This document summarizes a weekly chest x-ray interpretation session. It discusses various cases presented including pericardial effusions, pneumothoraces, thoracic aneurysm, malignant pleural effusions, cardiomegaly, pneumonia, and bronchogenic carcinoma. The goal is to promote mastery of chest x-ray interpretation among emergency medicine residents and other specialties. Cases are anonymized and discussed to analyze cardiac and pulmonary anatomy and diagnose common chest pathologies.

1. Chest X-Rays Of The Week
Michael Gibbs, MD, FACEP, FAAEM
Professor And Chair
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Vice President of Research
Atrium Health
CMC X-Ray Mastery Series
February 25th 2019

2. Disclosures
 This ongoing chest X-ray interpretation series is proudly sponsored by the
Emergency Medicine Residency Program at Carolinas Medical Center.
 The goal is to promote widespread mastery of CXR interpretation.
 There is no personal health information [PHI] within and ages have been
changed to protect patient confidentiality.

3. Process
 Many are contributing: Emergency Medicine, Fellows from the Center For
Advanced Practice, Trauma & Acute Care Surgery, SHVI, and Medical
Critical Care. Slides are shared with all contributors.
 Cases submitted this week be distributed next week.
 The 1st image will show a chest X-ray without identifiers and the 2nd image
will reveal the diagnoses.

4. It’s All About The Anatomy!

5. Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

6. Before Now
33 With A Complex Malignancy Now Presents With Dyspnea

7. Before Now
33 With A Complex Malignancy Now Presents With Dyspnea
The Cardiac
Silhouette Now
Looks Bigger And
More Globular

8. 33 With A Complex Malignancy Now Presents With Dyspnea
ED Bedside Ultrasound: Pericardial Effusion
*
*
*
*

9. 78 Year-Old With
HPTN, Atrial
Fibrillation Presents
With Dyspnea.

10. Before Now
78 Year Old With HPTN & Afib Presents With Dyspnea

11. Before Now
78 Year Old With HPTN & Afib Presents With Dyspnea
The Cardiac
Silhouette Now
Looks Bigger And
More Globular

12. 78 Year-Old With
HPTN, Atrial
Fibrillation Presents
With Dyspnea.
*
*
*
*
*
*
A Chest CT Obtained To Rule Out
Pulmonary Embolus Instead Reveals
A Large Pericardial Effusion.

13. On Presentation
78 Year Old With HPTN & Afib Presents With Dyspnea
Pericardiocentesis
 300 cc of fluid removed
 Cardiac silhouette smaller
Post-Procedure

14. Thoughts On Pericardial Effusions
• Think about the possibility of a pericardial effusion in patients with
chest pain, dyspnea, syncope or pre-syncope.
• Slowly accumulating pericardial effusions stretch the pericardium and
enlarge the cardiac silhouette on CXR. A careful comparison with old
CXRs is helpful.
• Rapidly accumulating pericardial effusions (e.g.: stab wounds, blunt
trauma) typically ARE NOT associated with cardiac silhouette
enlargement on CXR
• The liberal use of bedside point-of-care ultrasound is diagnostic

15. 33 Year-Old In A Roll
Over Motor Vehicle
Crash.

16. 33 Year-Old In A Roll
Over Motor Vehicle
Crash.
Deep Sulcus
Sign
Deep Sulcus
Sign
Bilateral Pneumothoraces

17. 56 Year Old Ventilated ICU Patient Who Develops Acute Hypoxia

18. 56 Year Old Ventilated ICU Patient Who Develops Acute Hypoxia
Pneumothorax: Subpulmonic & Along The Medial Pleural Reflection

20. Spontaneous Pneumothorax

21. 41 Year-Old With
Marfan Syndrome
Presents With Chest
Pain

22. 41 Year-Old With
Marfan Syndrome
Presents With Chest
Pain
Thoracic Aneurysm & Chronic Type-B Aortic Dissection

23. 41 Year-Old With
Marfan Syndrome.
Thoracic Aneurysm & Chronic Type-B Aortic Dissection

24. 63 Year-Old With
Metastatic Breast
Cancer

25. 63 Year-Old With
Metastatic Breast
Cancer
Malignant Left Pleural Effusion

26. 60 Year-Old With
Metastatic Ovarian
Cancer

27. 60 Year-Old With
Metastatic Ovarian
Cancer
Metastases To RUL + Bilateral Malignant Left Pleural Effusions

29. Cardiomegaly From Longstanding HPTN

30. 51 Year-Old With
HPTN And Severe
Heart Failure In The
Dickson Heart Unit

31. 51 Year-Old With
HPTN And Severe
Heart Failure In The
Dickson Heart Unit
Swan Ganz
Catheter
Left
Subclavian
Central Line
Cardiomegaly From Longstanding HPTN

32. 5 Year-Old With
Fever, Cough And
Tachypnea

33. 5 Year-Old With
Fever, Cough And
Tachypnea
RUL Collapse + RLL Necrotizing Pneumonia

34. 5 Year-Old With Fever, Cough And Tachypnea
RUL Collapse + RLL Necrotizing Pneumonia

35. 81 Year-Old With
Cough And Fever

36. 81 Year-Old With
Cough And Fever
RUL Density

37. 81 Year-Old With
Cough And Fever
Chest CT Suggests Bronchogenic Carcinoma

38. Summary Of Diagnoses This Week
• Pericardial effusions
• Various spontaneous and traumatic pneumothoraces
• Marfan syndrome: thoracic aneurysm + chronic Type-B aortic dissection
• Malignant pleural effusion
• Pulmonary metastatic disease
• Cardiomegaly
• Necrotizing pneumonia
• Bronchogenic carcinoma

39. See You Next Week!