HOW READ CHEST XR -12

ANAS SAHLE ,MD

Brief review

PATCHY

INFILTIRATION

NODULE

MASS

CAVITARY

OPACITY

Consolidation

Infection causes

Pneumonia

Non-infection causes

Lymphoma

Broncho-

alveolar

carcinoma

COP

WEGNER disease

Sarcoi

d

Cardiac failu

re

Solitary Pulmonary Nodule(SPN)

Comparison with a previous x-ray toAssess growth over time.

Cavitary lesion

Air + tissue

Air-fluid level

StraightAbscess

Wavy ruptured

Hydatid cyst

Air only

ThickIrregular

inner wall

Cavitating

neoplasm

Regular

inner wall

Chronic

abscess

ThinPeriph

eral Emphesemato

us bulla

Centralpneu

matocele

Wall thickness

site1. Fungal ball.2. Rupture hydatid cyct3. Necrotic tumor4. Blood glot

LINEAR PATTERN

LINEAR PATTERNPerihilar and peripheral basal septal lines,changes acutely and resolves with diuretics

LEFT VENTRICULAR FAILURE

Coarsening of lung markings in lower zones, nochange on review of recent films

Normal ageing

Coarse nodular and linear thickening ofmarkings, known malignancy, often associatedwith pleural effusion, rapid clinicaldeterioration of patient

Lymphangitis

LINEAR PATTERNLINEAR PATTERN

Short thin lines, often basal, new on review ofprevious films

Atelectasis

Longer thicker bands, often perihilar or basal,suggest recent infection or infarction

Subsegmentalcollapse

Any length, persist over time unchanged

Volume loss is key, persists over time

Scarring

Fibrosis

Causes of fibrosisMid zone lung Lower zone lung Upper zone lung

tuberculosis Drug indused fibrosis(most common)

sarcoidosis

Chronic extrinsic allergic alveolitis

UIP

Radio-therapy Asbestose-related fibrosis

Ankylosing spondylitis

Progressive massive fibrosis

histoplasmosis

Mediastinum

MEDIASTINAL ANATOMY 

Superior: Upper of T4

Inferior: Lower of T4( T4-T8)

19

INTRODUCTION

• The mediastinum extends from the thoracic inlet to the diaphragm

• contains many vital structures:» The heart and great vessels» Pulmonary hila» Esophagus

20

INTRODUCTION

• The mediastinum extends from the thoracic inlet to the diaphragm

• contains many vital structures:» The heart and great vessels» Pulmonary hila» Esophagus

21

INTRODUCTION

• The mediastinum extends from the thoracic inlet to the diaphragm

• contains many vital structures:» The heart and great vessels» Pulmonary hila» Esophagus

MEDIASTINAL ANATOMY 

Superior: Upper of T4

Inferior: Lower of T4( T4-T8)

23

The Anterior compartment

• The anterior compartment = the anterosuperior compartment = retrosternal space

• Is anterior to the pericardium

24

The Anterior compartment

• Includes:» The Thymus» The Extrapericardial aorta and its branche» The great veins, and lymphatic tissue.

25

Surgery Anatomy

26

The Middle compartment

• The middle compartment is bounded by

• The pericardium anteriorly• The posterior pericardial reflection• Inferior : the diaphragm• Superior: the thoracic inlet

27

The middle compartment

• This compartment includes:» the heart» intrapericardial great vessels» Pericardium» trachea

28

The posterior compartment

• Extends from the posterior pericardial reflection to the posterior border of the vertebral bodies and from the first rib to the diaphragm

29

The posterior compartment

• It includes the:» Esophagus» Vagus Nerves» Thoracic Duct» Sympathetic Chain» Azygous Venous

System.

30

The posterior compartment "visceral compartment"

• Visceral compartment: the area from the posterior pericardial reflection to the anterior border of the vertebral bodies in the middle compartment has "Paravertebral sulcus"

31

The posterior compartment

• In this classification, the cardiopericardial structures, the trachea and the esophagus, are part of the visceral compartment

32

Case-1• A 71-year-old man is seen with low-grade fever, generalized malaise, and a run-down

feeling. • He has lost weight and shows stigmata of chronic illness. • There is no history of occupational exposure. • On physical examination, vital signs are as follows:

– pulse 110 bpm; – temperature 99°F; – respirations19/min; – blood pressure 90/60 mm Hg.

• On exam, the man is frail and appears cachectic with temporal wasting. • Other aspects of his physical exam are unremarkable. • Laboratory data:

– Hb 10 g/dL; Hct 30%; MCV 90;– WBCs 3000/μL; differential normal; – BUN 19 mg/dL; creatinine 1.0 mg/dL;– sodium 129 mEq/L; potassium 5.0 mEq/L;

• ABGs (RA): pH 7.42, PCO2 35mm Hg, PO2 58 mm Hg. • Spirometry: FVC 60% of predicted; FEV1 60% of predicted. • PPD skin test is negative (0 mm); induced sputum for AFB smear is negative.

Case-1

POSITION •PA CXR

QUALITY •Poor Technical Quality

LESION •Bilateral nodular opacity apperance.

MEDIASTINAL\Hilum

•Central trachea and mediasteinal.

ANGELS •Disappear .

OTHER •No

Case-1

• 1. What is the most likely diagnosis?• a. Silicosis• b. Miliary TB• c. Metastatic thyroid carcinoma• d. Sarcoidosis• 2. What is the next step in the workup of this patient

that would most likely yield the diagnosis?• a. CT scan of the chest• b. Thyroid function tests• c. Bone marrow aspiration for culture• d. Thoracoscopic lung biopsy

Case-2

POSITION •PA CXR

QUALITY •Poor Technical Quality

LESION •Bilateral nodular opacity apperance.•At middle,upper zone.

MEDIASTINAL\Hilum

•Central trachea and mediasteinal.

ANGELS •Hazy left angle .

OTHER •No

Case-2

• 1. Based on the CXR shown, all of the following may be helpful in the diagnosis except:

• a. Occupational history• b. Sputum for AFB• c. Sputum for fungus• d. History of rheumatic fever• 2. This patient’s occupational history reveals exposure to iron

ore, asphalt, and dust related to working on loading docks for 10 years. The CXR is most consistent with:

• a. Silicosis• b. Asbestosis• c. Bagassosis• d. Chlorine gas exposure

Case-3

• A 70-year-old man with a history of emphysema and progressive dyspnea is admitted with mild hemoptysis.

• On exam, he is afebrile; he has a left-sided chest wall scar from a previous thoracotomy with decreased breath sounds in the left lung field.

• There are wheezes and rhonchi heard in the right lung field.

Case-3

POSITION •PA CXR

QUALITY •Poor Technical Quality

LESION •Left hemithorax homogenous opacity•Patchy consolidation in right lung•CUTT OFF SIGN

MEDIASTINAL\Hilum

•Left trachea and mediasteinal deviation

ANGELS •obscured left angle .

OTHER •No

Case-3

• Based on the CXR and clinical history, the most likely diagnosis is:

• a. Left lung atelectasis with mucus plug• b. Metastatic lung disease from lung primary• c. Multiple pulmonary infarcts• d. Septic emboli

Case-4

• A 53-year-old male smoker, unemployed with no occupational exposure,

• is admitted with progressive shortness of breath. • He has been unwell for some time and has received multiple

courses of antibiotics for “bronchitis.”• During the prior 4 mo, he has not had any medical follow-up. • On exam, he is a-febrile but looks ill. • Lung exams reveal diffuse rhonchi and crackles with no

localizing signs. • ABGs on room air show PaO2 of 68 mm Hg with mild

compensated respiratory alkalosis. • Sputum for AFB is negative.

Case-4

POSITION •PA CXR

QUALITY •Poor Technical Quality

LESION •Bilateral multiple nodular opacity•Masslike lesion at left middle zone

MEDIASTINAL\Hilum

•Wided superior mediastinum•Round opacity at upper right hilum

ANGELS •Right angle is disappered .

OTHER •May be opacity at left axila

Case-4

• 1. The most likely diagnosis is:• a. TB• b. Hypersensitivity pneumonitis• c. Metastatic disease• d. Acute interstitial pneumonitis• 2. Associated with this diagnosis is:• a. Clubbing• b. Increased IgE• c. Hypocalcemia• d. Eosinophilia