Abnormal Chest X-Rays

Question 1

What is increased translucency a sign of?

Answer 1

• air (gas)

- loss of tissue density

Question 2

What is increased opacification a sign of?

Answer 2

• fluid

- increased tissue eg. lymphadenopathy

Question 3

What is really white a sign of?

Answer 3

• hardware
• pacemaker (just underneath left clavicle)
• ETT (just under trachea)
• NG tube
• sternal wiring
• prosthetic heart valves
• CVP line
• chest drain

Question 4

What would you use an X-ray to check with an NG tube?

Answer 4

• that it isn’t too close to the carina (and therefore would need withdrawn)
• would be in danger of entering right main bronchus

Question 5

What would shift the trachea from the midline?

Answer 5

Pushed away from pathology:

• too black: pneumothorax (look for visceral pleural line)
• too white: pleural effusion

Pulled towards pathology:
- too white: atelectasis (lobar collapse)/fibrosis

Question 6

What would you expect to find on clinical examination of a patient with a pneumothorax?

Answer 6

• inspection: can be cyanosed and will have a high resp rate
• palpation: will have decreased expansion on side of pneumothorax and may have deviation of the apex
• percussion: hyper resonant sounds on side of pneumothorax
• auscultation: decreased or absent breath sounds over area of pneumothorax

Question 7

How would you describe lung consolidation on an X-ray?

Answer 7

• wedge shaped area of opacification
• whether it blurs the heart shadow or not
• where it narrows
• what zone and lobe it is at

Question 8

What is consolidation and the causes of it?

Answer 8

• replacement of normal air space gas with fluid or solid material

5 causes:

• pus (infection- pneumonia)
• blood (haemorrhage)
• fluid (oedema)
• cells (cancer)
• protein (alveolar proteinosis)

Question 9

What are the clinical signs of consolidation?

Answer 9

• percussion: dull
• increased vocal resonance
• auscultation: bronchial breath sounds

Question 10

What does consolidation look like on an air bronchogram?

Answer 10

tree in winter with snow on the branches

Question 11

What is the normal level of the horizontal fissure?

Answer 11

anterior 4th rib

Question 12

What is atelectasis (lobar collapse)

Answer 12

reduction in inflation of all or part of the lung

Question 13

What signs on an X-ray would raise suspicion of atelectasis?

Answer 13

• volume loss
• displacement of trachea
• displacement of diaphragm
• displacement of lung fissures
• compensatory over inflation of non-collapsed lung
• crowding of vessels and bronchi

Question 14

What would left upper lobe atelectasis look like?

Answer 14

• veil like opacification of left lung field (compare with right)
• elevated hemi-diaphragm
• loss of cardio-mediastinal contour

Question 15

What would covid look like on an X-ray?

Answer 15

• patchy opacification
• bilateral
• distribution to the base and periphery of the lungs

Question 16

What does pleural effusion look like on an X-ray?

Answer 16

• area uniformly white

- concave upper border (meniscus)

Question 17

How would you go about determining what type of fluid is present in effusion?

Answer 17

• review patient history and clinical examination
• is it visible on both lung fields? (systemic?)
• or is it large and unilateral? (cancer?)
• sample the effusion (use ultrasound) then determine if:
• exudate: high protein, malignancy, infection, rheumatoid
• transudate: low protein, CCF

Question 18

What does asbestos exposure look like on an X-ray?

Answer 18

• pleural plaques
• calcified
• covers pleural wall and diaphragm
• can cause mesothelioma

Question 19

What are the ABDCE signs of heart failure on a chest X-ray?

Answer 19

• A: alveolar oedema, bat winged shadowing from heart, opacification
• B: Kerley B lines, oedema in interstitium, lines coming out perpendicular from thoracic wall
• C: cardiomegaly, englarged heart
• D: upper lobe deviation, vessels going to top of lung gets fattier
• E: pleural effusion, blunting of costophrenic angles

Question 20

How would you differentiate a pacemaker from an implantable defibrillator?

Answer 20

an implantable defibrillator has thickened bits of wiring

Question 21

What is gas in the diaphragm a sign of?

Answer 21

surgery or perforation of abdominal viscus

Question 22

What is translucency of soft tissue a sign of?

Answer 22

surgical emphysema

Question 23

What are the hidden areas?

Answer 23

• neck
• apices
• mediastinum
• behind the heart
• costophrenic angles
• behind/below diaphragm
• soft tissues
• bones

Question 24

What is bilateral/unilateral hilar lymphadenopathy a sign of?

Answer 24

bilateral:

• hodgkins lymphoma
• sarcoid

unilateral/asymmetrical:

• TB
• metastatic spread