1. Practical Problem-basedCHEST RADIOLOGY:Conventional Film Ronald E. Pust, MD Dept. of Family & Community Medicine College of Medicine University of Arizona Copyright 2004 Ronald E. Pust all rights reserved 1

2. Objectives: Upon completion of this series, the participant should be able to: 1. Systematically “read” any chest roentgenogram, beginning with assessment of the film for radiographic quality. 2. Recognize normal and abnormal pulmonary anatomy on the chest film. 3. Delineate normal and abnormal cardiac anatomy on the chest film. 4. Discuss the chest film in terms of problem-solving: indications, sensitivity and specificity, cost-effectiveness in screening and other diagnostic situations. 5. Synthesize clinical case information with basic skills in chest film interpretation to arrive at a problem assessment or “differential diagnosis.”

3. Texts you may find useful on the basic chest film (old editions are as good as new editions): 1. Corne J, Carroll M, Brown, I, Delany, D. Chest X-ray Made Easy. London: Churchill Livingstone, 2000. 2nd edition. ($19.95 in AHSC Bookstore, pocket-sized, 127 pp.) (Excerpts are included in this manual.) 2. Felson B. Chest roentgenology. Philadelphia: W.B. Saunders Co., 1973. 3. Felson B. Principles of chest roentgenology, a programmed text. Philadelphia: W.B. Saunders Co., 1965. 2nd edition, 1999. 4. Forrest and Feigin. Essentials of Chest Radiology, W.B. Saunders Co., 1982. (Good basic text) 5. Lillington and Jamplis. A Diagnostic Approach to Chest Diseases: Differential Diagnoses Based on Roentgenographic Patterns. Baltimore: Williams and Wilkins Co., 3rd edition, 1987. 6. Mettler F. Essentials of Radiology, W.B. Saunders Co., 1996. 7. Squire, LF. Fundamentals of roentgenology (3rd ed.). (general principles). Cambridge: Harvard University Press, 1982 8. Squire, Colaice, and Strutynsky. Exercises in Diagnostic Radiology, Vol. 1: The Chest, 1972. (Paperback, problem oriented.) 9. Műller N,Fraser R, Colman N, Paré P.. Radiologic Diagnosis of Diseases of the Chest, W.B. Saunders Co., 2001.

4. Chest Radiology: Interpretation of Conventional Films Plunge in… I. Basics 4 Radiologic Densities Technique Normal film PA Left lateral Normal lung fields Normal heart & mediastinum II. Heart---Abnormal III. Lungs---Abnormal Lobar infiltrates Effusions Masses Cavities IV. Tuberculosis (Optional)

5. 28 yo male, Sharp trauma left lateral thorax, BP 104/60, p=120, r=24, t=normal Using whatever background you may have, describe this film . . .

6. Abnormalities: severe com- pression of the left lung (white → ) and “air musculogram” of L. pectoralis major (black →) caused by sub-q emphysema. What is the emergency “first aid” treatment?

7. Tension pneumothorax: physiology

8. Tension pneumothorax: “First-aid”

9. Classic Rx for tension (or any) pneumo-thorax is chest tube inserted over 3rd anterior rib in mid-clavicular line But, what appears in right chest 1-day post chest tube?

10. Partial right pneumothorax (non-tension) Now to review some basics and some normal films . . .

11. Basics: Assessing the film before “reading” it • Use the previous 2 and the following 2 films to review: • The 4 radiologic (and physical) densities: • Air, fat, water (soft tissue), bone (calcium) • The 2 orientation directions: • Patient: Identify the left side, name and number. • Beam direction: Posterior-to-anterior (PA) vs AP • The 3 technical quality indicators (“built in”) • Inspiration: Posteriorly, 9 or more ribs visible • Rotation: Spinous process centered between • medial ends of clavicles • Penetration (correctly exposed?): Use the PA • heart shadow, which increases in density from • cephalad to caudad, as an “exposure indicator.” • The intervertebral spaces should be visible • through the top half of the heart shadow, • but invisible in the lower half.

12. The next 5 frames provide normal PA and lateral radiographic chest anatomy 35 yo asymptomatic male, taken for a visa application. With the aid of the next film, describe the anatomy . . .

13. 1. Trachea 2. R main bronchus 3. L main bronchus 4. L pulm artery 5. RUL pulm vein 6. R (desc) pulm artery 7. RLL and RML veins 8. Aortic arch 9. S. vena cava 10. Azygous vein

14. Left lateral view of same (asymptomatic) 35 yo man. The left lateral is the standard lateral, because it distorts the heart shadow the least. Review the anatomy with the aid of frame 16.

15. Because the textbook anatomy view in #16 (for some reason !?) shows the right lateral, this frame is a mirror image of the previous frame. This should aid in anatomical interpretation from the next frame - #16)

16. 1. Trachea • 2. R main bronchus • 3. LUL bronchus • 4. RUL bronchus • 5. L pulmonary artery • 6. R pulmonary artery • 7. Pulmonary vein • 8. Aortic arch • 9. Brachiocephalic vessels • Note: Vascular details are variable from film to film

17. Same pt. as #12 and #14, 20 years later, now 55 yo. Is this a good example of a normal PA for a 55 yo?

18. 55 yo with four recently fractured ribs (L 2, 3, 4, 5), otherwise it’s a good normal 48 yo Tucson female, with chronic dyspnea. Describe and interpret film . . .

19. Prior frame shows high clavicles, low diaphragms and the changes of bronchiectasis and emphysema. The symmetric small masses in lower lung fields are nipple shadows. 13 yo boy with chronic low-grade fever. Can the likely cause be diagnosed from this film?

20. Heart: Normal vs. Abnormal • Identifying the 4 chambers • PA view: right atrium & • left ventricle • Lateral view: left atrium & • right ventricle

21. 22 yo Sonoran woman Complaint: dyspnea upon exertion after 1/2 block, chronic. Describe the film. Concentrate on mediastinal/ heart shadows.

22. Left lateral of same patient, describe . . .

23. 46 yo Tucson male, admits to alcohol problem, complains of swelling of the legs over 6 weeks. BP 95/60, P 112, R 22, Temp normal, 4+ edema/anasarca. EKG normal, except for low voltage and rate of 112. Heart exam normal except S3 gallop with distant heart sounds, PMI @ AAL. Describe. . .

24. III. Lungs---Abnormal Lobar infiltrates Effusions Masses Cavities

25. 24 yo male. T=103, cough, rusty sputum. Describe the abnormal elements in radiological and anatomical terms. . .

26. Prior film: Classic RUL consolidation with air bronchogram. Classic film of pneumococcal pneumonia. Review lobar and segmental anatomy radiologically . . .

27. Acute pneumococcal pneumonia: What lobe/segment (s) are involved?

28. Prior film: Posterior segment RUL pneumonia, (w/some apical segment involvement). Anterior segment clear (bounded inferiorly by the visible normal/horizontal minor fissure.) Chronic cough, acute fever in 45 yo male. Describe the abnormality radiologically and locate it anatomically. Describe the heart shadow . . .

29. Lower Lobe Shadows: Complete lobe & 2 of the 5 segments

30. 13 yo boy with mild chronic cough for 2 months. Admitted with T=103°. Describe the abnormality radiologically and anatomically. . .

31. Middle lobe (and lingular) shadows: Complete vs. segmental

32. This R lateral is classic confirmation of “RML syndrome.” It shows both partial RML atelectasis and partial RML (mainly lateral segment) consolidation.

33. The diagnosis is given for this 55 yo man with acute temperature of 103°. Work backwards to describe the abnormalities of heart and lungs on the PA chest film. . .

34. 52 yo male with weight loss and shortness of breath, both mild and of gradual onset. Describe radiologically and anatomically . . .

35. Prior film shows classic meniscus sign of right pleural fluid 93 yo Tohono O’odham female rancher who fell on right chest. Now sharp chest wall pain, some shortness of breath. Vital signs normal. Describe this PA and the next lateral film . . .

36. Lateral of same 93 yo great-grandmother How would you prove that this is mobile fluid and not old, stable pleural changes?

37. R lateral decubitus of 93 yo woman, showing “free flow” and horizontal layering of fluid. 40

38. 2-1/2 yo boy in Papua New Guinea (PNG), T=100°, other vitals normal. Dull left chest percussion. Describe the two abnormalities . . .

39. Film 38 shows loculated L empyema, causing R mediastinal shift. This film is of PNG male, 30 yo, with fever, weight loss x 3 months. Describe . . .

40. Prior film shows: Rightward shift of heart and media- stinum, severe chronic left pleural thickening, and an air/fluid level without a meniscus. This is a chronic bacterial empyema with a left broncho- pleural fistula. The next film is of a Tohono O’odham non-smoking man of 55. Referred because of PPD of 18 mm. Denies symptoms. Exam normal except T = 100.4° What is the differential of this pleural-based infiltrate?

42. The wedge-shaped shadow could be : infectious, neoplastic, vascular (pulmonary infarct), or uncommonly another cause . Note the air in the transvere colon, overlying the liver. 68 yo male UMC patient. Where is the mass?

43. Film 42 – the apical mass appears to widen the mediastinum. It was a lung carcinoma in the apical segment of the R U L. 45 yo male in UMC. No chest symptoms. Describe . . .

44. Film 43: “coin lesion” overlies posterior 9th rib. Coin lesion differential is very broad. Dx: coccidioidomycosis Nodule (on biopsy) 73 yo female, St. E’s Clinic patient, smoker w/chronic cough. Describe 2 abnormalities: one is general/obvious and other is specific/small. Also use lateral (next frame) . . .

45. Lateral of same patient

46. 1. PA showed flat, low diaphragm to 11th rib 2. Lateral (and PA !) shows calcified azygous lymph node. This is the most subtle example in this series of chest “masses.”

47. 50 yo Navajo diabetic woman with cough, PPD = 22 mm Describe . . .

48. Film 47: one cavity, thin walled, over ribs 5, 6. Broad differential of cavities includes… ? 56 yo Hispanic man with 3 months of cough, 6 lb. weight loss, smoker. Describe . . . .

49. Film 48: Fibronodular infiltrate, RUL > LUL. Dx: Active TB , no cavity. Woman from PNG, 37. Where is the cavity? What is wrong in the right upper lobe? Is the mediastinum normal?