chest x ray spotter set for radiology education and diagnosis imaging of chest pathology, description and diagnosis of chest x ray from the website

1. CXR CASE 1 TO 50
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3. There is marked tracheal and mediastinal deviation to the left, reflecting collapse
and volume loss of the left lower lobe.
There is a fracture of the 7th rib on the left side and a further fracture of the 7th
rib on the right side.

7. CXR AP
There is upper lobe predominant bronchial wall thickening with ring shadows and
patches of consolidation.
There are features of mild airflow obstruction with flattened hemidiaphragms.
The features suggest cystic bronchiectasis and given the symmetrical upper lobe
predominance and clinical features, cystic fibrosis (CF) is most likely.
CXR Lateral
This more clearly demonstrates the ring shadows and clear upper lobe predominance of
the bronchiectasis.
CT Chest
CT demonstrates markedly dilated airways and thickened airway walls with sputum
plugging on the right side.

9. There is dextrocardia.
* The stomach gas bubble is also on the right side, suggesting situs inversus*
There are coarse, thickened bronchial markings and small ring shadows, most notable in the up

11. This CXR demonstrates bronchiectasis.
There are coarse, thickened airway markings with ring shadows bilaterally, but worse in
the left upper lobe (obscuring the heart border) and left lower lobe, obstructing the
hemidiaphragm.
* There is also scoliosis of the spine*

13. There is consolidation throughout the right side, sparing the periphery.
There is also an air bronchogram behind the heart.
This is most likely a pneumonia.
*Note the ETT and left subclavian line*

15. There is upper lobe predominant bronchial wall thickening and ring shadows suggestive
of bronchiectais and possibly cystic fibrosis.
* In the left mid zone there is a cavity with a fluid level and surrounding consolidation
suggesting a lung abscess*

17. There are reduced lung markings throughout the right side with tethers of
lung to the chest wall suggesting giant bullae, not pneumothorax
There is a fracture to the right 9th rib, and possibly 8th

19. There is complete white out of the left lung with air bronchograms in the mid zone,
caused by pneumonia and a smaller patch of consolidation in the right mid zone.

21. There is complete white out of the left lung caused by pneumonia (air
bronchograms mid zone).
* There is partial volume loss with collapse because the right heart
border and trachea have shifted to the left. *
There is a large bore chest drain in situ on the left.
*ETT (probably a bit too proximal) and NG tube also present*

23. Non-infective exacerbation COPD
The lung fields are overinflated with flattened hemidiagragms consistent with
airways disease and COPD.
No focal consolidation to suggest pneumonia.

25. The lung fields are hyperinflated with flattened
hemidiagragms consistent with overinflation from
airways disease (probable COPD).
*There is a safety pin that appears to be in the
stomach, or external artifact*

27. Acute Respiratory Distress Syndrome (ARDS)
There is bilateral airspace opacification throughout both lungs, sparing the
apices.
*ETT, IJ line and NGT in situ *

29. There are bilateral perihilar infiltrates and consolidation.
This is most likely Pneumocystis Jiroveci Pneumonia (PJP)

31. There is complete collapse of the right upper lobe
* Note the resultant elevation of the right horizontal fissure *
Patchy Left Upper Lobe (LUL) opacification suggestive of consolidation
*ETT and NG tube also present*

33. There is complete white out on the left side.
Features are consistent with complete collapse of the left lung.
The trachea is deviated to the left and the right heart border is not
visible suggesting mediastinal shift to the left.
*There is an ETT and NG tube in situ*

36. CXR:
There is a 5.56 bullet projected over the lower left lung field lateral to the heart.
* There is no evidence of any injury to the chest or lungs*
AP Femur:
*There is destruction to the right distal femur from a high velocity projectile.
Multiple fragmentation of bone and perhaps metal.
CT Chest:
There is a bullet lodged in the left inferior pulmonary artery.

38. Presenting CXR:
There is complete collapse of the left lower lobe (LLL) creating the sail sign behind
the heart and volume loss in the left hemithorax.
There are age-related bony changes of the thoracic vertebral column and ribs
* The lung fields are overinflated, consistent with gas trapping from airways
disease *
Presenting CXR:
The left lower lobe is now re-inflated

40. CXR:
There is volume loss in the right hemithorax with collapse of the right upper
lobe.
*There is patchy consolidation in the right lower and middle lobes*
Bronchoscopy:
Bronchoscopy reveals a large obstructing polypoid mass in the right main
bronchus.

42. There is complete collapse of the right lung with tracheal deviation and
mediastinal shift

44. There is bilateral hilar lymphadenopathy
* The lung fields are otherwise clear*

46. There is bilateral multifocal airspace opacification, mainly in the perihilar and lower zones
* There are four large bore chest tubes in situ *
* There is an ETT, NGT and right subclavian vascular line *
* The multiple metallic artifacts are burns dressings*
ARDS has a mortality rate approaching 50%.
* Survivors are often left with chronic lung disease, with healing by fibrosis.*

48. There are widespread, patchy rounded infiltrates of varying size throughout both lung fie
The infiltrates appear more confluent and dense in the lower lobes, perhaps representin
Some of the lesions in the upper zones appear to be cavitating.
Possible differentials for this appearance include:
• cavitating pulmonary metastases (e.g. squamous cell, adenocarcinoma from GI tract or
• septic pulmonary emboli
• Granulomatosis with Polyangiitis

51. CXR Interpretation:
There is a small right pleural effusion.
There is loss of the left hemidiaphragm and left heart border with diffuse
increased opacification in the left lower zone.
CT Interpretation:
CT chest demonstrates a moderate pericardial effusion with associated peripheral
atelectasis.
At first glance the appreances on the plain PA CXR could be mis-interpretted as a pleur

54. CXR AP Interpretation:
PA chest x-ray demonstrates large superior soft tissue density.
*The hilar vessels are visualized through the mass
The rest of the lungs are unremarkable
* There is a large gastric bubble*
Lateral CXR Interpretation:
Lateral chest x-ray demonstrates anterior superior mediastinal mass

55. The ‘5 Terrible T’s’ refer to the common causes for anterior mediastinal masses.
• Thymoma
• Thyroid – ectopic thyroid mass
• Thoracic aorta – dilatation or aneurysm of ascending aorta
• Terrible lymphoma
• Teratoma / germ cell tumour

57. CXR Interpretation:
There is bilateral basal atelectasis with otherwise clear lung
fields
* AP, rotated film*
CT Interpretation:
CTPA demonstrates bilateral, proximal acute pulmonary
emboli

59. There is consolidation with a sharply delineated lateral margin on the right side
and some patchy changes on the left

61. There are diffuse increased interstitial markings
throughout both lungs without zonal distribution.
The reticular-nodular pattern is consistent with pulmonary
fibrosis
*There is an air-fluid level overlapping the heart shadow,
with absence of usual gastric air sinus. This is in keeping
with a large hiatus hernia*

63. CXR Interpretation:
There is diffuse reticulonodular infiltrate across all lung fields, but m
*There is loss of volume in both lung fields *
The appearances are consistent with pulmonary fibrosis

64. CXR Case 028

65. There is diffuse reticular-nodular shadowing throughout both
lung fields .
*The heart size is normal and the pleural spaces are clear
*The are surgical clips in the right mid zone, likely from a right
lower lobe biopsy. *
This is a case of a diffuse alveolitis causing
pulmonary fibrosis.

66. 029

67. There is bilateral hilar adenopathy and bands of atelectasis in both
Lung parenchyma looks normal.

68. 030

70. There is bilateral hilar adenopathy.
* There are a few subtle reticulonodular shadows within the
lung parenchyma.
Löfgren syndrome is generally a more mild acute presentation
of sarcoidosis, with fever, bilateral hilar adenopathy, erythema
nodosum and arthralgia.
It is far more common in Caucasians and generally has a good
prognosis with 80-90% resolving over 1-2 years
Clinical Image:
This is erythema nodosum

71. 031

72. There is bilateral hilar adenopathy with a predominantly nodular infilt
This is sarcoidosis (Stage II on radiological classification).

73. 032

74. There are multifocal bilateral reticulonodular air-space opacities,
predominantly perihilar and mid zone distribution.
There is marked pulmary parenchymal infiltrate and established fibr

75. 033

76. There are bilateral predominantly mid zone multifocal
parenchymal infiltrates, worse on the left.
There is marked coarse fibrosis in the mid zones, worse on
the left and affecting the horizontal fissure with some volume
loss of the right upper lobe.
This man has longstanding pulmonary and pleural fibrosis from sar
Old CXRs and CTs may help establish if any of the infiltrate is new

77. 034

79. CXR Interpretation:
This AP film has an irregular thin walled large cavity in the medial rig
The hilar vessels are visible suggesting it is situated either posterior
There are coarse reticular markings in the right middle lobe and ling
Lateral CXR Interpretation:
The lateral confirms the presence of a cavity in the right apical segm
The is some scattered surrounding airspace shadowing (consolidati

80. 035

81. There is a left upper lobe thick walled cavity with an air fluid
level and surrounding consolidation.
*There may be left hilar adenopathy. The rest of the lung field
and pleura look normal

82. 036

84. CXR Interpretation:
There is diffuse air space shadowing in the right mid zone with an
area of central lucency and air fluid level.
*A left nipple ring is noted
The rest of lung parenchyma and pleura are normal
CT Interpretation:
CT demonstrates a thick walled cavity in the apical segment of the
right lower lobe.
*There is an air fluid level with some surrounding consolidation

85. 037

87. AP CXR Interpretation:
There is a cavitating lesion in the right mid zone laterally with an air
Allowing for slight rotation and a left nipple ring, the film is otherwise
Lateral CXR Interpretation:
Lateral X-Ray confirms the presence of a cavitating lesion with air fl
The lesion is situated in the apical segment of the right lower lobe

88. 038

89. adowing with volume loss in the right upper lobe with an area of lu
ss, air space shadowing in the left lower lobe and possibly a smal
There is external artifact overlying the left lung apex and clavicle.
There is consolidation, a lung cavity and pleural effusion.
These features are most likely caused by infection and TB should

93. CXR Interpretation:
There is a left pleural effusion, left basal increased airspace opacification
with central lucency and an air fluid level.
*There are multiple different size < 1cm, rounded lesions throughout both
lung fields, some with minor cavitation.
Lateral CXR Interpretation:
Lateral X-ray demonstrates a cavity with an air fluid level and associated
pleural effusion with loculated fluid superior to the cavity.
CT Chest Interpretation:
CT confirms the presence of a large thick walled fluid containing cavity in
the left lower lobe with associated pleural thickening.
*There are small patches of consolidation in the lingula and on the right
side.

94. This lady has septic emboli causing lung abscess and pleural infec
*The source of the infection is presumed to be the pacing leads. Sta

95. 040

96. There is an air fluid level in a large cavity in the left upper zone with
There is increased lucency above the air fluid level with scanty lung
The rest of the lung parenchyma and pleural spaces are normal
Malignancy and TB would be the most important diagnoses to consider.
* A CT scan and culture of sputum (including Acid Fast Bacilli) would be the next best
steps.

97. 041

99. CXR Interpretation:
There are multiple large areas of airspace opacification projecting over both lung
fields.
* Areas of opacification project primarily over the lower and mid-zones, and
completely obscure the heart border.
* The right base is more dense, suggesting possible pleural effusion, with fluid
laterally and in the horizontal fissure.
Lateral CXR Interpretation:
T12 has diffusely and homogeneously increased density – an ‘ivory vertebra’ (this is
actually visible on the PA – but we are easily distracted…).
This refers to a diffuse homogeneous increase in opacity of a vertebral body that
otherwise retains its size and contours.
Multiple rounded patches of airspace opacification throughout the left lung field and
fluid within the horizontal fissure.

100. Methicillin-resistant Staphylococcus aureus was isolated from bloo
Echocardiogram demonstrated tricuspid valve endocarditis.
The patient had recently had a PICC line in situ for chemotherapy
MRSA Pneumonia and bacteraemia has a high fatality rate.
If a patient with known MRSA bacteraemia is requiring
inotropic support, mortality approaches 50%.

101. 042

102. There are multiple rounded ring shadows in the right upper lung,
with overlying chest wall deformity.
*A central line has been inserted, its tip projects over the superior
vena cava.
* A chest drain projects over the left mid-zone.
There is no associated pleural effusion.
* Median sternotomy wires are visible
This lady has had plombage for TB in the early 1950s.
Large bore drains are generally not indicated for 1st line secondary pneumothorax treatment!

103. 043

104. There is bilateral apical pleural calcification, more
pronounced on the right.
There is additional right upper lobe fibrosis and traction
causing the right hilum to be elevated, mediastinal shift and
volume loss on the right side.
This lady has old Right upper lobe (RUL) and pleural TB.
She will likely have chronic airways limitation due from
the architectural distortion.

105. 044

106. There is a calcified suprahilar lymph node on the right (station 4R
Remaining mediastinum, lung parenchyma and pleural are norma
This is old tuberculosis (TB).
Any history of active disease (cough, fevers, weight loss)
should be sought – although this is likely decades old

107. 045

109. CXR Interpretation:
There are bilateral multiple ring shadows in both apicies and
scattered calcification, more prominent in the left apex.
The trachea is deviated to the right and may be narrowed.
There is associated 2nd, 3rd, and 4th rib destruction
bilaterally.
The remaining lower lobes parenchyma appear normal.
CT Chest Interpretation:
Bilateral upper zone plombage is associated with complete
destruction of the upper lobes, and surgical rib removal /
damage to the upper thoracic ribs.

110. 046

111. There are small rounded opacities of variable size throughout
both lung fields, more dense on the right.
The right heart border is lost, suggesting middle lobe
involvement.
This is miliary tuberculosis (TB).
She is likely to be coughing mycobacterium around your
department and needs to be isolated.

112. 047

113. There are calcified nodules in the left mid zone and left upper zone behind th
*The aorta is unfolded.
*Lung volumes look a little small, with no evidence of interstitial lung disease
A Gohn focus is also referred to as a Ghon lesion and
a tuberculuma (i.e. calcified tuberculous caseating granuloma).
*When associated with a calcified ipsilateral hilar node it is
known as a Ranke complex.

114. 048

115. There is increased opacification throughout the left
hemithorax with loss of the left heart outline although the
left hemidiaphragm remains visible.
Air bronchograms are visible suggesting consolidation.
This is left upper lobe (including left lingula) pneumonia.
*The sputum was positive for acid fast bacilli – confirming acute tu

116. 049

117. There is bilateral apical pleural calcification and upper lobe
fibrosis, worse on the right.
Both hilar are elevated and there is volume loss on the right
side, with deviation of the mediastinum and trachea to the
right.
This is old TB.
*The volume loss is from the fibrosis and also a right-sided phrenic n

118. 050

119. The patient has had a thoracoplasty with consequential loss
of volume in the right hemithorax.
There is left upper lobe fibrosis.
There is patchy opacification throughout both lung fields
likely representing fibrosis however acute infiltrate,
particularly in the left lower zone is possible.
*There is marked kyphoscoliosis.
This man has chronic ventilatory failure secondary to his
iatrogenic chest wall deformity

120. Thoracoplasty – a surgical treatment for the aerobe mycobacterium
Unfortunately significant kyphoscoliosis usually slowly progresses –

121. https://litfl.com/cxr-case-050/

122. The end of part one CXR
PP done by MMO
Ref link-https://litfl.com/cxr-case-050/