Chest X rays Flashcards
A 60 year female presents to her GP with fatigue, weight loss and wheeze. There is no significant medical history. She is a non-smoker. On examination, she has saturations of 99% in air and is afebrile. There is wheeze in the RUZ. A CXR is requested to assess for malignancy or COPD
This X-ray demonstrates a large, round upper lobe lung lesion associated with multiple smaller nodules. This is highly suspicious of a right upper lobe primary lung cancer with lung metastases. The dense right hilum is suspicious for hilar nodal disease. The significance of the right apical thickening is not clear.
Initial blood tests may include FBC, U/Es, CRP, LFTs & bone profile
A staging CT chest and abdomen with IV contrast should be performed
The patient should be referred to respiratory/oncology for further management, which may include a biopsy and MDT discussion. Treatment may involve surgery, radiotherapy, chemotherapy or palliative treatment, which would depend on the outcome of the MDT discussion, investigations and the patient’s performance status/wishes
A 32 year old female on the surgical ward develops shortness of breath and a fever 36 hours post-appendicectomy. There is no other significant past medical history. She is a non-smoker. On examination, she has saturations of 91% in air, a RR of 25, a HR of 120, and is febrile with a temperature of 39.5°C. There is reduced air entry and crackles in the right lung base. A chest X-ray is requested to assess for possible pneumonia or effusion.
The X-ray demonstrates right lower zone consolidation, associated with a pleural effusion. This is consistent with pneumonia and a parapneumonic effusion. There is also a small-volume pneumoperitoneum, which is in keeping with the recent surgery.
The patient should be started on supplementary oxygen. Initial blood tests may include FBC, U/Es, blood cultures, and CRP. A sputum culture may also be taken.
She will require IV fluids and appropriate antibiotics for hospital-acquired pneumonia, and a follow up X-ray to ensure resolution of the consolidation should be performed. An ultrasound could be considered to assess the size of the parapneumonic effusion, and permit ultrasound-guided aspiration/drainage if required.
An 88 year old male presents to the ED with 3 weeks of progressive shortness of breath, cough and some haemoptysis. He has a 60 pack year smoking history. On examination, he has saturations of 85% in air and is afebrile. There is dullness to percussion and reduced air entry in the left lower zone. A chest X-ray is requested to assess for possible pneumonia or malignancy.
This X-ray demonstrates a left lower lobe collapse (sail sign, apparent double left heart border and loss of descending aortic outline). Resultant volume loss in the left hemithorax is indicated by mediastinal deviation and depression of the left hilum.
Coarsening of the lung markings and hyperinflation of the right lung are in keeping with chronic obstructive pulmonary disease (COPD).
Given the strong smoking history combined with 3 weeks of progressive symptoms, a proximal obstructing mass (tumour or hilar lymph node) is the most likely cause of the lobar collapse. Other differentials include a mucus plug or an inhaled foreign body.
Supplementary oxygen should be given.
Initial blood tests may include FBC, U/Es, LFTs, bone profile, CRP, ESR and TFTs. CT chest with IV contrast to assess for a proximal obstructing lesion, such as a tumour, should be performed. A CT of the abdomen will usually also be acquired at the same time to enable lung cancer staging.
The patient should be referred to respiratory:oncology services
for further management, which may include biopsy and MDT discussion. Treatment, which may include surgery, radiotherapy, chemotherapy, or palliative treatment, will depend on the outcome of the MDT investigations and the patient’s wishes.
A 42 year old female attends the cardiothoracic outpatient clinic for review 10 weeks post lung cancer surgery. Unfortunately her notes are unavailable. She says she has recovered well from the surgery. On examination, she is afebrile, and her saturations are 98% in air. There is reduced chest expansion on the right with no breath sounds and dullness to percussion. Examination of the left lung is normal. A chest X-ray is requested as part of the routine post-operative follow up.
This X-ray demonstrates a total white out of the right hemithorax with marked volume loss demonstrated by mediastinal deviation. There are surgical clips in the right mid and upper zones.
The findings are consistent with the normal appearance of a right pneumonectomy. The white out will be due to fluid filling the postpneumonectomy space. There is no air-fluid level (hydropneumothorax) to suggest a bronchopleural fistula.
It would be helpful to compare the current X-ray with previous imaging, but no specific investigation/action is required.
A 25 year old female presents to her GP with worsening shortness of breath. There is no significant past medical history and she is a non-smoker. On examination, she has saturations of 98% in air and is afebrile. Lungs are resonant throughout with good bilateral air entry and occasional wheeze. A chest X-ray is requested to assess for possible pneumonia, collapse, or pleural effusions.
This X-ray demonstrates a left-sided mediastinal mass. Loss
of the left heart border indicates involvement of the anterior mediastinal compartment. The left hilum and descending thoracic aorta are visible separate to the mass, indicating
the middle and posterior compartments are spared. The differentials includes lymphoma, thyroid malignancy, thymoma (although usually in older patients), and teratoma.
A full examination to assess for lymph node enlargement should be undertaken. Initial blood tests may include FBC, U/Es, LFTs, bone profile, and TFTs.
Further imaging in the form of contrast enhanced CT of the chest should be performed. If lymphoma is suspected then the neck, abdomen, and pelvis should also be included in the CT. A CT-guided anterior mediastinal mass biopsy may be required for a histological diagnosis.
The patient should be referred to respiratory/oncology services for further management, which may include biopsy and MDT discussion. Treatment, which may include surgery, radiotherapy, chemotherapy, or palliative treatment, will depend on the outcome of the MDT discussion, investigations, and the patient’s wishes.
An 80 year old male presents to ED with progressively worsening breathlessness. He used to work in the shipyards. He has a 60 pack year smoking history. On examination, he has saturations of 92% in air and is febrile with a temperature of 38.2°C. His RR is 25 with a HR of 80 bpm. There are crackles and dullness to percussion at the right lung base. There is also finger clubbing. A chest X-ray is requested to assess for possible pneumonia or malignancy.
The X-ray demonstrates multiple irregularly shaped densities throughout both hemithoraces. These are consistent with calcified pleural plaques and indicate past asbestos exposure. Focal consolidation at the right costophrenic angle is in keeping with pneumonia.
Initial blood tests may include FBC, U/Es and CRP. Sputum and blood cultures may also be helpful. A follow up chest X-ray 4-6 weeks after appropriate antibiotics should be performed to
ensure resolution of the pneumonia.
Previous imaging should be reviewed; if the pleural plaques are a new diagnosis the patient should be referred to respiratory for further assessment of asbestos-related lung disease.
A 58 year old male is brought to ED after falling off a ladder. He has right-sided chest pain and breathlessness. He has no significant past medical history. He is a non-smoker. On examination, he has saturations of 88% in air, his HR is 122 bpm and BP 108/68 mmHg. There is decreased air entry in the right hemithorax. A chest X-ray is requested to assess for a possible pneumothorax.
This X-ray demonstrates hazy opacification in the right hemithorax. The presence of normal bronchovascular markings indicates the abnormality is outside the lung parenchyma. Given the supine projection, these findings are in keeping with fluid layering dependently in the posterior pleural space (i.e. a moderate right-sided pleural effusion). The opacification is most marked in the mid/lower zones as this is the most dependent part of the posterior pleural space in the supine position.
In the context of trauma this effusion is likely to represent a haemothorax. There should be a high suspicion for underlying rib fractures even though none are visible on the X-ray. There is no evidence of pneumothorax, although this can be difficult to identify on a supine X-ray.
The patient needs to be assessed and resuscitated using the ATLS algorithm. Cardiothoracic surgery should be involved and a right sided chest drain will be required.
Imaging with contrast-enhanced CT will provide more accurate assessment of the thorax. Other parts of the body (head, cervical spine, abdomen or pelvis) can also be imaged with CT depending on the clinical assessment.
A 16 year old female presents to her GP with a chest wall deformity. There is no significant past medical history. She is a non- smoker. On examination, she has saturations of 100% in air and is afebrile. Her RR is 17 with a HR of 70 bpm. Lungs are resonant throughout, with good bilateral air entry. A chest X-ray is requested to assess for any bony abnormalities.
This X-ray demonstrates an indistinct right heart border with adjacent opacification. This may represent right middle lobe consolidation or collapse. However in combination with the abnormal rib orientation and clinical history of chest wall deformity, the appearances are consistent with pectus excavatum.
Further management will depend on the effects of the chest wall deformity. No further assessment or treatment may
be required. Pulmonary function tests and an ECHO can be performed to assess any pulmonary and/or cardiovascular compromise. The patient should be referred to cardiothoracics if surgery is contemplated. A CT of the chest may be required to assess the underlying anatomy pre-surgery.
A 40 year old male presents to ED with recurrent episodes of haemoptysis. He is an ex-intravenous drug user and has a 20 pack year smoking history. On examination, he has saturations of 90% in air and is afebrile. His RR is 20 with a HR of 80 bpm. There are crackles and wheeze in the upper zones of both lungs. A chest X-ray is requested to assess for possible pneumonia, tuberculosis, malignancy or COPD.
This X-ray demonstrates bilateral upper zone fibrosis with large apical cavities. There are also bilateral apical soft tissues masses with air-crescent signs, in keeping with mycetomas.
The differential diagnosis for upper lobe fibrosis includes
old TB, pneumoconiosis, ankylosing spondylitis, previous radiotherapy and sarcoidosis. Given the patient’s background and the large cavities, TB is the most likely cause.
Supplementary oxygen should be given. Initial blood tests may include FBC, U/Es, and CRP. Sputum cultures should be obtained. An arterial blood gas may also be helpful.
Appropriate antibiotic/antifungal therapy should be considered following discussion with respiratory and microbiology, bearing in mind that old TB does not require active treatment.
Comparison with previous imaging would be useful to assess for progression of changes. A high resolution CT (HRCT) of the chest would provide more detailed assessment if required. Input from the respiratory team would be helpful to guide further management.
A 68 year old female presents to her GP with unintentional weight loss. She has a 50 pack year smoking history. On examination, she has saturations of 100% in air and is afebrile. Lungs are resonant throughout with good bilateral air entry. There is a left-sided Horner’s syndrome. A chest X-ray is requested to assess for possible malignancy.
The X-ray demonstrates a left apical mass, which is likely accounting for the Horner’s syndrome. There is evidence
of mediastinal lymph node enlargement (widened right paratracheal stripe, dense left hilum and right retrocardiac mass). The interstitial opacification in the left lung probably represents malignant spread via the lymphatics (lymphangitis carcinomatosis).
Initial blood tests may include FBC, U/Es, LFTs and bone profile.
A staging CT chest and abdomen with IV contrast should be performed.
The patient should be referred to respiratory/oncology services for further management, which may include biopsy and MDT discussion. Treatment, which may include surgery, radiotherapy, chemotherapy, or palliative treatment, will depend on the outcome of the MDT discussion, investigations, and the patient’s wishes.
