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: • Malignant Pneumothorax • Lung Mass • Retained Bullet • Cavitary Lesion • Pleural Effusion • Mucus Plug with Atelectasis • Rib Fracture • Mediastinal Lymphadenopathy

1. Adult Chest X-Rays Of The Month
Alyssa Thomas MD & Claire Milam MD
Travis Barlock MD & Breeanna Lorenzen, MD
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs MD, Faculty Editor
Chest X-Ray Mastery Project™
July 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. 58-Year-Old Female
Presents With
Shortness of Breath

8. 58-Year-Old Female
Presents With
Shortness of Breath
Diagnosis: Pleural Effusion

9. Previous CXRCurrent CXR

10. Persistent Dyspnea
Prompted Ordering
of a CT Chest…

11. CT Chest Revealed Obstruction
of Left Lower Lobe (LLL)
Bronchus Due to Mucus Plugging
Diagnosis: Atelectatic Left Lower Lobe

12. Let’s Go Back to the
CXR…
The LLL Collapse is Difficult
To Appreciate

13. Do Not Forget Anatomy!
Right Upper
Lobe (RUL)
Right Middle
Lobe (RML)
Right Lower
Lobe (RLL)
Left Upper
Lobe (LUL)
Left Lower
Lobe (LLL)
Left Lower
Lobe (LLL)
Left Upper
Lobe (LUL)

14. Get The Lateral
CXR if Possible!
Left Lower
Lobe
Collapse Can
Just Appear
Like an
Effusion,
Because So
Little of the
Lobe is
Visible on
AP/PA

16. Mucus Plugging
The conditions that are best-known to cause mucus plugging are the following:
• Allergic Bronchopulmonary aspergillosis
• Plastic Bronchitis
• Asthma
Mucus can become abnormally thick due to
- Pathologic diseases causing stagnation of flow and blockage of tracheobronchial tree
- Anticholinergic medications
 Resulting in a Mucus Plug
Mucus plugs can partially or completely obstruct one or more airways resulting in
atelectasis or recurrent infection.

17. 64-Year-Old Female
Presents With
Chronic Cough

18. 64-Year-Old Female
Presents With
Chronic Cough
Diagnosis: Cavitary Lesion

20. 31-Year-Old Female
Presents With
Difficulty Breathing

21. 31-Year-Old Female
Presents With
Difficulty Breathing
Diagnosis: Spontaneous Pneumothorax

22. 31-Year-Old Female
Presents After
Pigtail Chest Tube
Placement.
Notice:
The Parenchyma Shows Signs
of Chronic Changes – Which
Likely Contributed to the
Etiology of Her Spontaneous
Pneumothorax. i.e. Blebs.

23. 20-Year-Old Male
Presents With
Gunshot Wound

24. 20-Year-Old Male
Presents With
Gunshot Wound
Diagnosis: Retained Bullets
Did You Find Both of
Them At First?
Remember Don’t Stop
Looking After Finding
One Abnormality!

25. 20-Year-Old Male
Presents With
Gunshot Wound
Diagnosis: Retained Bullets
Assess Position Anteriorly vs
Posteriorly: Get a Lateral Film.
Scout Films From CT Can Be
Helpful, Too!

26. Difficult to assess position
based on one view due to
overlapping bones.
Always get multiple views!
Best view to show
retained bullet in scapula.

27. CT Confirmation of Retained
Bullet in Scapula.

28. Anterior Posterior
Cranial
Caudal

29. 81-Year-Old Male
Presents With
Shortness of Breath

30. 81-Year-Old Male
Presents With
Shortness of Breath
Diagnosis:
Left Sided Mass Lesion and Pneumothorax

31. Air-Fluid Level

32. 81-Year-Old Male
After Pigtail Chest
Tube Placement
Don’t Forget the Left
Upper Lobe Mass!

33. 81-Year-Old Male
After Pigtail Chest
Tube Placement
Don’t Forget the Left
Upper Lobe Mass!
Notice There Is No
Longer an Air Fluid Level

34. CT Imaging

35. CT Imaging

36. Partially Necrotic Left Upper Lobe Mass
This Mass is
Loculated and Has a
Large Component of
Air, As Can Be Seen
on the CT Lung
Window, and Helps
Explains the Change
in the Mass of CXR.

37. 62-Year-Old Male
Presents with Lateral
Chest Pain After
Coughing

38. 62-Year-Old Male
Presents with Lateral
Chest Pain After
Coughing
Diagnosis: Normal

39. Diagnosis: Non-Displaced Rib Fracture With Surrounding Hematoma.
62-Year-Old Male Presents with Lateral
Chest Pain After Coughing and Normal CXR

40. Rib Fractures and Chest X-rays
Rib Fractures May Be Missed on Chest x-ray.
Studies Have Shown That Up to 75% of Rib Fractures
Will Be Missed with AP/Lateral Chest x-ray.
Citation: Chapman BC, Overbey DM, Tesfalidet F, et al. Clinical Utility of
Chest Computed Tomography in Patients with Rib Fractures CT Chest and
Rib Fractures. Arch Trauma Res. 2016;5(4):e37070. Published 2016 Sep 13.
DOI: 10.5812/atr.37070

41. Study:
What is the clinical significance of chest CT when the
chest x-ray result is normal in patients with blunt trauma?
Citation: Kea B, Gamarallage R, Vairamuthu H, et al. What is the clinical significance of chest
CT when the chest x-ray result is normal in patients with blunt trauma?. Am J Emerg Med.
2013;31(8):1268-1273. DOI:10.1016/j.ajem.2013.04.021
Study design: Retrospective observational study of 589 patients.
Methods: Patients over age 14 with blunt trauma who received a chest X-ray were enrolled.
Results: Of the 589 patients who had a chest CT after a normal chest X-ray, 66 (11%) had undiagnosed rib
fractures, but only 12 (2%) were clinically significant.
Conclusions: Chest CT after a normal Chest X-ray in blunt trauma will detect more injuries, but likely not
changes in patient management

42. Summary Of Diagnoses This Month
 Pleural Effusion
 Cavitary Lesion
 Retained Bullet
 Malignant Pneumothorax
 Lung Mass
 Mucus Plug with Atelectasis
 Spontaneous Pneumothorax
 Rib Fracture with Hematoma
 Mediastinal Lymphadenopathy

43. See You Next Month!