients outto you didn’t give you any useful history on any of them. For all ofthese, consider not only what the abnormality on the film is, but whatyou should do about it.

23

24 2 Yellow Belt Cases

Case 1

history: Patient checked out to you with the instructions to“check cxr.”

25

Case 1


Life Support — There is an endotracheal tube with its tip in goodposition at the level of the clavicular heads. There is also anasogastric tube that has a large loop in cervical esophagus andits tip in the thoracic esophagus.

Anatomy:

Airways — Airways normal, minor fissure normal.



Vascular — The heart and vascular pedicle are mildly enlarged, butpart of this may be due to the portable technique. In any case,there is clearly no pulmonary edema.


Categorize — Lung volumes are slightly lower than normal butthere are no other abnormalities.



The problem is the coiled nasogastric tube. There are really tworeasons this is a problem. The first is that the tube does not reach thestomach (remember, both the tip and the side port should be in thestomach, in this case neither is) so there is no way that the tube cando its job. The other problem is that the loop of tubing will act as anirritant in the patient’s throat and increase the risk of aspiration. Thetube should be repositioned.


Case 2


27

Case 2


Life Support — There are three internal devices. Make sure youhave identified all of them before reading further. The first isan endotracheal tube with its tip in good position at the levelof the clavicular heads. The second is a left subclavian catheterwith its tip just at the level of the svc. Both of these devicesare fine. The third is a feeding tube which has a giant loop inits course and which then goes into the trachea, down the rightmainstem bronchus and then well into the lower lobe bronchus.

Anatomy:




Vascular — The heart and vascular pedicle are enlarged. None ofthe pulmonary vessels appear enlarged, though, and there is nopulmonary edema.

Interfaces — There is a silhouette sign along the left hemidiaphragm.

Categorize — There is increased opacity in the left lung base. Thisopacity comes from the crowding of vessels and is a sign ofatelectasis. There is also some elevation of the right hemidi-aphragm, also a sign of atelectasis.

Limitations — The patient is rotated towards the right quite abit. This can be confirmed by remembering that the spinousprocesses (very posterior) should project midway between the


heads of the clavicles (very anterior). Here the spinous processesoverlap the left clavicular head.

Extra Look — Trachea appears normal. The atelectasis describedabove is seen through the heart. The hila are not well seenbecause of the widened vascular pedicle and the patient rotation.

The main problem is the feeding tube in the airway. This needs to becorrected immediately and certainly before the tube is used for feedingthe patient. The finding of atelectasis in the lung bases is extremelycommon in hospitalized patients and often occurs because of mucusplugging or poor depth of inspiration.

29

Case 3



Case 3


Life Support — There is an endotracheal tube in the esophagus.The patient is on a trauma (spine) board.

Anatomy:


Bones — There is a fracture of the right third rib (later-ally).

Contours — The left mediastinal contour is abnormal,with loss of the normal definition of the aortic knob andmain pulmonary artery.

Vascular — The heart is mildly prominent, but the vascular pedicleappears very wide.


Categorize — The lung parenchyma looks normal.

Limitations — The lateral portion of the left lung base is excludedfrom the image.

Extra Look — Trachea, right hilum and “hidden areas” all ap-pear normal. The left hilum is not seen because of the widenedmediastinum.

This patient has clearly suffered a recent trauma, which would ex-plain the rib fracture. The widening of the mediastinum is concerningfor blood, and further evaluation, usually with ct scanning, is neededto see if there is a vascular injury or a spinal fracture which might cause

31

the bleeding. The endotracheal tube in the esophagus is actually a nor-mal finding in this case, because it represents a “Combitube,” which is adual-lumen (see the two lumens?) tube that can be used for ventilationwhether it is in the esophagus or trachea. This type of tube is useful forpatients with difficult airways or where environmental conditions maybe less than ideal (such as a trauma).


Case 4


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Case 4


Life Support — There is a left subclavian central line with its tipin the superior vena cava (good position).

Anatomy:

Airways — The trachea deviates slightly to the right. Theminor fissure appears normal.


Contours — The left hemidiaphragm is displaced inferi-orly. The aortic knob and main pulmonary artery arenot well seen. The mediastinum is shifted to the right.

Vascular — The heart and vascular pedicle are normal in size,though they are shifted to the right. There is no pulmonaryedema.

Interfaces — The aortic knob and main pulmonary artery show asilhouette sign.

Categorize — There is a moderate-sized pneumothorax on the left.There are increased opacities resulting from crowded vessels inthe left lung (atelectasis pattern).



This is a typical iatrogenic pneumothorax caused by the placementof the left subclavian central line. There is partial collapse of the leftlung which causes both the atelectasis pattern seen and the silhouettesign along the aorta and pulmonary artery.


Case 5


35

Case 5


Life Support — There is a right-sided chest tube, but it never entersthe thoracic cavity. Both its tip and side-port are lateral to therib cage.

Anatomy:






Categorize — There are streaky black lines outside of the lungs(help! this isn’t one of the patterns). [Two circles over the rightlung are artifacts related to external structures.]



The chest tube is malpositioned. The black lines represent air dis-secting through the soft tissues of the chest wall (we often call this find-ing “subcutaneous emphysema” even though it usually involves muchmore than just the subcutaneous spaces). This case is a good exam-ple of why its important to treat patients and not chest films. Whatshould you do if this is your patient? Clearly the chest tube that isthere should be removed, since it’s not doing any good where it. Doesthis patient even need a chest tube? That’s for you (the clinician) todecide.


Case 6


37

Case 6


Life Support — There is an ivc filter protruding into the rightatrium.

Anatomy:


Bones — All appear normal except for some mild sco-liosis which may actually just be how the patient waspositioned.




Categorize — The lung parenchyma looks normal.



The ivc filter has migrated from its normal position (below the renalveins and well below the field of view on this study) in a very highposition where it is actually projecting into the heart.


Case 7


39

Case 7


Life Support — There is a left subclavian central line which extendsup into the left ij vein.

Anatomy:




Vascular — The heart, vascular pedicle and pulmonary vasculatureare all prominent. This is a good example of a patient witha large circulating vascular volume and some mild pulmonaryvascular engorgement (several good examples of vessels largerthan their adjacent bronchi).





The left subclavian line is malpositioned (it goes up the ij vein).


Case 8


41

Case 8


Life Support — There is an endotracheal tube which goes down theleft mainstem bronchus.

Anatomy:






Categorize — There are fluffy alveolar opacities throughout theright lung and, to a lesser extent, in the perihilar region of theleft lung.



The endotracheal tube is down the left mainstem bronchus. Thisobviously needs to be corrected because it causes two problems — overventilation of the left lung and non-ventilation (in fact, obstruction) ofthe right lung. The patient has bilateral pneumonia accounting for thealveolar pattern, but the appearance is no doubt made worse on theright by the obstruction of the airway, leading to some superimposedatelectasis.

Group 3

Orange Belt Cases

Orange Belt Cases

These cases show more of the basic patterns that you should rec-ognize, but they are slightly more difficult than some of the cases

that have been shown before. Work on not only analyzing the film sys-tematically, but also trying to come up with what you think the singlemost likely diagnosis is.

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44 3 Orange Belt Cases

Case 1

history: Patient in the emergency department with shortness ofbreath.

45

Case 1



Anatomy:

Airways — Airways normal. The minor fissure has fluidin it.



Vascular — The heart and vascular pedicle are normal in size. Nogood vessel-airway pairs are seen to evaluate the pulmonary vas-culature, but there is an interstitial pattern that could representinterstitial pulmonary edema.


Categorize — There are linear and irregular shadows (interstitialpattern). Upon closer inspection, these extra lines can be seento be septal lines (Kerley lines). (Notice the “Kerley B” lines).There is also so obscuration of the diaphragm in both lung bases(silhouette sign). There are bilateral pleural effusions.


Extra Look — Trachea and “hidden areas” appear normal. Thehila look large, but they are hard to judge on this film becauseof all the adjacent opacities.

This is a good example of an interstitial pattern in an acutely-ill pa-tient in the emergency department. The two most-likely diagnoses are


interstitial pneumonia and interstitial edema. If the heart and vascularpedicle were enlarged and if there were evidence of pulmonary vascularengorgement, then edema would be the most likely cause. Withoutthese findings, though, either diagnosis is possible, since patients withan acute mi may show pulmonary edema without the other findings.Additionally, the presence of the pleural effusions would be unusualfor interstitial pneumonia, but typical for pulmonary edema. Gener-ally, the history and physical exam (and lab work) will make it obviouswhich one is correct. In this case, the patient has interstitial pulmonaryedema.

47

Case 2

history: Patient in the emergency department with shortness ofbreath.


Case 2



Anatomy:






Categorize — There is a left apical pneumothorax (must-know pat-tern). There is an interstitial pattern.



This case is similar to the previous case in that there is an inter-stitial pattern in an acutely-ill patient in the emergency department.The difference here is that there is a pneumothorax and we don’t seepleural effusions. Again, history and clinical exam findings would bemost useful to you, but the lack of pleural effusions combined withthe very normal heart and vascular pedicle make interstitial pneumo-nia more likely. In this case the patient had undiagnosed aids and waspreventing with pneumocystis carinii (jirovecii) pneumonia (pcp). Thepneumothorax occurred because one of the peripheral cysts (not visible)had ruptured.

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Case 3

history: Increasingly-ill patient in the icu


Case 3


Life Support — There is an endotracheal tube with its tip midwaybetween the level of the clavicular heads and the carina (too low).There is a left subclavian line (introducer sheath) with its tip inthe left brachiocephalic vein. There is a nasogastric tube withboth its tip and side port in the stomach.

Anatomy:




Vascular — Heart, vascular pedicle and vasculature appear normal.There is, however, an interstitial pattern that could representpulmonary edema.


Categorize — There is a fairly large pneumothorax on the left (no-tice that it has apical, lateral, basilar and medial components).There is an interstitial pattern throughout the lungs. On the left,there is also some additional increased opacity which is difficultto classify but which likely represents crowding of the vasculatureand septal lines from the volume loss caused by the pneumotho-rax (atelectasis pattern).


Extra Look — Trachea and “hidden areas” all appear normal. Thehila are obscured by the overlying pathology in the lung.

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Here is yet another interstitial pattern with a fairly normal-appearingheart and vascular pedicle. In this case, the patient is not in the emer-gency department but in the icu. In this case, the history is crititcalbecause the patient’s diagnosis is ruptured cerebral aneurysm, and theedema pattern seen is that of neurogenic edema. The pneumothoraxin this case was caused by the line placement. Whether the patientrequires a chest tube or not is a clinical decision and cannot be deter-mined based upon this film. The endotracheal tube should be with-drawn about 2 cm to bring its tip in line with the level of the clavicularheads.


Case 4

history: 54 year-old internal medicine clinic patient with chronicdyspnea.

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Case 4



Anatomy:



Contours — The diaphragm is displaced inferiorly onboth sides, and it has a “scalloped” appearance.



Categorize — The lungs are hyperinflated in what appears to be anemphysema (must-know) pattern.



This patient has a type of emphysema known as panacinar emphy-sema. It occurs in patients with a genetic defeciency in alpha-1 an-titrypsin. Notice how normal the middle and the apices of the lungslook, while in the bases of the lungs there are far fewer vessels thanwould normally be seen. This type of emphysema is relatively rare(roughly 1-2 % of all emphysema), but its radiographic appearance isfairly characteristic.


Case 5

history: 56 year-old internal medicine clinic patient who is short ofbreath.

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Case 5


Life Support — There is a left subclavian Portacath with its tip inthe region of the superior vena cava.

Anatomy:

Airways — The trachea deviates to the right. No airwaysare visible on the right side beyond the carina. The mi-nor fissure is not seen.


Contours — No anatomic structures can be evaluated onthe right because of the complete loss of air on that side.

Vascular — Heart, vascular pedicle and vasculature (at least, whatcan be seen of them) appear normal.

Interfaces — All interfaces are well-preserved on the left, none canbe seen on the right.

Categorize — There is total white-out on the right with shift of themediastinum towards the side of the white-out.


Extra Look — Trachea, hila and “hidden areas,” where seen, allappear normal.

This is a classic “white-out” appearance from total atelectasis of theright lung. There are basically two possible etiologies for total white-out of one side of the chest — either total atelectasis from a central


obstruction or massive pleural effusion. With total atelectasis, the me-diastinum shifts towards the white-out, while with pleural effusion themediastinum shifts away. A second helpful finding in this case is the“cut-off” of the airway on the right at the site of the obstruction (rightmainstem bronchus). This patient had a lung cancer causing the ob-struction.

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Case 6

history: 61 year-old presents to the emergency department with acough.


Case 6



Anatomy:






Categorize — There is a thick, black line over the right side of thechest running parallel to the lateral margin of the thorax.



The only “abnormality” is a skin fold on the right. This should notbe confused with a pneumothorax, which could have the same generalshape, but would be thin white line.

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Case 7

history: 54 year-old presents to the emergency department with afever.


Case 7



Anatomy:






Categorize — There is a very large mass in the left lung base.It is partially filled with air and partially with fluid (i.e., it iscavitary).


Extra Look — The large mass is well-seen through the heart andleft hemi-diaphragm, but no other lesions are seen.

The two most-likely diagnoses are lung cancer and pulmonary ab-scess. In this case, the mass turned out to be an abscess.

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Case 8

history: 12 year-old with leg pain and shortness of breath.


Case 8



Anatomy:






Categorize — There are multiple, bilateral pulmonary nodules.



Look carefully and make sure you can see all of the nodules. Somestudents notice only the large nodule on the right, but miss all ofthe other nodules (satisfaction of search). These nodules representmetastatic Ewing’s sarcoma.

Group 4

Purple Belt Cases

Purple Belt Cases

Again you are on night duty and you are covering a lot of patientsfor you colleagues. Again they have given you a series of “to do”

items, including checking on a number of different chest films that havebeen ordered on these patients. Again it seems they have failed to giveyou a lot of information about these patients, but it does seem that thisgroup is a little bit more complicated than the last group of patientsyou were covering at night . . .

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64 4 Purple Belt Cases

Case 1

history: You are called by the nurse because the line is not functionproperly.

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Case 1


Life Support — There is a left subclavian line (port), but the linestops at the level of the clavicle. There is another segment oftubing projecting over the left side of the chest medially. Whatis this tubing and where is it? There are also some surgical clipsseen on the left, likely in the axilla from prior nodal dissectionsurgery.

Anatomy:


Bones — All appear normal except for an old left 7th ribfracture seen laterally.







The line has broken and fragment has traveled down the superiorvena cava, into and through the right atrium and is now lodged withits distal end extending into the left pulmonary artery and its proximalend in the right ventricle. The prior film shows what the line lookedlike before it broke.


Case 1 — Port line before it fractured. This films shows the normal(expected) course, and the tip is just into the right atrium.

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Case 2

history: Film to check endotracheal tube placement.


Case 2


Life Support — There is an endotracheal tube with its tip in goodposition at the level of the clavicular heads. There is also awell-positioned nasogastric tube. There are also two unexplaineditems — one that has the density of bone and is seen just lateralto the right heart border and another that has the density of metaland is seen in the stomach, just above the nasogastric tube.

Anatomy:



Contours — There is a calcified circular density seenwithin the aortic knob. The other anatomical structuresappear normal.



Categorize — There is some vascular crowding the lung bases (at-electasis pattern).


Extra Look — Trachea, hila and “hidden areas” all appear nor-mal. The unexplained object described above is in the expectedlocation of the right lower-lobe bronchus.

There is an aspirated tooth in the right lower-lobe bronchus and thereis a swallowed dental filling in the stomach. This patient had presented

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with severe facial trauma from a motor vehicle accident. The calcifiedaorta indicates aortic atherosclerosis and the atelectasis in the lungbases is a common finding in hospitalized patients.


Case 3

history: icu patient with “shortness of breath.”

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Case 3


Life Support — There are midline sternal wires and some surgicalclips seen. There are chain sutures in the left lung just abovethe hilum. There is an endotracheal tube that is a little low.There is a nasogastric tube that goes off the bottom of the filmand appears fine. There are two chest tubes, both coming inanteriorly and going towards the left. There is a right internaljugular line which coils upon itself in the svc.

Anatomy:




Vascular — The heart and vascular pedicle are big but there is nopulmonary edema.

Interfaces — There is a silhouette sign along the diaphragm bilat-erally and of the left pulmonary artery.

Categorize — The opacity in the left lung just above the hilum is acombination of alveolar flooding and vascular crowding. Thereare bilateral pleural effusions (must-know pattern).


Extra Look — All of the “hidden areas” as well as the hila aredifficult to see on this film because of the opacities in the lungs.The trachea and central airways appear fine.


The right IJ line is coiled and needs to be fixed. This case representsa typical post-surgical patient in the icu. It illustrates the importanceof looking at each life support device individually because it is easy tooverlook that one problem if the film is just looked at as if it were an inkblot. It is also important to recognize that all of the other “metallic”things seen represent things outside of the patient (the lines are ekgleads while the “coil” is a part of the ventilator device). These are seenin nearly all icu patients. All of the other findings above are fairlycommon post-surgical findings (including the pleural effusions, basilaratelectasis and combination of post-surgical hemorrhage and volumeloss in the left suprahilar region).

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Case 4

history: icu patient — “Check line placement.”


Case 4


Life Support — There is an endotracheal tube in good position.There is a nasograstic tube which also appears fine. There is aright internal jugular pulmonary artery catheter which has itstip in the left pulmonary artery. The tubing over the base ofthe heart represents a surgical drain in the pericardial space.There is an intra-aortic balloon counter pulsation pump with itstip into the arch of the aorta.

Anatomy:




Vascular — The heart and vascular pedicle are enlarged, the pul-monary vessels are engorged (see the pulmonary artery-bronchuspair seen end-on near the tip of the pa catheter), but there isno pulmonary edema.

Interfaces — There is a silhouette sign along the left hemidiaphragm.

Categorize — There is vascular crowding in the lung bases (atelec-tasis pattern).


Extra Look — Trachea and hila appear normal; the area behindthe heart appears opacified and nothing can be seen through thediaphragm.

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The intra-aortic balloon pump is too high and is obstructing theorigin of the left subclavian artery (and thus, the left vertebral artery).It needs to be pulled back. The other findings represent atelectasis inthe lung bases, likely related to bilateral pleural effusions.


Case 5

history: 58 year old patient with cough.

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Case 5


Life Support — There is a single-lead transvenous cardiac pacerdevice that comes in from a left subclavian approach. Noticehow “thinned” the pacer lead is as it crosses under the clavicle.

Anatomy:




Vascular — The heart is at the upper limits of normal, but thevascular pedicle and vasculature appear normal.





The pacer wire is frayed and is at high risk of failure.


Case 6

history: icu patient — “check line placement.”

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Case 6


Life Support — There are two malpositioned devices, make sure yousee both of them before reading any further. The endotrachealtube goes down the right mainstem bronchus. The feeding tubegoes all the way down the esophagus, turns around, comes allthe way back up off the top of the film and actually turns aroundagain such that its tip is just seen at the top of the film. Theright internal jugular line appears fine.

Anatomy:






Categorize — There is a pneumothorax on the left (seen laterallyand along the base). There is vascular crowding in the left lung(atelectasis pattern), likely from the pneumothorax.



Three important abnormalities are present: (1) an endotracheal tubedown the right mainstem bronchus, (2) a badly-looped feeding tube and(3) a medium-sized pneumothorax. This is another good example ofwhy a systematic approach to the film is so important for avoiding


satisfaction of search. You may wonder why the pneumothorax is onthe left, while the (presumably) new line is on the right. This commonlyoccurs when there has been an attempt at line placement on one sidethat does not go well and then the decision is made to go ahead andput the line in on the other side. The pneumothorax occurred duringthe failed attempt.

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Case 7



Case 7


Life Support — The endotracheal tube is well-positioned. Thenasogastric tube is not seen as well as you would like, but itdoes appear to go into the stomach. There are bilateral chesttubes which appear fine. There is a right subclavian introducersheath, which appears fine with its tip in the subclavian vein.There is also a left subclavian pulmonary artery catheter thathas its tip very deep into a lower lobe artery on the right.

Anatomy:

Airways — Airways normal, minor fissure displaces slightlyinferiorly (atelectasis in the middle lobe).



Vascular — The heart and vascular pedicle appear enlarged. Thereis also engorgement of the pulmonary vasculature, but there isno pulmonary edema.


Categorize — There is vascular crowding seen in both lung bases(atelectasis pattern).

Limitations — The film is a little bit under-penetrated and so thedistal extent of the nasogastric tube is not seen as well as youwould like, and the side-port is not seen (could be in the stomachor above the ge junction).

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Extra Look — The trachea appears normal. The hila are obscuredpartially by atelectasis. The vascular crowding (atelectasis pat-tern) is also seen through the heart.

The main problem is that the pulmonary artery catheter is so farout that it is at risk of occluding the artery and causing an infarct ofthe lung. While these catheters can float out fairly far while taking apulmonary capillary wedge pressure measurement, at other times theyshould be retracted back towards the hilum. If they are too far outthey may reside in a pulmonary artery whose diameter is not much (ifany) bigger than that of the catheter, and all flow through that arterymay be obstructed.


Case 8


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Case 8


Life Support — This patient has a tracheostomy. Its canula is atthe level of the clavicular heads. There is also a nasogastric tubewhich is well-seen and which extends off the bottom of the film,in good position. There is a right subclavian line which has itstip in the svc, but going through the line is a metallic wire thatstarts in the middle of the central line and goes down the svc,into the right atrium, loops in the right ventricle, then returnsto the right atrium and svc and ultimately points into the rightinternal jugular vein.

Anatomy:









The wire seen on this film represents a guidewire that was usedduring the placement of the central line. Somehow the guidewire gotlost and was left inside the patient.

Group 5

Blue Belt Cases

Blue Belt Cases

You now find yourself in clinic seeing patients. Many of them haveindications for chest x-rays, and you are lucky that you happen to

have an x-ray machine right in your clinic. Imagine these are the filmsyou got today, and that there is no radiologist to “overread” you.

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88 5 Blue Belt Cases

Case 1

history: 78 year-old who has a cough.

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Case 1



Anatomy:

Airways — The trachea deviates to the right. The minorfissure is not well seen.







Extra Look — Trachea deviates because of a mass (“don’t-miss”lesion); hila and “hidden areas” all appear normal.

This patient has a neck mass on the left. The most common cause isgoing to be thyroid enlargement from a goiter, but other masses shouldbe excluded (including thyroid cancer and adenopathy).


Case 2

history: 72 year-old with chest pain.

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Case 2


Life Support — The very bottom of an anterior cervical spine fusionplate is seen at the top of the film.

Anatomy:


Bones — The posterior left 3rd rib disappears medially.




Categorize — There is what appears to be a small pleural effusionat the left lung apex.



There is a lung cancer at the apex of the left lung, invading the left3rd rib. In this case it is hard to see the tumor itself, but the adjacentpleural effusion (may be pleural thickening or actual tumor itself) isvisible.


Case 3

history: 24 year-old with chronic dyspnea.

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Case 3



Anatomy:



Contours — The central hilar vessels appear large. Theother anatomical structures appear normal.





Extra Look — The hila are enlarged. The trachea and “hiddenareas” appear normal.

This is a good example of what to think about when you recognizethat the hila are enlarged. The main decision you need to make iswhether the enlargement comes from big vessels or from something“extra” (such as a mass or adenopathy) in the hila. If only one hilumis enlarged, then a mass or adenopathy becomes more likely. When itis both hila, though, the decision is tougher. Often, when the cause isadenopathy, you will be able to see adenopathy in other places (e.g.,along the right side of the trachea or below the carina). When thecause is pulmonary arterial enlargement, you may also see enlargementof the right side of the heart. In either case, a lateral view is extremely


Case 3 — Lateral view. The frontal film showed large hila. Can youtell from the lateral view whether the problem is adenopathy or en-largement of the central pulmonary arteries?

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Case 3 — Zoom of the lateral view. This zoomed view shows the rightpulmonary artery (short black dashes) and left pulmonary artery (longblack dashes). These are enlarged. Notice that below the area markedby white dashes (“infrahilar window”) does not show any abnormal softtissue density. Adenopathy can often be seen here.

helpful because the right and left pulmonary arteries are so well seenon it. Look at the lateral in this case

In this case, the lateral view clearly shows that it is the pulmonaryarteries themselves that are enlarged (See also the zoomed view). Thispatient has primary pulmonary hypertension.


Case 4

history: 83 year-old man with know prostate cancer.

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Case 4



Anatomy:


Bones — No focal bone abnormalities are present, butall of the bones appear abnormally dense and there isno differentiation between the bone cortex and the bonemarrow.

Contours — There is either something next to the aorticknob or the aortic knob is enlarged.


Interfaces — There is a silhouette sign along the left hemidiaphragmand left heart border.

Categorize — There are fluffy opacities in both lung bases, greateron the left (alveolar pattern).


Extra Look — Trachea and hila appear normal. Alveolar opacitiesare seen through the heart and left hemidiaphragm.

The dense bones with loss of the cortico-medullary differentiationrepresent diffuse metastatic disease to bone. This patient also has left-greater-than-right basilar pneumonia with an associated pleural effu-sion (it is the effusion that causes the density near the aortic knob).


Case 5

history: 32 year-old with cough and fever.

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Case 5



Anatomy:



Contours — There is blunting of the left costophrenicangle.



Categorize — There is an alveolar pattern seen in the left lung basebehind the heart. There is a small left pleural effusion.


Extra Look — Trachea and hila appear normal. The alveolar pat-tern is seen only through the heart (“don’t-miss” lesion).

This patient has a left lower lobe pneumonia with a small pleuraleffusion.


Case 6

history: 61 year-old with a cough and a known diagnosis.

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Case 6


Life Support — There is a left subclavian Portacath in good posi-tion. You might notice that the catheter is narrowed as it crossesunder the clavicle. This line may be starting to weaken there andmay ultimately end up breaking off like purple belt case #1.

Anatomy:


Bones — The right humerus has an abnormal appearance.There are extra calcifications seen, there are areas ofbone erosion and there is a pathological fracture.




Categorize — There is a small soft tissue nodule seen in the rightlung (just over the 6th rib).



This patient’s known diagnosis is sarcoma (synovial cell) of thehumerus. The lung nodule represents a metastasis. The pathologicalfracture of the humerus may represent one of the “corner-of-the-film”lesions you are always being warned about (I never said they don’toccur).


Case 7

history: 30 year-old with cough.

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Case 7



Anatomy:



Contours — There are extra “bumps” along the hila andright side of the trachea.





Extra Look — Trachea and “hidden areas” appear normal. Thehila are enlarged bilaterally.

This patient has bilateral hilar and mediastinal adenopathy. In thiscase, the “extra bump” above the right hilum represents adenopathyin the right paratracheal region, while the extra bumps in the hilarepresent hilar adenopathy. Look at a zoomed view of the lateral filmin this case, and compare it to the same view from case #3 (primarypulmonary hypertension).


Case 7 — Zoom of lateral view. Compare to Case # 3. Notice herethat there is a full circle (white dashes) of soft tissue — representingadenopathy, while in the case of pulmonary hypertension there wassparing of the infrahilar window because the abnormal density wascaused by enlarged pulmonary arteries.

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Case 8

history: 47 year-old with chest pain.


Case 8



Anatomy:


Bones — The left humeral head is missing.







Sometimes it is harder to see what is missing than what is present.In this case, a soft tissue sarcoma in the left arm has invaded and erodedmost of the left humeral head.

Group 6

Green Belt Cases

Green Belt Cases

Now that your skills are improving, you are taking on some morechallenging cases. You are now working in a cardiology clinic seeing

patients with heart and related problems. For each patient, try to comeup with as specific a diagnosis as possible.

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108 6 Green Belt Cases

Case 1


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Case 1



Anatomy:

Airways — The trachea is slightly off to the right, butthere is no focal bulge and this appearance is likely re-lated to the mild scoliosis.

Bones — There is mild scoliosis of the spine.

Contours — The main pulmonary artery is too large (it islarger than the aorta). The other anatomical structuresappear normal.






The main pulmonary artery is enlarged from pulmonic stenosis. Theenlargement seen represents a post-stenotic dilatation of the artery.


Case 2

history: Three heart valves have been replaced. Which ones havebeen replaced and where is the fourth (non-replaced) valve located?

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Case 2


Life Support — There is a right subclavian dual-lead transvenouspacemaker with lead tips in the right atrium and right ventricle.There are midline sternal wires and three heart valve replace-ments.

Anatomy:

Airways — The trachea deviates to the right, but the pa-tient is rotated towards the right, which would accountfor this. The minor fissure is not well seen.


Contours — The mediastinal contours are difficult to seebecause of the enlargement of the heart.

Vascular — The heart, vascular pedicle and pulmonary vasculatureall appear enlarged. There is no pulmonary edema.



Limitations — None, excellent quality film. (The film appears alittle light because it was windowed to make all of the valveseasier to see.) Also, the pacemaker does cover up a portion ofthe lungs, so any abnormalities beneath it would not be seen.


From superior to inferior, the three replaced valves are the pulmonic,aortic and mitral. The fourth valve, the tricuspid, is near the midline


and would be below all three. Its location is actually known on thisfilm, too, because the pacemaker lead must pass through it to get fromthe right atrium to the right ventricle.

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Case 3

history: 29 year-old with a cough.


Case 3



Anatomy:

Airways — The trachea deviates to the left in the medi-astinum. Make sure you know why before you read anyfurther. The minor fissure is not well seen.


Contours — The aortic arch is on the right side of thetrachea.






There is a right-sided aortic arch.

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Case 4

history: Patient with possible pacemaker problem.


Case 4


Life Support — Coming in from the right side is a peripherally-inserted central venous catheter, with its tip in the svc. Thereis a left subclavian dual-lead implanted defibrillator. One of thelead tips is in the right ventricle, the other is dislodged and freewithin the right atrium.

Anatomy:


Bones — There is an old right clavicular fracture andthere are multiple old left-sided rib fractures (near thedefibrillator).

Contours — There are atherosclerotic calcifications inthe aorta.

Vascular — The heart is enlarged, but the vascular pedicle andpulmonary vasculature appear normal.





The right atrial lead is dislodged. Pacer and defibrillator leads gen-erally screw into the walls of the right atrium and ventricle. A relativelycommon problem is for the atrial lead to come out and float freely inthe atrium. Notice how it perfectly parallels the right ventricular lead,

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Case 4 — Corrected atrial lead. Notice how after it has been fixed, theatrial lead goes down but then loops back up (white line), where it isthen attached to the atrial wall.

which is passing through the atrium. Compare to the image taken afterthe lead had been replaced.

In this case, the lateral view also helps because it shows that the“loop” seen on the frontal view is a gradual loop that goes from poste-rior to anterior. The subsequent figure compares the lateral view beforeand after the atrial lead was fixed.


Case 4 — Lateral views. A. Dislodged atrial lead (white line). B.Correctly positioned atrial lead (black line) in the same patient.

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Case 5

history: There are four different pacer/defibrillator leads on thisfilm. Where is each one going?


Case 5


Life Support — There is a left subclavian pacer/defibrillator witha total of 4 leads entering the left subclavian vein.

Anatomy:

Airways — The trachea is deviated, but the patient is ro-tated, which would account for this finding. The minorfissure is not well seen.



Vascular — The heart is enlarged, but the vascular pedicle andpulmonary vasculature appear normal.





One of the four leads is not connected to the control pack (you cansee that the top side of the control pack has three leads connecting toit, and that there is an additional lead not connected to anything butseen through the control pack). Three of the leads go through the leftbrachiocephalic vein, into the svc and then into the right atrium. Oneof those three terminates in the right atrium (notice it curving backupwards), while the other two continue into the right ventricle. It isone of these two ventricular leads that is not connected (intentionally).

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The more difficult lead to understand is the fourth lead, which goes notinto the svc but down the left side of the chest. It is traveling in apersistent left superior vena cava (an anatomic variant). A persistentleft svc drains into the coronary sinus. The pacer lead goes into thecoronary sinus and then into one of the veins of the heart where it ispositioned so that it can be used to pace the left ventricle.


Case 6

history: Where do the two pacer leads on this film go?

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Case 6


Life Support — There is a left subclavian dual-lead transvenouspacemaker. A single, tiny suture wire is seen near the aorticknob.

Anatomy:


Bones — The right 4th and 5th ribs appear abnormallyclose to each other. The other bones appear normal.







The key is to recognize the evidence of prior surgery (the suture wireand the rib deformities on the right). This patient had a d-transpositionof the great arteries which was repaired in childhood using the Mustardprocedure, so there is a pathway from the svc to the left atrium, whichis where these pacer leads are going (the other continues into the leftventricle).


Case 7

history: 50 year-old with acute shortness of breath.

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Case 7



Anatomy:





Interfaces — There is a silhouette sign along the left heart border,all other interfaces are well-preserved.

Categorize — There is a fluffy (alveolar pattern) opacity in the leftlung base.



The alveolar opacity in the left lung base represents a pulmonaryinfarction from an acute pulmonary embolism. Infarct in the lungmanifests itself as hemorrhage, and thus the alveolar pattern. Thisappearance has been termed “Hampton’s hump” after the person whodescribed it. Classically, a Hampton’s hump will be an alveolar patternthat is peripheral and wedge-shaped. The sign is not very common andin reality it can be nearly impossible to distinguish a Hampton’s humpfrom a pneumonia (since both give the same alveolar pattern).


Case 8

history: 53 year-old with chronic shortness of breath.

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Case 8



Anatomy:

Airways — The trachea deviates slightly because thehead is turned; the minor fissure is normal.


Contours — The heart and central pulmonary arteriesappear enlarged.

Vascular — The heart and vascular pedicle are enlarged. In addi-tion, the central hilar vessels are enlarged. Even the vessels moreperipherally in the lungs are too big. There is no pulmonaryedema.





The pattern you see is that of high-output or shunt vasculature. Un-like the case of primary pulmonary arterial hypertension (blue belt case#3), here the large hilar vessels continue on as large vessels all the waythrough the lung. The peripheral vessels look like those of pulmonaryvascular engorgement, but the massively-enlarged central pulmonaryarteries have developed because of a congenital and uncorrected atrial


septal defect (giving a left-to-right shunt), hence the name shunt vas-culature. A similar pattern may be seen patients who do not havea shunt but do have a “high output state,” such as a chronic severeanemia (thus the name high-output vasculature).

Group 7

Brown Belt Cases

Brown Belt Cases

You find yourself once again covering a bunch of patients at night,but this time you are covering for a surgical service that covers

not only postoperative cases but also the trauma service. Your goal isto look at these trauma or post-operative films and determine what, ifany problems, are present.

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130 7 Brown Belt Cases

Case 1

history: 34 year-old in the trauma bay following a motor vehicleaccident.

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Case 1


Life Support — There is an endotracheal tube in good position.There is a right subclavian introducer sheath in place, thoughit has a mild kink in it as it goes under the clavicle. There isa nasogastric tube which extends into the stomach, but takes arather wide course and terminates high, almost above the heart.

Anatomy:

Airways — The trachea deviates to the right. The minorfissure appears normal.

Bones — There are several displaced rib fractures on theleft.

Contours — The diaphragm is much higher than normalon the left. The entire left side of the mediastinum is ob-scured by either the elevated diaphragm or the opacitiesin the left lung.

Vascular — Heart, vascular pedicle and vasculature, though difficultto evaluate due to all the adjacent opacities, appear normal.

Interfaces — All interfaces are along the left side of the mediastinumshow a silhouette sign.

Categorize — There is a left pleural effusion (likely pleural bloodin this case). There is elevation of the left hemidiaphragm withcrowding of the vasculature in the left lung base (atelectasispattern). There is also superimposed fluffy opacity (alveolarpattern) in the left lung.


Limitations — The film was obtained with the patient on a spine(trauma) board, which causes some artifacts, but it is otherwisea good film.

Extra Look — The trachea is deviated to the right and the regionsbehind the heart or left side of the diaphragm cannot be seen atall.

This is a case of a traumatic rupture in the left side of the di-aphragm. What appears to be the diaphragm on that side is actuallyabdominal contents (including the stomach) passing through the largehole in the diaphragm into the thoracic cavity. The compression frombelow, along with the pleural effusion/hemorrhage, accounts for the at-electasis, and pulmonary contusion accounts for the alveolar pattern inthe left lung.

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Case 2



Case 2


Life Support — There is an endotracheal tube in good position.There is a nasogastric tube which deviates to the right as itcourses down the esophagus and then terminates in the stom-ach. The side port is not well seen on this study and could beabove the ge junction.

Anatomy:

Airways — The trachea deviates towards the right. Theminor fissure is displaced inferiorly slightly.


Contours — The superior mediastinum appears widenedand there is loss of the normal outline of the aortic knob.


Interfaces — There is a silhouette sign of the aortic knob and pul-monary artery.

Categorize — There is very minimal vascular crowding in the rightlung base and mild inferior displacement of the minor fissure(signs of atelectasis).


Extra Look — The trachea is deviated to the right. The hila and“hidden areas” appear normal.

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This patient has a traumatic rupture of the thoracic aorta. Theworrisome signs are the deviation of the nasogastric tube (a sign of amediastinal hematoma displacing the esophagus), the widened superiormediastinum and loss of distinctness of the aortic knob (also from thehematoma). In major trauma centers almost all patients from majormotor vehicle accidents get ct scans, but it is possible to have this in-jury in what may have seemed like something less than a major accidentand these patients may occasionally be seen non-trauma centers.


Case 3


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Case 3


Life Support — The endotracheal tube, nasogastric tube, right sub-clavian introducer sheath and right sided chest tube all appearfine.

Anatomy:


Bones — There are multiple displaced rib fractures on theleft.

Contours — The contours of the left side of the medi-astinum are all obscured.


Interfaces — There is a silhouette sign of the left heart border aswell as of the aortic knob and main pulmonary artery.

Categorize — There is fluffy opacity seen throughout the left lung(alveolar pattern) with some sparing of the left costophrenicangle.


Extra Look — The airways appear normal. The right hilum appearsnormal. The left hilum is obscured by the lung opacity, and theareas behind the heart and left side of the diaphragm show thealveolar process described above.


This patient has a large pulmonary contusion on the left. Contusion(blood) is one of the causes of an alveolar pattern in trauma patients.Another important cause of alveolar flooding in these patients is aspi-ration. In this case, though, the overlying rib fractures are a sure signof where the brunt of the force hit the chest.

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Case 4

history: 31 year-old in the icu recovering from a recent burn injury.


Case 4


Life Support — The tracheostomy canula, feeding tube and rightsubclavian central line appear fine. Some scattered skin staplesrelated to grafting surgery are also seen.

Anatomy:



Contours — The left side of the diaphragm is not seen,but otherwise the anatomical structures appear normal.


Interfaces — There is a silhouette sign of the left hemidiaphragm.

Categorize — There are bilateral, peripheral alveolar opacities through-out the lung.


Extra Look — The trachea is normal but the hila and “hiddenareas” are obscured by all the opacities.

This pattern represent injury edema. Injury edema is a non-cardiogenicpulmonary edema seen in patients with ards. The pattern is typicallyalveolar and peripheral, but usually always fairly severe as well. Thepatients are generally quite sick (almost always intubated) and are alsoat risk for ventilator-acquired pneumonia which can have an identicalappearance. It is usually not possible to tell injury edema from diffusebilateral pneumonia, and it is not uncommon for these patients to haveboth.

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Case 5

history: 59 year-old, post op film.What surgery was done and are there any problems?


Case 5


Life Support — There are midline sternal wires. There is an aorticvalve replacement. There are well-positioned endotracheal andnasogastric tubes as well as a right internal jugular pulmonaryartery catheter. There are also four chest tubes. All four enteranteriorly. Two go straight up the mediastinum and are difficultto see, one goes off to the right laterally and the other to leftover the heart.

Anatomy:



Contours — There are aortic atherosclerotic calcifica-tions. The heart and mediastinum are enlarged. Theleft side of the diaphragm is not well seen.

Vascular — The heart and vascular pedicle are enlarged (thoughsome of the enlargement seen could be related to the surgery).In addition, there is engorgement of the pulmonary vascular,especially centrally, but there is no pulmonary edema.

Interfaces — There is a silhouette sign of the left hemidiaphragmand left heart border. The hilar interfaces are also lost.

Categorize — There is vascular crowding in both lung bases and inthe perihilar regions (atelectasis pattern).


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Extra Look — The basilar atelectasis is seen through the heart anddiaphragm and the hila are obscured by the adjacent atelectasisthere. The trachea is normal.

This patient has just returned from aortic valve replacement surgeryand all of the findings described are typical and expected.


Case 6

history: 63 year-old, post op film.What surgery was done and are there any problems?

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Case 6


Life Support — There are chain sutures seen in both lungs (suprahi-lar regions).

Anatomy:


Bones — Spinal scoliosis but otherwise normal.

Contours — The hila are superiorly retracted slightly andthey are obscured. There are some black streaks in thesoft tissues over the left shoulder. These streaks repre-sent air in the soft tissues (“subcutaneous emphysema”).The ascending aorta is too prominent (see along theright side of the mediastinum over the right heart bor-der) but this is a common finding in some older patients.


Interfaces — There is a silhouette sign of both hila from the adjacentlung opacities.

Categorize — In the regions of the chain sutures there is a mixedpattern of alveolar flooding and vascular crowding (atelectasis).


Extra Look — The apparent deviation of the trachea comes froma combination of the scoliosis and patient rotation.

These are the typical findings of a patient who has undergone bi-lateral lung volume reduction surgery (lvrs). lvrs is done in patients


with severe centrilobular emphysema that has an upper lobe predom-inance. This patient’s surgery occurred 4 days prior to this film. Im-mediately following the surgery there were bilateral chest tubes andpneumothoraces present. The pneumothoraces have resolved and thetubes have been pulled, but some air remains in the adjacent soft tissues(an expected finding). The opacities around the chain sutures representa combination of bleeding and volume loss.

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Case 7

history: 49 year-old with history of prior surgery.What surgery was done and are there any problems?


Case 7


Life Support — There is a right sided Portacath. The line is well-positioned. The “loop” actually occurs where the tubing is stillin the soft tissues. This line enters the right ij vein and has itstip in the svc.

Anatomy:



Contours — All appear normal, though there is an “ex-tra” soft tissue structure projecting over the right heartborder and the right hilum.



Categorize — There is what appears to be a “mass” lesion overlyingthe right side of the heart and the right hilum.



This patient has had a prior esophagectomy and gastric “pull-through”procedure, and all of the findings seen are expected. The study was per-formed because of esophageal cancer. What appears to be a “mass” (orwhat is sometimes mistaken for a large ascending aorta) is the stomach,which has been pulled into the chest to replace the resected esophagus.The stomach’s appearance can change dramatically from film to filmdepending upon how distended it is with food, fluids or air.

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Case 8

history: 42 year old, post “device placement.”What device was placed and are there any problems?


Case 8


Life Support — The device consists of two large-bore tubes extend-ing up from the abdomen. One tip goes towards the left ventricleand the other towards the ascending aorta. There are also mid-line sternal wires from a prior surgery.

Anatomy:



Contours — The main pulmonary artery appears en-larged, but the other anatomical structures appear nor-mal.


Interfaces — There is a silhouette sign of the left hemidiaphragm.


Limitations — The lateral portion of the right lung base is notincluded in the image (however, note that this film is labeled “1of 2.” A second film to include that area had been obtained).


The “device” is a left ventricular assist device (lvad). It takesblood from the left ventricle and pumps it into the aorta. The mainpump for this device is located in the abdomen. Often these devices areused to keep a patient alive while awaiting heart transplant. You mayalso see a similar device that has four large-bore tube (a bi-ventricularassist device, bi-vad). The lateral view is included here so you canbetter see where the tubing goes.

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Case 8 — Lateral view. The inferior tube takes blood from the base ofthe left ventricle while the superior tube pumps blood into the aorta..

Group 8

Black Belt Cases

Black Belt Cases

You should congratulate yourself for making it this far through thecase book. If you have worked through all of the cases so far, then

you really have developed a firm framework upon which you can con-tinue to build your understanding of the plain chest film. The claviclesystem is just one way to analyze films, and whether you have been us-ing it or your own method, you will soon discover that there is alwaysmore to know. Because you have used a disciplined and systematicapproach for analyzing films, however, you will find that it becomeseasy to incorporate knew knowledge into what you are already doing.The cases I have chosen for the “black belt” level aren’t necessarily anymore difficult than those you have seen already. In fact, many of themare relatively straight-forward. The purpose is to introduce some newconcepts so you can practice your skills and learn how to deal with newconcepts as you encounter them. This is really where you should bewhen you finish medical school, and here the black belt represents not

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154 8 Black Belt Cases

the end of your training, but just the beginning.

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Case 1



Case 1



Anatomy:



Contours — The diaphragm is elevated bilaterally, butgreater on the left. All of the mediastinal and hilaranatomical contours are at least partially obscured.

Vascular — Heart, vascular pedicle and vasculature are difficult toevaluate because of all of the adjacent parenchymal abnormali-ties.

Interfaces — There is a silhouette sign of most of the mediastinalborders and of both hemidiaphragms.

Categorize — There is a predominantly-linear pattern (interstitial)throughout the lungs. The severity is greater in the lung bases,but abnormalities are seen everywhere. The abnormal lines donot appear to be normal anatomical septa becoming visible. In-stead they are irregular bands which do not correspond to anyanatomical structures. In addition, the lung volumes are lowand the diaphragm is elevated (atelectasis pattern). There arealso small bilateral pleural effusions or areas of thickening of thepleura.


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Extra Look — The trachea appears normal. The hila and “hiddenareas” are obscured by the abnormal interstitial pattern.

This patient has severe pulmonary fibrosis. The interstitial patterncan be subdivided into two categories — the pattern that results fromthe normally-invisible septa becoming apparent on the film, and thepattern that results from new, non-anatomical lines. There have beenseveral cases of the former (including interstitial pulmonary edema andinterstitial pneumonia). Here is a case of the latter. The linear patternresults from bands of fibrotic tissue, and the low lung volumes are aconsequence of the poor pulmonary compliance due to the stiffeningof the lungs. While there are many causes and types of pulmonaryfibrosis, this patient has one of the most common (and deadly) — thatof idiopathic pulmonary fibrosis (ipf).


Case 2

history: 24 year-old post bronchoscopy.

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Case 2



Anatomy:





Interfaces — There is a silhouette sign along the right heart border.

Categorize — There is an alveolar pattern in the middle lobe.



Without the history, this film could very easily be interpreted as aright middle lobe pneumonia. In fact, though, the alveolar pattern isbeing caused by residual lavage fluid left behind after the bronchoscopyprocedure, a very common and expected finding. This case reminds usthat the parenchymal patterns can at best give you a broad category ofwhat may be wrong, but that the ultimate diagnosis must come fromyour additional knowledge about the patient’s history and other clinicalfindings.


Case 3

history: 29 year-old, post-operative day #1.What surgery was performed and are there any abnormalities?

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Case 3


Life Support — Skin staples cross the chest transversely and thereare transverse sternal wires present. There are also surgical clipsseen in the mediastinum. There are an endotracheal tube, naso-gastric tube and right internal jugular pulmonary artery catheterwhich appear well-positioned. There are also four chest tubesseen (all anterior, two on the left and two on the right).

Anatomy:



Contours — All appear normal. There are some blackstreaks of air outlining muscle fibers in the pectoralismajor muscle.



Categorize — There is a small left apical pneumothorax. There isan alveolar flooding pattern seen throughout both lungs.


Extra Look — Trachea, hila and “hidden areas” all appear normalexcept for the alveolar pattern.

This patient has had bilateral lung transplantation. For this surgery,a transverse (rather than midline sternal) approach is used. The air inthe pectoralis muscle is an expected and inconsequential post-operative


finding. The alveolar pattern represent reimplantation pulmonary edema,which often occurs within the transplant during the first several daysto one week following surgery. While it is not a “normal” finding, it isquite common and will usually resolve in a few days on its own.

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Case 4

history: 69 year-old with long pulmonary history.


Case 4



Anatomy:

Airways — The carina and central airways are superiorlyretracted. The minor fissure is displaced superiorly.


Contours — The hila are obscured by large masses. Theaorta and main pulmonary artery are also obscured. Theright hemidiaphragm has an abnormal shape. There arealso multiple round, calcified densities seen near the hila.

Vascular — The heart size is normal. The vascular pedicle andpulmonary vasculature cannot be judged, but there is no pul-monary edema.

Interfaces — There are silhouette signs along the right hemidi-aphragm and the right heart border, as well as along the superiormediastinum bilaterally.

Categorize — There are large bilateral mass lesions. In addition,there are innumerable small nodules seen throughout the lungs.There is also evidence of scarring, with superior retraction of thehila and minor fissure. There is a right-sided pleural effusion (orthickening of the pleura).


Extra Look — Trachea and “hidden areas” appear relatively nor-mal. The hila are completely obscured by the masses.

165

This patient has long-standing silicosis which has gone on becomeprogressive massive fibrosis. The changes of silicosis take many yearsto manifest on the chest film, and then many more years to progressto this extent. Silicosis begins as multiple nodules, predominantly inthe upper lungs which coalesce over time to form these large perihilarmasses known as progressive massive fibrosis. There is also a lot ofscarring and distortion of the normal pulmonary architecture whichoccurs, as can be seen from the superior retraction of the hilar andthe shrinking of the upper lobes. The lymph nodes with peripheral(“egg-shell”) calcifications are a common finding.


Case 5

history: 63 year-old with a long pulmonary history.

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Case 5



Anatomy:



Contours — There are very bright lines seen along thediaphragm bilaterally.



Categorize — There are poorly-defined densities seen over the lungsbilaterally, but best seen just over the middle of the right lung.These do not have characteristics matching any of our parenchy-mal patterns.



There are calcified and non calcified plaques seen along the pleura,a consequence of prior occupational exposure to asbestos fibers. Thebright white lines along the diaphragm represent calcified pleural plaquesseen from the side. The ill-defined opacities over the lungs representboth calcified and non-calcified pleural plaques seen en face. In almostall cases, plaques such as these are the result of repeated exposure toasbestos fibers, but their presence does not indicate asbestosis. Thatterm is used to describe the interstitial lung disease caused by asbestosexposure, and usually manifests itself as pulmonary fibrosis with otherrelated clinical findings.


Case 6

history: 48 year-old with moderate shortness of breath.

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Case 6



Anatomy:

Airways — Airways normal, minor fissure displaced in-ferior slightly.





Categorize — There is an interstitial pattern seen in the right lung.It is somewhat denser and slightly more “nodular” than otherinterstitial patterns we have encountered thus far.



This patient has lung cancer which has developed lymphangitic spread.Lymphangitic spread (spread of a malignancy through the pulmonaryinterstitium) can occur with primary lung tumors but also with malig-nancies from other sites (especially breast cancer). The tumors growthrough the interstitial spaces without causing much, if any, architec-tural distortion.


Case 7

history: 24 year-old with a long pulmonary history.

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Case 7



Anatomy:






Categorize — There is an interstitial pattern seen throughout bothlungs. The reticular markings are somewhat thicker than otherinterstitial patterns encountered so far. Some of these lines looklike tubes seen either from the side (“tram-tracking”) or end-on(“ring shadows”). There are also nodules seen, especially in thelung bases.



This is the pattern of fairly severe bronchiectasis in patient withcystic fibrosis. The interstitial pattern results from dilated bronchi(and bronchioles) with markedly thickened walls. What appear to benodules are actually mucus-filled bronchi. These patients are at a veryhigh risk of pneumonia, and so it is not uncommon to find superimposedalveolar opacities as well.


Case 8

history: 54 year-old with hemoptysis.

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Case 8



Anatomy:






Categorize — There are patchy, bilateral, fluffy (alveolar) opacities.



Without the clinical history, these opacities could easily be inter-preted as representing bilateral pneumonia. In fact, this patient hasWegener’s Granulomatosis and these opacities represent flooding of thealveolar spaces with hemorrhage, a common occurrence in Wegener’s.