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How  read  chest xr  6 How read chest xr 6 Presentation Transcript

  • HOW READ CHEST XR -6 ANAS SAHLE ,MD
  • Brief review
  • POSITION PA AP QUALITY ROTATION PENETRATION INSPIRATION LESION HomoDensityinfiltratio Heterogenous Centralperiph Silhouet n Wellill defined Zone eral Necrotic sign MEDIASTINAL Central deviasionwided COSTO-PHRENIC ANGEL Freeoblitern OTHER Bone soft tissuediaphragm
  • ConsolidationInfection causes Non-infection causes Broncho- WEGNER CardiacPneumonia Lymphoma alveolar COP Sarcoid disease failure carcinoma
  • LymphomaRadiological features:CXR :•mediastinal and hilar soft tissue mass in keeping withlymphadenopathy.•Lymphadenopathy may extend confluently into the neckor abdomen.•Splenic enlargement may be demonstrated by increasedsoft tissue density under the left hemidiaphragm.•Rarely primary lung lymphoma may be present.•This manifests as diffuse air space opacification, oroccasionally parenchymal nodular disease.
  • LymphomaDifferential diagnosis:•Sarcoid.• TB.• Anterior mediastinal mass: •thyroid, •thymus/thymoma, •teratoma.
  • Wegener’s granulomatosisRadiological features:CXR :• pulmonary nodules of varying size.•They can cavitate and can occur anywhere inthe lung.•Patchy, sometimes extensive consolidation orground glass change (which may reflectpulmonary haemorrhage).•Pleural effusions in one-third
  • Wegener’s granulomatosisDifferential diagnosis:•Churg–Strauss syndrome – •this is asthma associated with a small vessel vasculitis, •p-ANCA positive.• Rheumatoid arthritis (RA) – • some forms of RA can mimic Wegener’s granulomatosis.•Infection – •particularly fungal infections, TB or septic emboli from disseminated infection.•Cryptogenic organising pneumonia.• Metastatic disease.
  • CASE-1•A 40-year-old man with a history of substanceabuse and HIV infection.•complaints of fever, weight loss, production offoul smelling sputum, and shortness of breathfor 2 wk.•On physical exam he is tachypneic and hasclubbing of his digits.•Lung exam reveals diffuse rhonchi and an areaof egophony with whispering pectoriloquy in theright chest posteriorly.•ABGs reveal PaO2 of 59 mm Hg on room air.
  • CASE-1What is the most likelydiagnosis?a. Pneumococcalpneumoniab. PCP pneumoniac. Lung abscessd. Squamous cellcarcinoma
  • POSITION •PA CXRQUALITY •Good Technical Quality •Round opacitiy with air-fluid level •In right upper zone near hilumLESION •Ill-defined linear opacity surrond it •Central trachea and mediasteinal.MEDIASTINALANGELS •Free costo-phrenic angels.OTHER •No
  • Case-2•A 42-year-old black man with a history of IVDA developslow-grade fever, night sweats, weight loss, cough, andhemoptysis.•On physical examination, vital signs are: pulse 109 bpm;temperature 100°F; respirations 22/min; blood pressure110/70 mm Hg.•On general exam, the patient appears ill and has palpablenodes in the anterior and posterior cervical triangle.•Laboratory data: Hb 11 g/dL; Hct 32%; WBCs 7.2/μL; BUN12mg/dL; creatinine 0.3 mg/dL; sodium 129 mEq/L;potassium 3.2 mEq/L; LDH 217 IU/L;•PPD negative.• ABGs on RA: pH= 7.4; PCO2= 34 mm Hg; PO2=66 mm Hg.
  • POSITION •PA CXRQUALITY •Poor Technical Quality •(PENETRATION,ROTATION?) •Cavitary lesion in left upper zone. •Ill-defiened nodules most in right lungLESION that conluenced in middle zone. •Hyperlucency area in right lower zone. •Trachea pulled to leftMEDIASTINALANGELS •Left angel is obliterated.OTHER •No
  • Case-2• 1. What is the most likely diagnosis?• a. TB• b. Lymphoma• c. Sarcoidosis• d. Mycetoma• 2. What is the next management option?• a. Obtain ACE level• b. Start four-drug anti-TB treatment• c. Start antifungal treatment• d. Repeat PPD and start INH chemoprophylaxis
  • Case-3• A 56-year-old male smoker is admitted with shortness of breath, rightsided chest wall pain, and productive cough.• He has a past history of seizure disorder and is on anticonvulsants.• Dilantin level is within therapeutic range.• On examination, there is dullness to percussion in the right upper zone with decreased breath sounds.• Sputum for AFB and fungi are negative on initial smear and cultures are pending.
  • Case-3
  • POSITION •AP CXRQUALITY •Poor Technical Quality •(PENETRATION,ROTATION?) •Homogeneous density in right upper lobe(right upper lobe collapse).LESION •No air-bronchogram. •S,sign. •Trachea pulled to rightMEDIASTINALANGELS •freeOTHER •No
  • Case-3• 1. The most likely diagnosis is:• a. Bronchogenic cancer• b. Aspiration pneumonia• c. Fungal pneumonia• d. TB• 2. The next step in the management of this patient should be:• a. Start anti-TB medications till cultures are final• b. Start Rx with itraconazole• c. Place patient on antireflux and aspiration precautions• d. Consult for bronchoscopy
  • Case-4• A 32-year-old female nonsmoker is admitted with a 5-wk history of• intermittent hemoptysis. She denies any sputum production, fever, or repeated infections.• There is no history of contact with TB.• On physical examination, the patient is afebrile; she has dullness on percussion and decreased breath sounds in the LLL zone posteriorly. CV exam is normal.• PPD is 4-mm induration.• Bronchoscopy :shows a polypoid lesion partially obstructing the left lower lobe orifice. This lesion bled easily during the procedure.• Bronchial washings are negative for malignancy and the biopsy is pending.
  • Case-4
  • POSITION •PA CXRQUALITY •Poor Technical Quality •(ROTATION?) •Homogeneous density overlap left heart broder without silhout sign •(Sail sign)double density inLESION retrocardiac aerea •No air-bronchogram. •Elevate Left hemidiaphragm .MEDIASTINAL •Central trachea,mediastinalANGELS •freeOTHER •No
  • Case-4• 1.What is the radiological diagnosis?• a. LLL pneumonia• b. LLL atelectasis• c. Pneumothorax• d. Pleural effusion• 2. The clinical, radiological, and endoscopic features described are consistent with:• a. Endobronchial carcinoid• b. Bronchiectasis• c. Bronchoalveolar cell carcinoma• d. Primary TB
  • discussion• The presence of a polypoid lesion obstructing the left lower lobe orifice is the cause of the left lower lobe atelectasis seen on the x- ray.• The absence of air bronchograms is evidence against pneumonia,• and failure to see the visceral pleural line with a collapsed lung rules out pneumothorax.• There is no evidence of pleural disease and no pleural effusion is seen.• The clinical and radiological features are consistent with endobronchial carcinoid.• The absence of cystic or multicystic opacities and the lack of sputum rule out bronchiectasis and alveolar cell carcinoma.• Primary TB usually presents as pneumonia and is inconsistent with the x-ray shown.
  • Case-5• A 26-year-old woman with a past history of seizure disorder is admitted to the medical ICU with status epilepticus.• Due to continued seizures, she is placed in a barbiturate coma.• As part of supportive measures, she is intubated, placed on a mechanical ventilator, and given IV fluids through a central line.• She remains stable overnight.• In the morning, however, the respiratory therapist reports that she has had excessive muco-purulent secretions throughout the night and that her peak and plateau airway pressures have risen 20 cm.• She is febrile with a temperature of 100.2°F the next morning.
  • Case-5
  • POSITION •AP CXRQUALITY •Poor Technical Quality •(penetration?) •Homogeneous density at right upper zone obscured right upper heart border.LESION •No bronchogram. •Elevate horizontal fissure(s,sign). •RUL,ATELECTASIS. •Central trachea,mediastinalMEDIASTINALANGELS •freeOTHER •No
  • Case-5• 1,Based on the clinical history, what is the likely etiology of the CXR abnormality?• a. Right-sided hemothorax• b. Lung abscess• c. Aspiration pneumonia with right upper lobe atelectasis• d. Lung contusion• 2. An important step in management of this patient would be:• a. Chest tube placement• b. Thoracotomy• c. Fiberoptic bronchoscopy, antibiotic therapy, and chest physiotherapy• d. Abrupt cessation of barbiturates