Presentation of students and residents on basics of chest plane film.

1. The
Physics and Physiology
of the Chest X-ray
Michael Aref, MD, PhD
Department of Nuclear, Plasma, and Radiological
Engineering
Internal Medicine Residency Program
College of Medicine
University of Illinois at Urbana-Champaign

2. Röntgen
 In a dark room Röntgen passed
an electrostatic charge through
a cathode tube generating a
faint shimmering in a nearby
barium platinocyanide screen.
 An invisible ray
An x-ray
had passed from the tube to the
screen.
 Father of Diagnostic
Radiology

4. Attenuation
I x = Ι0ε


−µξ



 

Intensity, I, decreases exponentially with thickness, x.
The attenuation coefficient, μ, increases with increasing
density, ρ, and vice versa

5. Radiological Densities
Biological Chemical Density, ρ
Composition Composition (kg/L)
Air N2, O2, CO2 1.2
CH3(CH2)m(CH=CHCH2)n(
Fat CH2)pCOO- 900
Water H2O 1000
(Soft Tissue)
Bone Ca10(PO4)6(OH)2 3160
Metal (hydroxyapatite)
Blood Minute Fe 7000

6. Attenuation Comparison
Air
Fat
Water
Intensity Bone
Thickness

7. Density Gedanken Experiment

8. Attenuation Comparison

9. Negative Exposure Trickery
www.brooksidepress.org

10. Projection
knitting.designedlykristi.com

11. Projection
The point-of-view dependent, two-dimensional
representation of a three-dimensional object
knitting.designedlykristi.com

12. Projection Gedanken Experiment

13. What’s this?

14. Focus

15. Focus Gedanken Experiment

16. PA and AP views
www.med.yale.edu

17. Lateral View Localizes
STENTOR Teaching File

18. High IQ ABC’s
 Identification
 Quality
 Airway, aorta, and adenopathy
 Bones and breast shadow
 Cardiac silhouette
 Diaphragm
 Everything else
 Fields, fluid, and foreign
objects
 Gastric air bubble
 History

19. Projected Anatomy

20. Where’s the mass?
Middle
Mediastinum

21. Where’s the mass?
Posterior Mediastinum

22. Where’s the mass?

23. Where’s the mass?

24. 61-year-old woman with dyspnea
 The inferior margin of the
opacity in the right upper
thorax is due to the
B. major fissure in RUL collapse
without a hilar mass.
C. minor fissure in RUL collapse
with a hilar mass.
D. minor fissure in RUL collapse
without a hilar mass.
E. major fissure in RUL collapse
with a hilar mass.

25. 61-year-old woman with dyspnea
 The inferior margin of the
opacity in the right upper
thorax is due to the
B. major fissure in RUL collapse
without a hilar mass.
C. minor fissure in RUL collapse
with a hilar mass.
D. minor fissure in RUL collapse
without a hilar mass.
E. major fissure in RUL collapse
with a hilar mass.

26. 61-year-old woman with dyspnea
 The inferior margin of the
opacity in the right upper
thorax is due to the
B. major fissure in RUL collapse
without a hilar mass.
C. minor fissure in RUL collapse
with a hilar mass.
D. minor fissure in RUL collapse
without a hilar mass.
E. major fissure in RUL collapse
with a hilar mass.

27. 45-year-old woman with chronic
cough
 All of the following are true
with regard to right middle
lobe collapse except
B. a triangular opacity is
superimposed on the heart on
the lateral radiograph.
C. the right heart border is
obscured.
D. the minor fissure is inferiorly
displaced.
E. the right heart border is
shifted to the left.

28. 45-year-old woman with chronic
cough
 All of the following are true
with regard to right middle
lobe collapse except
B. a triangular opacity is
superimposed on the heart on
the lateral radiograph.
C. the right heart border is
obscured.
D. the minor fissure is inferiorly
displaced.
E. the right heart border is
shifted to the left.

29. 45-year-old woman with chronic
cough
 All of the following are true
with regard to right middle
lobe collapse except
B. a triangular opacity is
superimposed on the heart on
the lateral radiograph.
C. the right heart border is
obscured.
D. the minor fissure is inferiorly
displaced.
E. the right heart border is
shifted to the left.

30. 62-year-old man with a cough
productive of blood-tinged sputum
 Signs of left lower lobe collapse
include all of the following except
B. obscuration of the lateral wall of the
descending thoracic aorta.
C. inferior displacement of the left
hilum.
D. obliteration of the posterior aspect
of the left hemidiaphragm on the
lateral view.
E. triangular opacity in the left
retrocardiac area on the frontal
view.
F. shift of the major fissure toward the
anterior chest wall on the lateral
view.

31. 62-year-old man with a cough
productive of blood-tinged sputum
 Signs of left lower lobe collapse
include all of the following except
B. obscuration of the lateral wall of the
descending thoracic aorta.
C. inferior displacement of the left
hilum.
D. obliteration of the posterior aspect
of the left hemidiaphragm on the
lateral view.
E. triangular opacity in the left
retrocardiac area on the frontal
view.
F. shift of the major fissure toward the
anterior chest wall on the lateral
view.

32. 62-year-old man with a cough
productive of blood-tinged sputum
 Signs of left lower lobe collapse
include all of the following except
B. obscuration of the lateral wall of the
descending thoracic aorta.
C. inferior displacement of the left
hilum.
D. obliteration of the posterior aspect
of the left hemidiaphragm on the
lateral view.
E. triangular opacity in the left
retrocardiac area on the frontal
view.
F. shift of the major fissure toward the
anterior chest wall on the lateral
view.

33. 49-year-old woman with cough
 Signs of left upper lobe collapse
include all of the following except
B. crescent of air around the transverse
section of the aortic arch resulting
from hyperexpansion of the
superior segment of the left lower
lobe.
C. anterior displacement of the left
major fissure on the lateral view.
D. obscuration of the left heart border.
E. tracheal deviation to the left.
F. inferior displacement of the left
hilum.

34. 49-year-old woman with cough
 Signs of left upper lobe collapse
include all of the following except
B. crescent of air around the transverse
section of the aortic arch resulting
from hyperexpansion of the
superior segment of the left lower
lobe.
C. anterior displacement of the left
major fissure on the lateral view.
D. obscuration of the left heart border.
E. tracheal deviation to the left.
F. inferior displacement of the left
hilum.

35. 49-year-old woman with cough
 Signs of left upper lobe collapse
include all of the following except
B. crescent of air around the transverse
section of the aortic arch resulting
from hyperexpansion of the
superior segment of the left lower
lobe.
C. anterior displacement of the left
major fissure on the lateral view.
D. obscuration of the left heart border.
E. tracheal deviation to the left.
F. inferior displacement of the left
hilum.

36. Airror
sprojects.mmi.mcgill.ca
www.surgical-tutor.org.uk

37. 40-year-old man with fever and
dyspnea
 The most likely
diagnosis is
B. massive left pleural
effusion.
C. total atelectasis of the left
lung.
D. right pneumothorax.
E. aplasia of the left lung.
F. mediastinal hematoma.

38. 40-year-old man with fever and
dyspnea
 The most likely
diagnosis is
B. massive left pleural
effusion.
C. total atelectasis of the left
lung.
D. right pneumothorax.
E. aplasia of the left lung.
F. mediastinal hematoma.

39. Tall, 21-year-old man who noted the sudden onset of
dyspnea, and right-sided pleuritic chest pain
 The most likely diagnosis is
B. pulmonary embolism.
C. overinflation associated with
asthma.
D. pneumothorax.
E. normal chest, with a skin fold
projected over the right
hemithorax.E. left lower lobe
atelectasis.

40. Tall, 21-year-old man who noted the sudden onset of
dyspnea, and right-sided pleuritic chest pain
 The most likely diagnosis is
B. pulmonary embolism.
C. overinflation associated with
asthma.
D. pneumothorax.
E. normal chest, with a skin fold
projected over the right
hemithorax.E. left lower lobe
atelectasis.

41. 62-year-old man with dyspnea that
increased over 2 days
 The most likely
diagnosis is
B. left pleural effusion.
C. collapse of the left lung.
D. right pneumothorax.
E. collapse of the right lung.
F. mediastinal hematoma.

42. 62-year-old man with dyspnea that
increased over 2 days
 The most likely
diagnosis is
B. left pleural effusion.
C. collapse of the left lung.
D. right pneumothorax.
E. collapse of the right lung.
F. mediastinal hematoma.

43. COPD
STENTOR Teaching File

44. Silicosis
STENTOR Teaching File

45. Cystic Fibrosis

46. 64-year-old man, Navy veteran, with a
cough productive of blood-tinged sputum
 The most likely diagnosis is
B. progressive massive fibrosis,
due to silicosis.
C. pneumonia in a patient with
chronic interstitial lung
disease.
D. lung cancer in a patient with
asbestosis.
E. rounded atelectasis in a
patient with asbestosis.
F. berylliosis.

47. 64-year-old man, Navy veteran, with a
cough productive of blood-tinged sputum
 The most likely diagnosis is
B. progressive massive fibrosis,
due to silicosis.
C. pneumonia in a patient with
chronic interstitial lung
disease.
D. lung cancer in a patient with
asbestosis.
E. rounded atelectasis in a
patient with asbestosis.
F. berylliosis.

48. 55-year-old man who worked as a
coal miner for 30 years
 The most likely diagnosis is
B. progressive massive fibrosis,
due to silicosis.
C. pneumonia in a patient with
chronic interstitial lung
disease.
D. lung cancer in a patient with
asbestosis.
E. rounded atelectasis in a
patient with asbestosis.
F. berylliosis.

49. 55-year-old man who worked as a
coal miner for 30 years
 The most likely diagnosis is
B. progressive massive fibrosis,
due to silicosis.
C. pneumonia in a patient with
chronic interstitial lung
disease.
D. lung cancer in a patient with
asbestosis.
E. rounded atelectasis in a
patient with asbestosis.
F. berylliosis.

50. Pulmonary malignancies
Bronchoalveolar
Carcinoma
Chronic Histoplasmosis
Granulomas
Metastasized Esophageal SCC 1° SCC

51. 53-year-old man scheduled for
coronary artery bypass grafting
 Characteristics suggesting
that a nodule is benign are
B. size of the nodule does not
change over 2 years.
C. it contains central
calcification.
D. CT attenuation values within
the nodule are greater than
200 Hounsfield units (Hu).
E. all of the above.

52. 53-year-old man scheduled for
coronary artery bypass grafting
 Characteristics suggesting
that a nodule is benign are
B. size of the nodule does not
change over 2 years.
C. it contains central
calcification.
D. CT attenuation values within
the nodule are greater than
200 Hounsfield units (Hu).
E. all of the above.

53. 64-year-old man with cough and weight loss
and a 50-pack-per-year history of tobacco use
 The best description of the
chest radiograph is
B. mass in the left upper lobe.
C. left upper lobe collapse.
D. mediastinal mass.
E. consolidation of the left
upper lobe.
F. enlargement of the left
pulmonary artery.

54. 64-year-old man with cough and weight loss
and a 50-pack-per-year history of tobacco use
 The best description of the
chest radiograph is
B. mass in the left upper lobe.
C. left upper lobe collapse.
D. mediastinal mass.
E. consolidation of the left
upper lobe.
F. enlargement of the left
pulmonary artery.

55. 64-year-old man with cough and weight loss
and a 50-pack-per-year history of tobacco use
 The best description of the
chest radiograph is
B. mass in the left upper lobe.
C. left upper lobe collapse.
D. mediastinal mass.
E. consolidation of the left
upper lobe.
F. enlargement of the left
pulmonary artery.

56. 70-year-old woman with uterine carcinoma
treated with surgical resection 3 years ago
 The most likely cause of the
multiple pulmonary nodules
is
B. metastasis.
C. herpes simplex pneumonia.
D. histoplasmosis.
E. Wegener's granulomatosis.
F. arteriovenous malformations

57. 70-year-old woman with uterine carcinoma
treated with surgical resection 3 years ago
 The most likely cause of the
multiple pulmonary nodules
is
B. metastasis.
C. herpes simplex pneumonia.
D. histoplasmosis.
E. Wegener's granulomatosis.
F. arteriovenous malformations

58. Airways
www.smbs.buffalo.edu www.mevis.de

59. Pneumonia
STENTOR Teaching File

60. Pneumonia
STENTOR Teaching File

61. 32-year-old man with fever, cough,
and hemoptysis
 Which of the following
is not an accurate
descriptor of the opacity
in the left upper lobe
B. Lobar distribution
C. Ill-defined margins
D. Reticular pattern
E. Air bronchograms
F. Airspace disease

62. 32-year-old man with fever, cough,
and hemoptysis
 Which of the following
is not an accurate
descriptor of the opacity
in the left upper lobe
B. Lobar distribution
C. Ill-defined margins
D. Reticular pattern
E. Air bronchograms
F. Airspace disease

63. 57-year-old man with fever and a
cough productive of purulent sputum
 Which one of the following
best explains the opacity in
the left hemithorax?
B. Collapse of the left upper lobe
due to bronchial obstruction
C. Airspace consolidation of the
lingula
D. Empyema loculated within
the left major fissure
E. Carcinoma in the left upper
lobe

64. 57-year-old man with fever and a
cough productive of purulent sputum
 Which one of the following
best explains the opacity in
the left hemithorax?
B. Collapse of the left upper lobe
due to bronchial obstruction
C. Airspace consolidation of the
lingula
D. Empyema loculated within
the left major fissure
E. Carcinoma in the left upper
lobe

65. 69-year-old man with progressive dyspnea,
orthopnea, and pedal edema and a history of
hypertension
 Which of the following best
describes the chest
radiograph?
B. Normal heart size, alveolar
pulmonary edema
C. Cardiomegaly, interstitial
pulmonary edema, and small
bilateral pleural effusions
D. Unilateral interstitial disease
E. Cardiomegaly, oligemia in the
right lung

66. 69-year-old man with progressive dyspnea,
orthopnea, and pedal edema and a history of
hypertension
 Which of the following best
describes the chest
radiograph?
B. Normal heart size, alveolar
pulmonary edema
C. Cardiomegaly, interstitial
pulmonary edema, and small
bilateral pleural effusions
D. Unilateral interstitial disease
E. Cardiomegaly, oligemia in the
right lung

67. Fluids and Gravity

68. Pleural Effusion

69. My First Thoracentesis

70. 45-year-old man with increasing dyspnea and
abdominal swelling of 1-week duration
 Which of the following radiographic signs
suggest the presence of pleural effusion?
B. Meniscus-shaped opacity in a posterior
costophrenic angle on the lateral projection
C. Biconvex lens-shaped opacity projecting in
the midthorax on the lateral projection
D. Fluid levels that have different lengths on the
PA and lateral views in a hemithorax
E. Homogeneous increased density in a
hemithorax with preservation of the vascular
shadows in the lungs
F. Separation of the gastric air bubble from the
inferior lung margin by more than 2 cm

71. 45-year-old man with increasing dyspnea and
abdominal swelling of 1-week duration
 Which of the following radiographic signs
suggest the presence of pleural effusion?
B. Meniscus-shaped opacity in a posterior
costophrenic angle on the lateral projection
C. Biconvex lens-shaped opacity projecting in
the midthorax on the lateral projection
D. Fluid levels that have different lengths on the
PA and lateral views in a hemithorax
E. Homogeneous increased density in a
hemithorax with preservation of the vascular
shadows in the lungs
F. Separation of the gastric air bubble from the
inferior lung margin by more than 2 cm

72. 62-year-old woman with worsening shortness of breath and
mild hemoptysis 1 day after receiving IV chemotherapy
 The most likely cause for her
dyspnea and hemoptysis is
B. pulmonary metastases.
C. malignant pleural effusion.
D. pulmonary embolism.
E. septic emboli.
F. drug-related pneumonitis.

73. 62-year-old woman with worsening shortness of breath and
mild hemoptysis 1 day after receiving IV chemotherapy
 The most likely cause for her
dyspnea and hemoptysis is
B. pulmonary metastases.
C. malignant pleural effusion.
D. pulmonary embolism.
E. septic emboli.
F. drug-related pneumonitis.

74. 62-year-old woman with worsening shortness of breath and
mild hemoptysis 1 day after receiving IV chemotherapy
 The most likely cause for her
dyspnea and hemoptysis is
B. pulmonary metastases.
C. malignant pleural effusion.
D. pulmonary embolism.
E. septic emboli.
F. drug-related pneumonitis.

75. The Final
Can you spot the pathology?

76. References
 Paul and Juhl’s Essentials of Radiologic Imaging,
11th edition
 Felson’s Principles of Chest Roentgenology, 2nd
edition
 Chen MYM, Pope TL, and Ott DJ, Basic
Radiology, The McGraw-Hill Companies, 2008