1. Jennifer Lim-Dunham, MD Arcot J. Chandrasekhar, M.D. December 10, 2014
CXR Review TCM2
Jennifer Lim-Dunham, MD
Arcot J. Chandrasekhar, M.D.
December 10, 2014
LOYOLA
UNIVERSITY
MEDICAL CENTER
Loyola University Chicago
LOYOLA
UNIVERSITY
MEDICAL CENTER
Loyola University Chicago

2. Is this a PA or AP film?
PA film
AP film

3. AP
Supine film
Scapula (red arrow) 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) PA
Upright film
Scapula does not overlap lung fields
Clavicles projecting over upper chest
Air fluid levels in abdomen or chest
Penetration/exposure normal

4. Is this film centered?
Yes No

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

6. Image Characteristics
PA or AP
Centered or rotated
Degree of penetration
Degree of inspiration

7. What is your answer? Cavity Mass Consolidation Pneumothorax
Pleural effusion

8. Consolidation Triangular density Air bronchogram (red arrows)
No loss of lung volume (midline). Distinguishes consolidation/pneumonia from atelectasis
Unrecognizable vasculature
R upper lobe (Silhouette sign)
Know that these are the hallmarks of alveolar or airspace disease or consolidation, usually from pneumonia

9. Roentgen Signs Silhouette Sign
Loss of silhouette indicates that there is airless (lung or mass or fluid) adjacent to that silhouette.
Know the loss of which heart borders correspond to which lobes.
(“Consolidation”)

10. What is your assessment?
Consolidation
Atelectasis
Congestion
Mass
Pleural effusion

11. Resorptive Atelectasis
Triangular density
Loss of lung volume. Minor/horizontal fissure is elevated (arrows).
Unrecognizable vasculature
Right upper lobe (Silhouette sign)
Compensatory hyperinflation
Know types of atelectasis: resorptive, relaxation, adhesive.
Know which fissures become elevated in atelectasis
(“Atelectasis”)

12. What is your choice? Mass Consolidation Congestion Cavity
Diffuse interstitial disease

13. Cavitating Mass Hole in lung Wall characteristics
Lumen characteristics
Contents
Number
Location
Cavity signifies lung abscess or necrotic mass or tumor

14. What is your diagnosis? Pneumothorax Pleural effusion Consolidation
Atelectasis
Congestion

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

16. Unilateral White Out Pleural Effusion
Mediastinal shift to contralateral side
Larger hemithorax

17. Your choice?
Diffuse alveolar disease
Diffuse interstitial disease

18. Acute Diffuse Alveolar Disease
Soft fluffy densities
Butterfly distribution
Air bronchogram
Diffuse white out
Acute vs. chronic

19. Acute diffuse alveolar disease You choice?
Pulmonary edema
Pulmonary hemorrhage
Influenza
Adult respiratory distress syndrome

20. Acute LV Failure: Pulmonary Edema
Diffuse white out
Soft fluffy densities
Butterfly distribution
Air bronchogram (arrowheads)
A: ET tube, B: NG tube, C: Central line

21. Chronic Heart Failure Vascular Phase
First phase: Cephalization

22. Congestive Heart Failure Interstitial Phase
Second phase. Kerley B lines

23. Congestive Heart Failure Alveolar Phase
Third phase
Basal densities
Pleural effusions
Hilar fullness
Peribronchial edema

24. What is your diagnosis? Diffuse alveolar disease
Diffuse interstitial disease

25. Diffuse Interstitial Disease Miliary Tuberculosis
Reticulonodular
Ground glass / dirty lungs
Kerley lines
Miliary nodules
Honeycombing
These terms are used to described specific types of intersititial disease
Distinguish interstitial from airspace disease

26. What is your impression?
Atelectasis
Pneumothorax
Consolidation
Lung mass

27. Pneumothorax Air in pleural cavity Visible lung margin
Relaxation atelectasis
Mediastinal shift to contralateral side
Enlarged hemithorax
Deep costophrenic sulcus

28. Mediastinal Widening Supracardiac Vessel / Anterior mediastinal Area
Mediastinal nodes
Mediastinal mass
Aortic aneurysms

29. 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
Central line (PICC, subclavian)
Swan Ganz catheter
Aortic balloon pump
IV tubing, oxygen tubing, EKG leads
Artifacts
Foreign bodies
(“Tubes and lines”)

30. 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