HOW READ CHEST XR -10

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

1 )Linear (reticular) abnormality is due to pathology involving:

• airways, • lymphatics, • veins, • interstitium of the lung.

2 )Volume loss is a key finding in fibrosis.

LINEAR PATTERNLINEAR PATTERN

Perihilar 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 PATTERN

LINEAR PATTERNShort 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

Case-1• A 49-year-old white woman presents with progressive cough and

dyspnea.• She denies any history of arthritis, skin lesions, or eye complaints.• On physical examination, vital signs are:

– pulse 90 bpm; – temperature 98°F;– respirations 32/min;– blood pressure 119/76 mm Hg.

• General exam: patient is in moderate distress, and pertinent physical findings reveal clubbing of the fingers and bilateral “Velcro” rales on lung auscultation.

• ABGs on room air: pH 7.47; PCO2 32 mm Hg; PO2 60 mm Hg with further de-saturation on mild exertion

Case-1

POSITION •PA CXR

QUALITY •Good Technical Quality

LESION •Bilateral reticular infitration •At lower zone and left mid zone

MEDIASTINAL\Hilum

•Central trachea and mediasteinal.

ANGELS •Hazy left angle .

OTHER •No

Case-1

:1-Least likely to be associated with this condition isa. Positive antinuclear antigenb. Positive rheumatoid factorc. Increased erythrocyte sedimentation rated. Increased IgE

2 -What is the most likely diagnosis?a. Idiopathic pulmonary fibrosisb. Langerhans granulomatosis/histiocytosis-X disordersc. Rheumatoid lungd. Sarcoidosis

3 -PFTS would be expected to showa. An obstructive patternb. A restrictive patternc. A normal patternd. A reversible obstructive pattern

Case-2

• A 65-year-old woman from Honduras complains of arthralgias and difficulty getting out of a chair and doing her daily chores at home.

• She has muscle aches and generalized weakness, dyspnea, and cough.

• On physical• examination, vital signs are:

– pulse 98 bpm; – temperature normal; – Respirations 23/min– bilateral crackles on lung exam.

• Neuro exam reveals proximal muscular weakness with no sensory deficit.

• CPK and aldolase are increased: • sedimentation rate is 120 mm/min. • PFT: restrictive pattern.

Case-2

POSITION •PA CXR

QUALITY •Poor Technical Quality

LESION •Bilateral reticular infitration •Diffuse bilateral lung especially left lower zone.

MEDIASTINAL\Hilum

•Central trachea and mediasteinal.

ANGELS •Free .

OTHER •Right hemi-diaphragm elevated

Case-2

1 .What is the most likely diagnosis?a. Paraneoplastic syndromeb. Polymyositisc. Sjِgren syndrome

d. Scleroderma

2 .There is an increased association of one of the following with this conditiona. Carcinoma of the pancreasb. Diabetes mellitusc. Diabetes insipidusd. Alzheimer’s disease

Case-3

• A 48-year-old female nurse is seen with complaints of cough.

• She has been treated for “bronchitis” without much improvement.

• On exam, she is afebrile and has crackles in the upper zones of the lung field.

• PPD is negative and sputum for AFB is negative.

Case-3

POSITION •PA CXR

QUALITY •Good Technical Quality

LESION •Bilateral reticular infitration •Diffuse bilateral lung especially middle,upper zone.

MEDIASTINAL\Hilum

•Central trachea and mediasteinal.•Bilateral hilar enlargement\parathraceal

ANGELS •Disappear.

OTHER •No

Case-3

• 1. The most likely diagnosis is:• a. Tuberculosis• b. Blastomycosis• c. Sarcoidosis• d. Silicosis• 2. All of the following findings may be seen in this

patient except• a. Uveitis• b. Skin lesion• c. Bony cysts• d. Hypocalcemia

Case-4• A 56-year-old black male non-smoker is seen with a history of dyspnea• on walking two blocks and chronic chest congestion and cough. • He has been followed for progressive shortness of breath after his

CABG. • Recently, he was ill with a flulike illness, but he denies any fever or

chills presently.• Past history: reveals a GI clinic follow-up for inflammatory bowel disease

for• which he has been on chronic steroid therapy off and on. • On physical examination, vital signs are:

• pulse 110 bpm; • temperature normal; • respirations24/min; • blood pressure 120/78 mm Hg.

• General exam: patient appears frail but in no distress. • Pertinent findings:

• coarse rhonchi and scattered expiratory wheeze with squeaks. • Heart exam reveals normal S1-S2 with no gallop.• There is no hepatomegaly or pedal edema.

Case-4

• Laboratory data: • Hb 11 g; Hct 33%; • WBCs 15.0/μL; differential normal.

• PFTs/spirometry: • FVC 3.43 L (78% of predicted); • FEV1: 2.15 L (63% of predicted); • FEV1/FVC% 72%;• TLC 5.34 L (69% of predicted);• DLCO 14 cc/min/mm Hg (57% of predicted).

• Echocardiogram shows an:• ejection fraction of 55%.• no focal dyskinesia.

Case-4

POSITION •PA CXR

QUALITY •Poor Technical Quality

LESION •Bilateral reticular infitration •Diffuse bilateral lung especially peripherial lower right zone.

MEDIASTINAL\Hilum

•Central trachea and mediasteinal.

ANGELS •Free .

OTHER •No

Case-4

• 1. What is the most likely diagnosis?• a. Congestive heart failure• b. COPD• c. Nonspecific pneumonitis• d. Bronchiolitis obliterans with organizing pneumonia (BOOP)• 2. There may be an increased risk of one of the

following during therapy in this patient:• a. Pulmonary embolism• b. Staphylococcal infection• c. Mycobacterial infection• d. HIV infection

Case-5

• A 50-year-old woman is admitted with progressive shortness of breath.

• She was well until about 2 mo ago, when she noted that she was getting tired and fatigued easily.

• She gives a history of working as a domestic worker and “cleaning lady” for many years.

• Recently, she was working for a company that did maintenance work on boats in a marina area.

• She now has cough, shortness of breath, and low-grade fever with malaise.

• This has continued despite symptomatic treatment.

Case-5

• On exam she is found to be in:• mild to moderate distress • with harsh vesicular breath sounds, • Diffuse rhonchi• bilateral basilar crackles on lung exam, more

on the right.• Routine labs are normal, • PPD is 5 mm.• sputum is negative for fungal.• AFB smear with cultures pending.

Case-5

POSITION •AP CXR

QUALITY •Poor Technical Quality

LESION •Bilateral reticular (linar) infitration •bilateral lower lung zone.

MEDIASTINAL\Hilum

•Central trachea and mediasteinal.

ANGELS •Bilateral hazy angels .

OTHER •No

Case-5

• 1. The most likely diagnosis is• a. Silicosis• b. Asbestosis• c. Extrinsic allergic alveolitis• d. Nontuberculous mycobacterial infection• 2. Associated with this condition is• a. Increased lung volumes• b. Decreased diffusion• c. Peripheral eosinophilia• d. Inorganic dust exposure