TCM2 Radiology Pre Exam Review Semester One Chest x-ray Pathology Jennifer Lim-Dunham, MD Department of Radiology December 3, 2018 LOYOLA UNIVERSITY MEDICAL CENTER Loyola University Chicago LOYOLA UNIVERSITY MEDICAL CENTER Loyola University Chicago

Exam Thursday December 13, 2018 Pass Fail 30 questions multiple choice Review this powerpoint Review the 15 pdfs (identical to material on LUMEN under Radiology/ PCM) http://www.stritch.luc.edu/lumen/MedEd/Radio/curriculum/radiology-curric1_f.htm

Three question types

The chest x-ray is diagnostic for which one of the following? Question type 1 Given a radiology image and asked to choose which diagnosis matches the image The chest x-ray is diagnostic for which one of the following? 1. Right lower lobe mass 2.Consolidation of the right lower lobe 3. Right lower lobe atelectasis 4. Right pleural effusion 5. Diaphragm pushed up by enlarged liver

Select which history best matches the CXR. Question type 2 Given a radiology image and asked to choose which patient history matches the image Select which history best matches the CXR. A. 52 y/o male presents with sudden onset of sharp chest pain and severe shortness of breath. B. 46 y/o female presents with sharp chest pain, fever and chills of two days duration. C. 48 y/o male . He is asymptomatic. CXR is taken for an insurance application. D. 56 y/o smoker presents with 10 lb weight loss and cough with blood tinged sputum.

Question type 3 . Knowledge questions about general anatomy, pathophysiology or radiology principles Emphysema can be distinguished from chronic bronchitis by the presence of: A. Flat diaphragm B. Vertical heart C. Blebs D. Increased retrosternal air E. Increased A-P diameter

Next semester: PCM2 Hands on Radiology Workshop: Reading a CXR Small group sessions in February 2019 Use what you have learned this semester from CXR weekly lessons, this exam, and my PCM2 lectures “Systematic Approach to CXR Pathology” TCM2 Radiology Exam on Neurology and Abdominal imaging pathology in April 2019 (Pass fail, preceded by review session) More information to follow later

CXR image characteristics and patient positioning

Is this a PA or AP film?

Quality characteristics PA vs. AP (upright vs supine)

Scapula projecting overlapping lung fields AP Anterior posterior Scapula projecting overlapping lung fields Clavicles projecting above the inlet of thorax. No air fluid levels in abdomen or chest Underpenetrated (too white, not enough xrays going through the body) Heart bigger PA Posterior Anterior Scapula does not overlap lung fields Clavicles projecting over upper chest Air fluid levels in abdomen or chest Penetration/exposure normal

Is this film centered? Yes No

Not centered. Patient rotated to his right Draw a line along the central spinous process Draw a line along the medial end of clavicles Distance between medial end of right clavicle and midline longer than on left Right ribs longer than left

Appropriate. Can see vessels in lungs and can see spine behind heart Overpenetrated. Overexposed. Too dark. Lungs look completely black. Too many xrays reaching xray plate. Appropriate. Can see vessels in lungs and can see spine behind heart Underpenetrated. Underexposed. Lungs and heart too white. Cannot see spine behind heart. Too few xrays reaching xray plate.

Proper inspiration: right diaphragm should be between 9th and 10th posterior ribs How to count ribs

CXR anatomy

Arrow: AP aortico pulmonary window (concave space between aortic knob and main pulmonary artery)

Transverse (horizontal or minor) fissure on the right Scapula

Lung pathology

Types of focal lung abnormalities Consolidation Mass Cavity

Consolidation Triangular density RUL of lung Air bronchogram (arrows) are hallmark of alveolar/ airspace disease or consolidation Bronchi become visible because of density contrast between normal air in bronchi and abnormal fluid in surrounding alveoli Consolidation may be secondary to pneumonia (no volume loss) or atelectasis (volume loss, elevation right minor fissure, as shown here)

Radiographic Signs Silhouette Sign Loss of silhouette (outline, shadow) is abnormal and indicates that there is airless, consolidated lung adjacent to that structure. Left heart border obscured = lingula consolidation Know which heart borders are obscured with consolidation in which lobes of the lung. http://www.stritch.luc.edu/lumen/MedEd/Radio/curriculum/radiology-curric1_f.htm (“Consolidation”)

Silhouette Sign Right heart border obscured= right middle lobe consolidation (arrows)

Atelectasis = Collapse of all or part of lung Left upper lobe lobe atelectasis There is density in left upper lung Left upper mediastinal border obscured (silhouette sign) Forward shift of oblique/major fissure on lateral CXR (arrows) indicates loss of LUL lung volume. Therefore atelectasis rather than pneumonia. Clinical history will also help distinguish atelectasis (hypoxia, no fever) from pneumonia (fever and cough)

Normal positions major and minor fissures. Fissures are not normally seen unless outlined by abnormal lung. Sharply demarcated, straight borders

Resorptive Atelectasis Triangular density Loss of lung volume. Minor/horizontal fissure is elevated (arrows). Right upper lobe (Silhouette sign, right upper mediastinal border obscured) Types of atelectasis: resorptive (endobronchial obstruction); adhesive (loss of surfactant); relaxation (loss of negative pressure in pleural space). Know which fissures become elevated in atelectasis http://www.stritch.luc.edu/lumen/MedEd/Radio/curriculum/radiology-curric1_f.htm (“Atelectasis”)

Right lower lobe lung Resorptive atelectasis. Right lower lobe lung density but right heart margin still visible, therefore right lower lobe and not middle lobe. Atelectasis because major or oblique fissure is pulled down. Resorptive because most likely due to endobronchial obstruction

Adhesive atelectasis Diffuse bilateral confluent lung opacities are consistent with ARDS in this patient with tracheostomy tube. Lungs become atelectatic due to diffuse loss of surfactant = adhesive atelectasis.

Complete collapse (resorptive atelectasis) of left lung white-out of left hemithorax with signs of lung volume loss on left (mediastinal shift to left, crowding of left ribs) indicating that it is due to atelectasis Usually due to obstruction of bronchus from mucus plug or, in a child, foreign body DDx for this appearance on CXR is left pleural effusion, but there would be signs of increased rather than decreased volume in left hemithorax

Types of solitary round lesions in lung Solitary pulmonary nodule in right lower lobe of lung Distinct, sharply demarcated borders Lung masses: Larger than 3 cm Solitary lung nodules: 1-3 cm Lung nodules < 1 cm This lesion could be cancer or benign tumor

What kind of lesion is this? Mass Consolidation Congestion Cavity Diffuse interstitial disease

Cavity Arrow points to dense mass with central lucency (black area), indicating air in the center Cavity signifies lung abscess or necrotic (dead tissue) tumor If in lung apex, also consider TB.

Cavitary lung mass with air fluid level (flat line with air on top and fluid on bottom because of gravity). Ddx lung abscess vs. lung tumor Necrotic lung tumor. Months long history of weight loss, hempotysis. Lung abscess. Weeks long history of pneumonia, fever, cough.

Alveolar vs. interstitial lung disease. Your choice? Diffuse alveolar disease (confluent density over broad area) Diffuse interstitial disease (Lines)

Acute Diffuse Alveolar Disease secondary to pulmonary edema or ARDS Soft fluffy densities over broad area Butterfly distribution (central, near hila, bilaterally symmetric) Air bronchogram

Acute diffuse alveolar disease can be due to many causes. Your choice? Pulmonary edema Pulmonary hemorrhage Influenza Adult respiratory distress syndrome

Pulmonary Edema from Congestive Heart Failure Diffuse bilateral soft fluffy densities “Batwing” or “Butterfly” distribution Air bronchogram (arrowheads) Cardiomegaly supports pulmonary edema rather than ARDS or hemorrhage Influenza is interstitial, not airspace, disease

Congestive Heart Failure Vascular Phase First phase: Cephalization of pulmonary blood flow (more to upper lobes than normal)

Congestive Heart Failure Interstitial Phase Second phase. Kerley B lines (Interstitial, short straight lines that extend to pleural surface)

Congestive Heart Failure Alveolar Phase Third phase Basal and bilateral “batwing” densities close to hila Pleural effusions Cardiomegaly

What is your diagnosis? Diffuse alveolar disease Diffuse interstitial disease

Diffuse Interstitial Disease Miliary Tuberculosis Reticulonodular (lines and dots) Ground glass / hazy density Miliary nodules < 5mm

COPD (chronic bronchitis and emphysema) Hyperinflated lungs Flattened diaphragm (yellow arrow) Retrosternal air (red arrow) Hyperlucent lungs Blebs (white arrow) in emphysema only Avascular zones

Pathology of pleura

What is your diagnosis? Pneumothorax Pleural effusion Consolidation Atelectasis Congestion

Pleural Effusion Homogeneous density Dependent position Loss of diaphragm and costophrenic angle (Silhouette sign) Slanting meniscus Mediastinal shift to contralateral side

Unilateral White Out Left lung collapse/ateletasis Mediastinal shift to left, ipsilateral side Left hemithorax volume smaller than right Left pleural effusion Mediastinal shift to right, contralateral side Left hemithorax volume larger than right

What is your impression? Atelectasis Pneumothorax Consolidation Lung mass

Left Pneumothorax Air in pleural cavity Loss of normal lung vascular markings in periphery of chest Visible pleural/lung interface Relaxation atelectasis Mediastinal shift to contralateral side Enlarged hemithorax

Mediastinum and tubes and lines

Anterior Mediastinal Widening Abnormal soft tissue in paratracheal and supracardiac areas Mediastinal nodes Mediastinal mass Aortic aneurysms Normal comparision

Tubes and Lines Learn to identify them. Make sure that the tip is in the right place. There are no complications from their placement. ET tube NG tube or feeding tube http://www.stritch.luc.edu/lumen/MedEd/Radio/curriculum/radiology-curric1_f.htm (“Tubes and lines”)

ETT tube A: ET tube, B: NG (enteric) tube, C: Central line ETT tip should be between carina and suprasternal notch (T1 vertebral body level)

Feeding tube positioning Correctly positioned tube with tip at junction fourth duodenum and jejunum. Duodenum is C shaped. Improperly positioned tip in right lung