POSITION PA AP QUALITY ROTATION PENETRATION INSPIRATION LESIONOPACIT OPACITY Homo Heterogenous Wellill defined Zone Centralperipher Silhouet sign al Y Necrotic PATCHY HILUMMEDIASTINAL NODULE Central deviasionwided MASS COSTO-PHRENIC ANGEL Freeoblitern CAVITARY OTHERINFILTIRATION Bone soft tissuediaphragm
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 abnormalitiesLymph node enlargement Rib destruction/erosion
Cavitary lesion Air + Air-fluid level Air onlytissue Wall thickness Straight Wavy Thick Thin 1. Fungal ball. 2. Rupture hydatid cyct site 3. Necrotic tumor ruptured 4. Blood glot Hydatid Abscess Irregular Regular Peripheral Central inner wall inner wall cyst Emphesemato Cavitating Chronic us pneumatoc neoplasm abscess ele bulla
LINEAR PATTERN LINEAR PATTERNLEFT VENTRICULAR FAILURE Perihilar and peripheral basal septal lines, changes acutely and resolves with diureticsNormal ageing Coarsening of lung markings in lower zones, no change on review of recent filmsLymphangitis Coarse nodular and linear thickening of markings, known malignancy, often associated with pleural effusion, rapid clinical deterioration of patient
LINEAR PATTERN LINEAR PATTERNAtelectasis Short thin lines, often basal, new on review of previous filmsSubsegmental Longer thicker bands, often perihilar or basal,collapse suggest recent infection or infarctionScarring Any length, persist over time unchangedFibrosis Volume loss is key, persists over time
Causes of fibrosis Mid zone lung Lower zone lung Upper zone lungtuberculosis Drug indused fibrosis sarcoidosis (most common)Chronic extrinsic allergic UIPalveolitisRadio-therapy Asbestose-related fibrosisAnkylosing spondylitisProgressive massivefibrosishistoplasmosis
The Middle compartment • The pericardium anteriorly • The posterior• The middle pericardial reflection compartment is bounded by • Inferior : the diaphragm • Superior: the thoracic inlet
The middle compartment• This compartment includes: » the heart » intrapericardial great vessels » Pericardium » trachea
The posterior compartment• Extends from the posterior pericardial reflection to the posterior border of the vertebral bodies and from the first rib to the diaphragm
The posterior compartment• It includes the: » Esophagus » Vagus Nerves » Thoracic Duct » Sympathetic Chain » Azygous Venous System.
The posterior compartment "visceral compartment"• Visceral compartment: the area from the posterior pericardial reflection to the anterior border of the vertebral bodies in the middle compartment has "Paravertebral sulcus"
The posterior compartment• In this classification, the cardiopericardial structures, the trachea and the esophagus, are part of the visceral compartment
Case-1• A 71-year-old man is seen with low-grade fever, generalized malaise, and a run- down feeling.• He has lost weight and shows stigmata of chronic illness.• There is no history of occupational exposure.• On physical examination, vital signs are as follows: – pulse 110 bpm; – temperature 99°F; – respirations19/min; – blood pressure 90/60 mm Hg.• On exam, the man is frail and appears cachectic with temporal wasting.• Other aspects of his physical exam are unremarkable.• Laboratory data: – Hb 10 g/dL; Hct 30%; MCV 90; – WBCs 3000/μL; differential normal; – BUN 19 mg/dL; creatinine 1.0 mg/dL; – sodium 129 mEq/L; potassium 5.0 mEq/L;• ABGs (RA): pH 7.42, PCO2 35mm Hg, PO2 58 mm Hg.• Spirometry: FVC 60% of predicted; FEV1 60% of predicted.• PPD skin test is negative (0 mm); induced sputum for AFB smear is negative.
POSITION •PA CXRQUALITY •Poor Technical Quality •Bilateral nodular opacity apperance.LESIONMEDIASTINALHilum •Central trachea and mediasteinal.ANGELS •Disappear . •NoOTHER
Case-1• 1. What is the most likely diagnosis?• a. Silicosis• b. Miliary TB• c. Metastatic thyroid carcinoma• d. Sarcoidosis• 2. What is the next step in the workup of this patient that would most likely yield the diagnosis?• a. CT scan of the chest• b. Thyroid function tests• c. Bone marrow aspiration for culture• d. Thoracoscopic lung biopsy
POSITION •PA CXRQUALITY •Poor Technical Quality •Bilateral nodular opacity apperance.LESION •At middle,upper zone.MEDIASTINALHilum •Central trachea and mediasteinal.ANGELS •Hazy left angle . •NoOTHER
Case-2• 1. Based on the CXR shown, all of the following may be helpful in the diagnosis except:• a. Occupational history• b. Sputum for AFB• c. Sputum for fungus• d. History of rheumatic fever• 2. This patient’s occupational history reveals exposure to iron ore, asphalt, and dust related to working on loading docks for 10 years. The CXR is most consistent with:• a. Silicosis• b. Asbestosis• c. Bagassosis• d. Chlorine gas exposure
Case-3• A 70-year-old man with a history of emphysema and progressive dyspnea is admitted with mild hemoptysis.• On exam, he is afebrile; he has a left-sided chest wall scar from a previous thoracotomy with decreased breath sounds in the left lung field.• There are wheezes and rhonchi heard in the right lung field.
POSITION •PA CXRQUALITY •Poor Technical Quality •Left hemithorax homogenous opacity •Patchy consolidation in right lungLESION •CUTT OFF SIGNMEDIASTINALHilum •Left trachea and mediasteinal deviationANGELS •obscured left angle .OTHER •No
Case-3• Based on the CXR and clinical history, the most likely diagnosis is:• a. Left lung atelectasis with mucus plug• b. Metastatic lung disease from lung primary• c. Multiple pulmonary infarcts• d. Septic emboli
Case-4• A 53-year-old male smoker, unemployed with no occupational exposure,• is admitted with progressive shortness of breath.• He has been unwell for some time and has received multiple courses of antibiotics for “bronchitis.”• During the prior 4 mo, he has not had any medical follow-up.• On exam, he is a-febrile but looks ill.• Lung exams reveal diffuse rhonchi and crackles with no localizing signs.• ABGs on room air show PaO2 of 68 mm Hg with mild compensated respiratory alkalosis.• Sputum for AFB is negative.
POSITION •PA CXRQUALITY •Poor Technical Quality •Bilateral multiple nodular opacity •Masslike lesion at left middle zoneLESION •Wided superior mediastinumMEDIASTINALHilum •Round opacity at upper right hilumANGELS •Right angle is disappered . •May be opacity at left axilaOTHER
Case-4• 1. The most likely diagnosis is:• a. TB• b. Hypersensitivity pneumonitis• c. Metastatic disease• d. Acute interstitial pneumonitis• 2. Associated with this diagnosis is:• a. Clubbing• b. Increased IgE• c. Hypocalcemia• d. Eosinophilia