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HOW READ CHEST XR -8




     ANAS SAHLE ,MD
Brief review
POSITION
                             PA                                                AP


                                                      QUALITY
                ROTATION                             PENETRATION                    INSPIRATION




                                                       LESION
       OPACI
        OPACITY
                          Homo
                      Heterogenous      Wellill defined         Zone
                                                                          Centralperiph     Silhouet
                                                                               eral             sign
         TY                Necrotic
  PATCHY

                                                  MEDIASTINAL
  NODULE                                Central deviasionwided

   MASS                                   COSTO-PHRENIC ANGEL
                                                 Freeoblitern
  CAVITARY


                                                       OTHER
INFILTIRATION                          Bone soft tissuediaphragm
Consolidation

Infection
 causes                    Non-infection causes



                        Broncho-
                                         WEGNER              Cardiac
Pneumonia   Lymphoma    alveolar   COP             Sarcoid
                                         disease             failure
                       carcinoma
Solitary Pulmonary Nodule(SPN)
• Is
         •   Single.
         •   Discrete.
         •   intrapulmonary density.
         •   < 3cm in diameter.
         •   completely surrounded by aerated lung.
• DDX:
         •   Bronchogenic ca.
         •   Solitary metastasis.
         •   Granuloma (infectioninflamation).
         •   Benign lung tumor(hamartoma).
         •   Round pneumonia.
         •   Round atelectasis.
         •   AVM.
Solitary Pulmonary Nodule(SPN)
                         Appearance
 Margin                  Calcification                cavitation

             Comparison with a
                      Size
             previous x-ray to >8mm
          <8mm
             Assess growth over
             time. Location
   Upperhillar zone                     Lowerbasesup-pleural


                 Associated abnormalities
Lymph node enlargement                   Rib destruction/erosion
Nodule  Mass
           Nodule                         Mass
• Well defined opacity it s   • Well defined opacity more
  diameter up to 3cm.            than 3cm.
• The most common is:          • The most common is:
   –   Tuberculoma                – Bronchgenic CA
   –   Hamartoma                  – Hydatid cyst
   –   Bronchogenic CA            – metastases
   –   Hydatid cyst
   –   Metastases
   –   AVM
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Cavitary lesion
Air-fluid level                               Air only
                                          Wall thickness

Straight    Wavy                  Thick                               Thin
                                                                      site
           ruptured
                      Irregular inner   Regular inner
Abscess    Hydatid         wall             wall
                                                         Peripheral          Central
             cyst


                        Cavitating        Chronic       Emphesematous
                                                                         pneumatocele
                        neoplasm          abscess           bulla
Case-1

• A 40-year-old man with a history of substance abuse and HIV
  infection is seen in the ER with complaints of:
       • fever,
       • weight loss,
       • production of foul-smelling sputum,
       • and shortness of breath for 2 wk.
• On physical exam he is :
       • tachypneic
       • has clubbing of his digits.
• Lung exam reveals:
       • diffuse rhonchi
       • and an area of egophony with whispering pectoriloquy in the
          right chest posteriorly.
• ABGs reveal PaO2 of 59 mm Hg on room air.
CASE-1

What is the most likely
diagnosis?
a. Pneumococcal
pneumonia
b. PCP pneumonia
c. Lung abscess
d. Squamous cell
carcinoma
POSITION      •PA CXR


QUALITY       •Good Technical Quality


               •Round opacitiy with air-fluid level
               •In right upper zone near hilum
LESION         •Ill-defined linear opacity surrond it




              •Central trachea and mediasteinal.
MEDIASTINAL
ANGELS        •Free costo-phrenic angels.


OTHER         •No
Case-2

•   A 60-year-old man with a history of COPD and old TB is seen with
•   mild hemoptysis and chronic cough.
•   He is HIV negative and has been ill for about 2 wk.
•   Vital signs: pulse 110 bpm; temperature 101°F; respirations
    24/min; blood pressure 108/70 mm Hg.
•   No skin lesions are noted.
•   Laboratory data: Hb 14 g/dL; HCA 42%; WBCs 8.7/μL; BUN 24
    mg/dL; creatinine 0.8 mg/dL; sodium 131 mEq/L; potassium 4.3
    mEq/L.
•   ABGs on RA: pH 7.37; PCO2 43 mm Hg; PO2 87 mm Hg.
•   Sputum tests reveal numerous AFB-positive organisms on smear.
•   Spirometry shows an obstructive ventilatory impairment with
    marginal reversibility.
Case-2
POSITION            •PA CXR

QUALITY             •Poor Technical Quality


                     •Cavitary lesion
                     •In right upper zone
LESION


                    •Central trachea and mediasteinal.
MEDIASTINALHilum
                    •Right hilum pulled upward

ANGELS              •Disappear .

                    •No
OTHER
Case-2



• the most likely diagnosis is
   – a. Lung abscess
   – b. Non-TB mycobacteria
   – c. Actinomycosis
   – d. Aspiration pneumonia
Case-3

• A 60-year-old man with a past history of
  smoking for 30 years (he stopped 3 years ago,
  prior to cardiac bypass surgery).
• is admitted with cough and mild hemoptysis.
• He is afebrile with no shortness on breath.
• Physical exam is negative except that the lung
  exam reveals rhonchi in the left upper lung
  zone.
Case-3
POSITION            •PA CXR

QUALITY             •Poor Technical Quality


                     •Well defined round density
                     •(mass lesion)
LESION               •7*11cm.
                     •In left para-hilar area.
                     •Obscured aortic


                    •Right deviated trachea.
MEDIASTINALHilum

ANGELS              •Disappear .

                    •No
OTHER
Case-3


• The finding/abnormality most likely to occur
  with the lesion seen on the CXR:
• Serum calcium of 13.6 mg/dL.
• b. Sputum positive for fungal elements
• c. Increased D-dimer levels.
• d. Koilonychia.
Case-4

• A 38-year-old city worker presents with fever,
  chills, and cough with left-sided chest pain 2
  days after the Mardi Gras festival.
• She denies any hemoptysis, weight loss, or
  chronic illness.
• Past history is unremarkable.
• On physical exam, she has a BMI of 32;
  temperature is 101°F.
• She was observed to have splinting of her
  right side during the inspiration.
Case-4
POSITION            •PA CXR

QUALITY             •Poor Technical Quality


                     •Well defined round density
                     •(mass lesion)
LESION               •3*2,5 cm.
                     •In right middle zone.




                    •Cardiomegaly .
MEDIASTINALHilum

ANGELS              •Hazy .

                    •No
OTHER
Case-4

• 1.The most likely diagnosis is:
•   a. Bronchogenic carcinoma
•   b. Round pneumonia
•   c. Alveolar sarcoidosis
•   d. Fungus ball
• 2. Associated findings may include:
•   a. Hyponatremia
•   b. Increased ACE levels
•   c. Hypercalcemia
•   d. Clubbing
Case-5



• A 62-year-old female smoker presents with a
  history of “pneumonia” 6 wk ago.
• She has been on multiple antibiotics, and
  although she feels relatively better now,
• her CXR remains unchanged.
Case-5
POSITION            •PA CXR

QUALITY             •Poor Technical Quality


                     •Ill defined mass-like density
                     •Behined heart shadow
LESION               •7*4 cm.
                     •Silhoutte descending aorta.




                    •Central tracheamediastinum .
MEDIASTINALHilum

ANGELS              •Hazy .

                    •No
OTHER
Case-5


• The next step in the management of this
  patient will include:
•   a. Change of antibiotics
•   b. Sputum for TB
•   c. Flexible bronchoscopy.
•   d. Open lung biopsy
How  read  chest xr  8

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How read chest xr 8

  • 1. HOW READ CHEST XR -8 ANAS SAHLE ,MD
  • 3. POSITION PA AP QUALITY ROTATION PENETRATION INSPIRATION LESION OPACI OPACITY Homo Heterogenous Wellill defined Zone Centralperiph Silhouet eral sign TY Necrotic PATCHY MEDIASTINAL NODULE Central deviasionwided MASS COSTO-PHRENIC ANGEL Freeoblitern CAVITARY OTHER INFILTIRATION Bone soft tissuediaphragm
  • 4. Consolidation Infection causes Non-infection causes Broncho- WEGNER Cardiac Pneumonia Lymphoma alveolar COP Sarcoid disease failure carcinoma
  • 5. Solitary Pulmonary Nodule(SPN) • Is • Single. • Discrete. • intrapulmonary density. • < 3cm in diameter. • completely surrounded by aerated lung. • DDX: • Bronchogenic ca. • Solitary metastasis. • Granuloma (infectioninflamation). • Benign lung tumor(hamartoma). • Round pneumonia. • Round atelectasis. • AVM.
  • 6. Solitary Pulmonary Nodule(SPN) Appearance Margin Calcification cavitation Comparison with a Size previous x-ray to >8mm <8mm Assess growth over time. Location Upperhillar zone Lowerbasesup-pleural Associated abnormalities Lymph node enlargement Rib destruction/erosion
  • 7. Nodule Mass Nodule Mass • Well defined opacity it s • Well defined opacity more diameter up to 3cm. than 3cm. • The most common is: • The most common is: – Tuberculoma – Bronchgenic CA – Hamartoma – Hydatid cyst – Bronchogenic CA – metastases – Hydatid cyst – Metastases – AVM
  • 33. Cavitary lesion Air-fluid level Air only Wall thickness Straight Wavy Thick Thin site ruptured Irregular inner Regular inner Abscess Hydatid wall wall Peripheral Central cyst Cavitating Chronic Emphesematous pneumatocele neoplasm abscess bulla
  • 34. Case-1 • A 40-year-old man with a history of substance abuse and HIV infection is seen in the ER with complaints of: • fever, • weight loss, • production of foul-smelling sputum, • and shortness of breath for 2 wk. • On physical exam he is : • tachypneic • has clubbing of his digits. • Lung exam reveals: • diffuse rhonchi • and an area of egophony with whispering pectoriloquy in the right chest posteriorly. • ABGs reveal PaO2 of 59 mm Hg on room air.
  • 35. CASE-1 What is the most likely diagnosis? a. Pneumococcal pneumonia b. PCP pneumonia c. Lung abscess d. Squamous cell carcinoma
  • 36. POSITION •PA CXR QUALITY •Good Technical Quality •Round opacitiy with air-fluid level •In right upper zone near hilum LESION •Ill-defined linear opacity surrond it •Central trachea and mediasteinal. MEDIASTINAL ANGELS •Free costo-phrenic angels. OTHER •No
  • 37. Case-2 • A 60-year-old man with a history of COPD and old TB is seen with • mild hemoptysis and chronic cough. • He is HIV negative and has been ill for about 2 wk. • Vital signs: pulse 110 bpm; temperature 101°F; respirations 24/min; blood pressure 108/70 mm Hg. • No skin lesions are noted. • Laboratory data: Hb 14 g/dL; HCA 42%; WBCs 8.7/μL; BUN 24 mg/dL; creatinine 0.8 mg/dL; sodium 131 mEq/L; potassium 4.3 mEq/L. • ABGs on RA: pH 7.37; PCO2 43 mm Hg; PO2 87 mm Hg. • Sputum tests reveal numerous AFB-positive organisms on smear. • Spirometry shows an obstructive ventilatory impairment with marginal reversibility.
  • 39. POSITION •PA CXR QUALITY •Poor Technical Quality •Cavitary lesion •In right upper zone LESION •Central trachea and mediasteinal. MEDIASTINALHilum •Right hilum pulled upward ANGELS •Disappear . •No OTHER
  • 40. Case-2 • the most likely diagnosis is – a. Lung abscess – b. Non-TB mycobacteria – c. Actinomycosis – d. Aspiration pneumonia
  • 41. Case-3 • A 60-year-old man with a past history of smoking for 30 years (he stopped 3 years ago, prior to cardiac bypass surgery). • is admitted with cough and mild hemoptysis. • He is afebrile with no shortness on breath. • Physical exam is negative except that the lung exam reveals rhonchi in the left upper lung zone.
  • 43. POSITION •PA CXR QUALITY •Poor Technical Quality •Well defined round density •(mass lesion) LESION •7*11cm. •In left para-hilar area. •Obscured aortic •Right deviated trachea. MEDIASTINALHilum ANGELS •Disappear . •No OTHER
  • 44. Case-3 • The finding/abnormality most likely to occur with the lesion seen on the CXR: • Serum calcium of 13.6 mg/dL. • b. Sputum positive for fungal elements • c. Increased D-dimer levels. • d. Koilonychia.
  • 45. Case-4 • A 38-year-old city worker presents with fever, chills, and cough with left-sided chest pain 2 days after the Mardi Gras festival. • She denies any hemoptysis, weight loss, or chronic illness. • Past history is unremarkable. • On physical exam, she has a BMI of 32; temperature is 101°F. • She was observed to have splinting of her right side during the inspiration.
  • 47. POSITION •PA CXR QUALITY •Poor Technical Quality •Well defined round density •(mass lesion) LESION •3*2,5 cm. •In right middle zone. •Cardiomegaly . MEDIASTINALHilum ANGELS •Hazy . •No OTHER
  • 48. Case-4 • 1.The most likely diagnosis is: • a. Bronchogenic carcinoma • b. Round pneumonia • c. Alveolar sarcoidosis • d. Fungus ball • 2. Associated findings may include: • a. Hyponatremia • b. Increased ACE levels • c. Hypercalcemia • d. Clubbing
  • 49. Case-5 • A 62-year-old female smoker presents with a history of “pneumonia” 6 wk ago. • She has been on multiple antibiotics, and although she feels relatively better now, • her CXR remains unchanged.
  • 51. POSITION •PA CXR QUALITY •Poor Technical Quality •Ill defined mass-like density •Behined heart shadow LESION •7*4 cm. •Silhoutte descending aorta. •Central tracheamediastinum . MEDIASTINALHilum ANGELS •Hazy . •No OTHER
  • 52. Case-5 • The next step in the management of this patient will include: • a. Change of antibiotics • b. Sputum for TB • c. Flexible bronchoscopy. • d. Open lung biopsy