Drs. Claire Milam and Alyssa Thomas are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides on: • Esophageal Impaction • Obstructive Lung Mass • Descending Aortic Aneursym • Pleural Effusion • Dextrocardia and Situs Inversus • Thyroid Mass • Pulmonary Tuberculosis • Malignant Pleural Effusion • Hiatal Hernia • Subcutaneous Emphysema • Pseudoaneurysm • Asbestosis

1. Adult Chest X-Rays Of The Month
Alyssa Thomas MD & Claire Milam MD
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs MD, Faculty Editor
Chest X-Ray Mastery Project
March 2020

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 providing cases and these slides are shared with all contributors.
 Contributors from many CMC/LCH departments, and now from EM
colleagues in Brazil, Chile and Tanzania.
 Cases submitted this month will be distributed next month.
 When reviewing the presentation, the 1st image will show a chest X-ray
without identifiers and the 2nd image will reveal the diagnosis.

4. Visit Our Website
www.EMGuidewire.com
For A Complete Archive Of Chest X-Ray Presentations And Much More!

5. Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

6. It’s All About The Anatomy!

7. 75-Year-Old
Female Presents
With Vomiting.
What Do You See?

8. Here Is Her Prior CXR For Comparison.
Prior CXR Today’s CXR

9. Here Is Her Prior CXR For Comparison.
Prior CXR Today’s CXR

10. Diagnosis: Esophageal Impaction

11. Diagnosis: Esophageal Impaction

12. 75-Year-Old with
Esophageal
Impaction.
Can You See Any
Other Evidence of
The Impaction?

13. 75-Year-Old with
Esophageal
Impaction.

14. Density over the heart corresponds with lower food bolus
75-Year-Old with Esophageal Impaction.

15. 58-Year-Old
Presents With
Shortness of
Breath.

16. 58-Year-Old
Presents With
Shortness of
Breath.
Diagnosis: Right Pleural Effusion

17. 58-Year-Old
Presents With
Shortness of
Breath.
Diagnosed With
Right Pleural
Effusion.
Treatment With
Ultrasound
Guided
Thoracentesis.

18. Post Thoracentesis  Much ImprovedDiagnosis: Right Pleural Effusion

20. Light’s Criteria
Transudate Versus Exudate1,2
Pleural Fluid Protein/Plasma Protein >0.5
Pleural Fluid LDH/Plasma LDH >0.6
Pleural Fluid LDH >200 IU
1In patients with heart failure on diuretics, Light’s Criteria may misclassify a
transudate as an exudate up to 25% of the time.
2In heart failure patients, a serum protein 3.1 g/dl higher than the pleural fluid,
or a serum albumen 1.2 g/dl higher than the pleural fluid will help correctly
identify a transudate.

23. Parapneumonic Effusions
• The most common exudative effusions are those associated with
underlying pneumonia
• Mortality is higher among pneumonia patients who have a
parapneumonic effusion, compared with those with pneumonia and
no effusion
• With the aging of the population, the incidence and mortality due to
parapneumonic effusion and empyema continues to rise

24. Right Parapneumonic Effusion

26. Malignant Effusions
• The second most common exudative effusions are those associated
with underlying malignancy
• The majority of malignant pleural effusions arise from lung cancer,
breast cancer, and lymphoma
• The presence of a malignant pleural effusion is associated with higher
mortality and significantly shorter survival

27. Lung Mass With Malignant Effusion

28. Lung Mass After Effusion Drainage

30. 65-Year-Old With
A History Of
Smoking.

31. 65-Year-Old With
History of
Smoking.
Complete Opacification Of The
Left Lung.
Can You See Any Hints To The
Cause?

32. 65-Year-Old With
History of
Smoking.
Complete Opacification Of The
Left Lung.
Can You See Any Hints To The
Cause?

33. 65-Year-Old With
A History of
Smoking.
Atelectasis and
Collapse of Left
Lung Secondary
To Obstructive,
Mass on the
Bronchus.
Heterogeneity
Concerning For
Malignancy.

34. 65-Year-Old With
History of
Smoking.
Diagnosis:
Obstructive Lung Mass With Associated Atelectasis And Lung Collapse
Remember: Not
Only Fluid Causes
Complete
Opacification!

35. 36-Year-Old
Presents for Routine
Pre-operative CXR.

36. 36-Year-Old
Presents for Routine
Pre-operative CXR.
Not An Inverted
Image!

37. 36-Year-Old
Presents for Routine
Pre-operative CXR.
Not An Inverted
Image!
Diagnosis: Dextrocardia
What Associated
Diagnosis Do You
Think This Patient
May Have?

38. 36-Year-Old
With
Dextrocardia
Associated Diagnosis: Situs Inversus

39. 36-Year-Old
With
Dextrocardia And
Situs Inversus.
RIGHT LEFT

41. 76-Year-Old
Presents with
Chest Pain

42. 76-Year-Old
Presents with
Chest Pain
Density in the cardiac silhouette

43. Diagnosis: Descending Aortic Aneurysm

44. Density Behind The Cardiac
Silhouette Is The Dilated Aorta.

45. 41-Year-Old
Presents with
Difficulty Breathing.

46. 41-Year-Old
Presents with
Difficulty Breathing.
Diagnosis: Thyroid Mass

47. 41-Year-Old
Presents with
Difficulty Breathing. Do Not Forget to Take Note of
Mass Effect
 Notice Here the Tracheal
Deviation
Diagnosis: Thyroid Mass

49. 50-Year-Old Male
Presents with
Chronic Dry Cough.

50. 50-Year-Old Male
Presents with
Chronic Dry Cough.

51. Apical Opacity With Central
Cavitation
Diagnosis: Pulmonary Tuberculosis
50-Year-Old Male
Presents with
Chronic Dry Cough.

52. 80-Year-Old Male
With A History of
Tobacco Use
Presents With
Dyspnea.

53. Diagnosis: Malignant Pleural Effusion
80-Year-Old Male
With A History of
Tobacco Use
Presents With
Dyspnea.

54. Diagnosis: Malignant Pleural Effusion

55. 79-Year-Old Female
Has A Chest X-Ray
After A Car Crash.

56. 79-Year-Old Female
Has A Chest X-Ray
After A Car Crash.
Diagnosis: Hiatal Hernia

57. Notice the Gastric Bubble
Diagnosis: Hiatal Hernia

58. What Else Can You Diagnose?
79-Year-Old Female
Has A Chest X-Ray
After A Car Crash.

59. Don’t Forget About the
Bones!
79-Year-Old Female
Has A Chest X-Ray
After A Car Crash.
Diagnose: Osteoporosis

60. 23-Year-Old Female
Presents After
Multiple Episodes
of Coughing.

61. Diagnosis: Subcutaneous Emphysema
23-Year-Old Female
Presents After
Multiple Episodes
of Coughing.

62. Diagnosis: Subcutaneous Emphysema

63. Pneumomediastinum
2° Iatrogenic 2° Medical & Traumatic Spontaneous
 Endoscopic procedures
 Intubation
 Pleural instrumentation
 Central vascular procedure
 Chest/abdominal surgery
 Blunt chest injury
 Penetrating chest injury
 Asthma/COPD
 Bronchiectasis
 Interstitial lung disease
 Thoracic malignancy
 Tobacco use
 Recreational drugs
 Breath holding
 Weight lifting
Vasileios K. Journal of Thoracic Disease 2015; 7:S44-S49.
Management Essentials
 Manage the underlying cause
 Pain management & cough suppression as indicated
 Oxygen may increase gas absorption in severe cases
 Brief period of observation vs. close outpatient follow-up

64. 68 Year Old Male
Presents with
Hemoptysis

65. 68-Year-Old Male
Presents with
Hemoptysis
Diagnosis: Pseudoaneurysm

66. Diagnosis: Pseudoaneurysm

67. 48-Year-Old Male
Presents with
Chest Pain and Dry
Cough

68. 48-Year-Old Male
Presents with
Chest Pain and Dry
Cough
Diagnosed with Costochondritis and
Discharged Home

69. 48-Year-Old Male
Presents with
Chest Pain and Dry
Cough
What Abnormality Do You Notice?

70. 48-Year-Old Male
Presents with
Chest Pain and Dry
Cough
Bilateral Rounded
Opacities
What Abnormality Do You Notice?

71. Diagnosis: Asbestosis
Calcified Nodular
Pleural Plaques

72. Summary Of Diagnoses This Month
 Esophageal Impaction
 Obstructive Lung Mass
 Descending Aortic Aneurysm
 Pleural Effusion
 Dextrocardia and Situs Inversus
 Thyroid Mass
 Pulmonary Tuberculosis
 Malignant Pleural Effusion
 Hiatal Hernia
 Subcutaneous Emphysema
 Pseudoaneurysm
 Asbestosis

73. See You Next Month!