1. Radiological signs of Disease

2. Air Fluid Levels You can encounter air fluid levels in chest x-rays in the following conditions: Cavitary lung lesions Loculated empyema Hydropneumothorax Esophageal obstruction Mediastinal abscess Hydropneumopericardium Hiatal hernia Chest wall abscess

3. Most disease processes will either increase or decrease the density of the lung parenchyma

4. A mediastinal lesion should have a sharp margin convex towards the lungs and its base abutting the mediastinum .

5. A pleural lesion should be seen as a homogenously dense opacity abutting the pleural surface, without air bronchogram. If the pleural lesion is free fluid, it will gravitate to the dependant lung parts first to form a miniscus (concavity) along its upper surface.
An extra pleural lesion demonstrates a homogenous density which makes obtuse angles with the chest wall, or may appear similar to pleural disease.

6. A lung opacity may be due to a mass or lung- parenchymal opacification
A lung opacity may be due to a mass or lung- parenchymal opacification. Identification of clear margins vs indistinct or diffuse opacification is important in making the differentiation.If the diffuse opacification demonstrates lucencies or air bronchogram within it, it is most likely air space disease (consolidation).

7. Signs of lobar collapse
Local increase in density due to non-aerated lung.
Decreased lung volume.
Displacement of pulmonary fissures.
Elevation of hemidiaphragm.
Displacement of hila.

8. left upper lobe atelectasis following right upper lobectomy.
  The left lung lacks a middle lobe and therefore a minor fissure, so left upper lobe atelectasis presents a different picture from that of the right upper lobe collapse. The result is predominantly anterior shift of the upper lobe in left upper lobe collapse, with loss of the left upper cardiac border. The expanded lower lobe will migrate to a location both superior and posterior to the upper lobe in order to occupy the vacated space. As the lower lobe expands, the lower lobe artery shifts superiorly. The left mainstem bronchus also rotates to a nearly horizontal position.

9. Pleural effusion + lobar densities
Pneumonia with empyema
Pulmonary infarction
Bronchogenic carcinoma
Tuberculosis

10. Pleural effusion + subsegmental atelectasis
Postoperative (thoracotomy, splenectomy, renal surgery) secondary to thoracic splinting + small airway
mucous plugging
Pulmonary infarction
Abdominal mass
Ascites
Rib fractures

11. Upper lung zone distribution
Cystic fibrosis
Ankylosing spondylitis
Sarcoidosis
Silicosis
Histiocytosis (Langerhan's cell)
TB, fungal
Radiation pneumonitis ( cancers of head/neck and breast)

12. Peripheral lung zone distribution
BOOP (bronchiolitis obliterans organizing
pneumonia)
UIP (usual interstitial pneumonitis, and DIP
desquamative interstitial pneumonitis)
Infarcts
Eosinophilic pneumonia
Alveolar sarcoidosis
Contusions

13. 'Bat's wing distribution
Acute Chronic
* Pulmonary oedema: * Atypical pneumonia
- cardiac * Lymphoma/Leukemia
- non cardiac * Sarcoidosis: interstitial
* Pneumonia: form much more common
- often 'unusual' etiology; * Pulmonary alveolar
- pneumocystis carinii (AIDS); proteinosis
- TB, viral pneumonias; * Alveolar cell carcinoma:
- mycoplasma localised form more
common
* Pulmonary haemorrhage:
- Goodpasture's syndrome;
Wegner's and other vasculitides
- anticoagulants;
- bleeding diathesis: haemophilia,
DIC;
 extensive contusion.

14. LUNG VOLUME Idiopathic pulmonary fibrosis.
*Reduced
Idiopathic pulmonary fibrosis.
Chronic interstitial pneumonia
Asbestosis
Collagen vascular disease
Chronic pulmonary tuberculosis
*Normal
Sarcoidosis
Histiocytosis
*Increased
Bronchial Asthma
Emphysema
Lymphangioleiomyomatosis

15. Reticulations & Hilar Adenopathy
- Sarcoidosis
Silicosis
- Lymphoma/leukemia
- Lung primary: particulary oat cell carcinoma
- Metastases: lymphatic obstuction/spread
- Fungal disease
- Tuberculosis
- Viral pneumonia (rare combination)

16. Lung mass of more than Clinical history and patient’s age .
Mass borders .
Comparison with previous examinations.
Presence of calcifications.
Associated adjacent rib erosions, pleural effusion, hilar or mediastinal nodal enlargement.
Presence of more than one mass.

17. SIGNS OF INTERSTITIAL DISEASE

18. Distribution of opacities
Unifocal or multifocal.
Lobar.
Segmental.
Perihilar.
Peripheral.
Upper, middle or lower zones.

19. Lung fields appear dark because of air
Lung fields appear dark because of air. Ninety-nine percent of the lung is air. The pulmonary vasculature, interstitium constitute 1% and give the lacy lung pattern.

20. You have to know what is normal before you can recognize abnormalities
You have to know what is normal before you can recognize abnormalities. Knowledge of anatomy is essential for this purpose.

21. Normal Female .older,young
Note breast shadows
Look for asymmetry or missing breast (surgery)
Be aware of basal lung changes due to breast tissue.
Review lateral to evaluate basal changes.

22. Which lung is larger. Which diaphragm is higher and why
Which lung is larger? Which diaphragm is higher and why? What is the normal size of the heart? What is the normal size and shape of the aorta?

23. Dextrocardia

24. Silhouette sign is extremely useful in localizing lung lesions

25. LUL/Posterior segemnt
Silouhette
Adjacent lobe/segment
Right Diaphragm
RLL/Basal segments
Right Heart margin
RML/Medial segment
Ascending Aorta
RUL/Anterior segment
Aortic knob
LUL/Posterior segemnt
Left Heart margin
Lingula/Inferior segment
Descending Aorta
LLL/Superior and medial segments
Left Diaphragm
LLL/Basal segments

26. Consolidation / Lingula
Density in left lower lung field
Loss of left heart silhouette
Diaphragmatic silhouette intact
No shift of mediastinum
Blunting of costophrenic angle

28. Lobar Pneumonia Right Middle Lobe

29. Note the upward movement of the left hilum following LUL resection for cancer

30. Pleural Effusion /
Upright and Supine

31. Hyperlucent Lung Factors Bilateral diffuse Unilateral Localized
Vasculature: Decrease
Air: Excess
Tissue : Decrease
Bilateral diffuse
Emphysema
Asthma
Unilateral
Swyer James syndrome
Agenesis of pulmonary artery
Absent breast or pectoral muscle
Partial airway obstruction
Compensatory hyperinflation
Localized
Bullae
Westermark's sign : Pulmonary embolus .

32. Emphysema

33. R mastectomy

34. Unilateral Hyperlucent Lung Left Upper Lobe Resection

35. Unilateral Hyperlucent Lung Right Upper Lobe Resection

36. Unilateral Hyperlucent Lung Peanut in Left Bronchus Partial Airway Obstruction Left lung hyperlucent
Left lung stays hyperlucent on expiration
Mediastinal shift with respiration

38. Honeycombing

39. Honeycombing Seen in end stage lung disease
Indicative of diffuse interstitial fibrosis
Due to bronchiolectasia
Most of the time in bases
Upper lobe distribution seen in eosinophilic granuloma

40. Lymphangitic Metastasis
Cancer Breast
Kerley lines
Subpulmonic effusion on right

41. Sarcoidosis / Miliary Nodules / Hilar Nodes

42. Milary Tuberculosis
Interstitial nodules
Uniform size
Sharper edges

43. Aspergilloma

44. Aspergilloma. Bilateral upper lobe disease
Long standing cavity due to sarcoidosis
Cavity containing round density
Crescent sign - semilunar air space above mass density

45. Aspergillosis 
Solitary Pulmonary Nodule
Patient on steroids. Develops solitary pulmonary nodule with air bronchogram. Short doubling time indicating inflammatory process. Air bronchogram indicating that it is an alveolar process.
- On steroids 7/77 (film below)
- Develops solitary pulmonary nodule within one month 8/77
- Air bronchogram in the density
FNAB: Aspergillus
Resolved with discontinuation of steroids.

46. Pneumonectomy
Opacity left hemithorax
Tracheal shift to left
Cardiac and left diaphragmatic silhouettes missing
Crowding of ribs

47. Pleural Effusion Massive

48. Atelectasis Right Lung

49. Pneumothorax

50. Tension Pneumothorax No vascular markings on right
Shift of mediastinum to left
Deep sulcus
Atelectatic right lung
Increased haziness on left: Diversion of entire cardiac output

51. Tracheal Shift / Thyroid Mass  

52. AP Window Nodes - Small Cell Cancer

53. Hilar Nodes
Note bilateral symmetrical hilar nodes and para tracheal nodes. 
A clear space between the nodes and heart, identifies the nodes as hilar.

54. Pulmonary Schistosomiasis
Aneurysmal dilatation of pulmonary arteries

55. Pulmonary Edema 
Cardiomegaly
Bilateral alveolar densities
Bilateral pleural effusions
Hilar haze
 Rapid clearance

56. Adult Respiratory Distress Syndrome
Non-cardiogenic pulmonary edema
Distinguishing characteristics:
Normal size heart
No pleural effusion

57. Pulmonary Osteoarthropathy
Anterior Mediastinal Mass

58. Lung Cancer
RUL primary lesion
Para tracheal nodes

59. Achalasia Cardia
Inhomogeneous cardiac density
Right sided inlet to outlet shadow
Crossing mid line
Barium swallow below: Dilated esophagus

60. Aneurysm Arch of Aorta
Mediastinal mass
Extrapleural

61. Aneurysm Arch of Aorta
Leaking Blood into Pleural Space
Mediastinal mass
Calcification of periphery evident along upper margin
Loss of silhouettes of
aortic knob
left heart margin
left diaphragm
Left pleural effusion
Tracheal indentation Old and New x rays

62. Aneurysm Arch of Aorta
"Mass" density
Extrapleural
Middle mediastinal mass

63. Aneurysm of Descending Aorta- Inhomogeneous cardiac density
Retrocardiac density
Extrapleural
Peripheral in location
One margin indistinct in PA and lateral view

64. Dissecting Aneurysm
Mediastinal widening
Inlet to outlet shadow on left side
Retrocardiac: Intact silhouette of left heart margin
Pulmonary artery overlay sign: Density behind left lower lobe
Wavy margin
Lat view demonstrates increased density over spine

65. Aneurysm of Descending Aorta
"Mass" density
Extrapleural
Posterior mediastinal mass

66. Bronchiectasis Normal appearing CXR in most Tubular shadows Tram line
Gloved fingers
Mucocele
Ring shadows with thickened bronchial walls
Air fluid levels
Watch for dextrocardia
Immotile cilia syndrome
Diffuse lung fibrosis
Due to recurrent infections

67. Cystic Fibrosis - Bronchiectasis
Bilateral diffuse
Multiple cavities / Bronchiectasis
Peribronchial fibrosis
Prominent hilum
Hyperinflated

68. Carcinoid

69. Branchial cyst .Asymptomatic young lady presents with abnormal chest x-ray. Mass density
Round with sharp margins .L. old film..R.new film

70. Branchial cyst .Cystic nature is evident in CT

71. Coarctation Aorta
Post stenotic dilatation: Mogul sign
Rib notching: Difficult to see in this presentation

72. Coarctation Aorta

73. Right Sided Aortic Arch
Aortic knob missing on left and seen on right
Descending aorta missing on left and seen on right
Paravertebral line on right

74. Right Sided Aortic Arch
Aortic knob on right
Descending aorta on right
Paravertebral line

75. Hamman-Rich Syndrome
Rapid progression of interstitial disease

76. Anterior Mediastinal Mass  
Widened mediastinum
Loss of cardiac silhouette
Intact silouhette of descending aorta
Lateral view below.
This is a case of  anaplastic carcinomaRetrosternal area is filled with mass density.

77. Tuberculosis
LUL cavities
RUL infiltrate 
Bilateral upper lobe disease

78. Pulmonary Embolism
.  The primary purpose of a chest film in suspected PE is to rule out other diagnoses as a cause of dyspnea or hypoxia.  Most CXRs in patients with PE are normal. 

79. These are two PA fiilms demonstrating Hampton's hump (rounded opacities) in patients with pulmonary embolism

80. Aneurysm of Descending Aorta
"Mass" density
Extrapleural
Posterior mediastinal mass