Clinical Cases

Clinical Cases For each case, there is first a slide with some history Think about a likely differential diagnosis, based on the clinical information The next slide features the CXR Look at it carefully, and think how you would describe it – either over the telephone to your Registrar, or a written report in the medical notes The next slide has an annotated explanation of the CXR findings with the diagnosis Think what the physical examination findings would be Think what additional investigations might be useful Try to decide what treatment would be appropriate

CASE 1 Elderly male, 2 previous myocardial infarctions, presents with crushing central chest pain radiating to jaw and left arm, and extreme breathlessness

Pulmonary Oedema Perihilar haze Kerley B Lines Alveolar Oedema Enlarged Heart

Kerley B Lines in detail

CASE 2 70 year old man. Left pneumonectomy three years ago for lung cancer. Admitted with haemoptysis, weight loss

Tracheal deviation White out Heart moved over here (mediastinal shift) …these are all features of the previous left pneumonectomy (which are identical to total left lung collapse). What however is the other abnormality?

Lung cancer recurrence Thick walled 8cm cavity Right mid/lower zone Lung cancer recurrence

CASE 3 40 year old man. 3 month history of increasing breathlessness CASE 3 40 year old man. 3 month history of increasing breathlessness. Reduced left chest expansion and stony dull percussion note.

Left Pleural Effusion Mediastinum pushed over to right White-out No diaphragm visible Left Pleural Effusion

CASE 4 30 year old, acute onset of breathlessness and pleuritic chest pain. Afebrile.

Right Pneumothorax Line parallel to chest wall No lung markings lateral to the line Don’t confuse with scapula/breast shadow

CASE 5 55 year old alcoholic with severe abdominal pain CASE 5 55 year old alcoholic with severe abdominal pain. Tender +++ epigastrium with guarding and rebound

Pneumoperitoneum Free gas under diaphragm = perforated viscus

Other examples of Pneumoperitoneum

CASE 6 74 year old female. 2 month history of progressive weight loss, malaise, drenching night sweats and itch. She has found a lump in her neck.

Mediastinal Lymph node enlargement Probable Lymphoma

CASE 7 26 year old female. 3 month history of malaise CASE 7 26 year old female. 3 month history of malaise. Shiny, painful rash on shins and red, dry eyes.

Bilateral Hilar Lymph node enlargement Sarcoidosis

CASE 8 65 year old. Admitted for elective surgery (inguinal hernia repair). No past history. Smoker. Recent weight loss and cough.

Multiple bilateral pulmonary masses …multiple metastases until proven otherwise

Involved in high speed road traffic incident. CASE 9 19 year old motorcyclist. Involved in high speed road traffic incident.

Multiple left posterior rib fractures (flail segment) Pulmonary contusion left lung (secondary to trauma) – compare left with right side Surgical emphysema left lateral chest wall

CASE 10 55 year old man. 6 month history of progressive breathlessness and a dry cough. No haemoptysis.

Loss of clear cardiac and mediastinal contours Fibrosing Alveolitis Loss of clear cardiac and mediastinal contours Generalised increased interstitial shadowing, particularly in mid/lower zones

CASE 11 20 year old, sudden onset of extreme breathlessness

Bilateral Pneumothoraces Red arrows denote lung edge. Note no lung markings lateral to this.

CASE 12 20 year old, sudden onset of extreme breathlessness

Normal!

Take Home Points Have a systematic approach to looking at a CXR Always interpret the CXR in conjunction with other clinical and investigative findings Always ask yourself “does my interpretation make sense?”