1. TCM2 Radiology Pre Exam Review Semester One Chest x-ray Pathology
Jennifer Lim-Dunham, MD
Department of Radiology
December 3, 2018
LOYOLA
UNIVERSITY
MEDICAL CENTER
Loyola University Chicago
LOYOLA
UNIVERSITY
MEDICAL CENTER
Loyola University Chicago

2. Exam Thursday December 13, 2018 Pass Fail 30 questions multiple choice Review this powerpoint Review the 15 pdfs (identical to material on LUMEN under Radiology/ PCM)

3. Three question types

4. The chest x-ray is diagnostic for which one of the following?
Question type 1
Given a radiology image and asked to choose which diagnosis matches the image
The chest x-ray is diagnostic for which one of the following?
1. Right lower lobe mass
2.Consolidation of the right lower lobe
3. Right lower lobe atelectasis
4. Right pleural effusion
5. Diaphragm pushed up by enlarged liver

5. Select which history best matches the CXR.
Question type 2
Given a radiology image and asked to choose which patient history matches the image
Select which history best matches the CXR.
A. 52 y/o male presents with sudden onset of sharp chest pain and severe shortness of breath.
B. 46 y/o female presents with sharp chest pain, fever and chills of two days duration.
C. 48 y/o male . He is asymptomatic. CXR is taken for an insurance application.
D. 56 y/o smoker presents with 10 lb weight loss and cough with blood tinged sputum.

6. Question type 3 . Knowledge questions about general anatomy, pathophysiology or radiology principles
Emphysema can be distinguished from chronic bronchitis by the presence of:
A. Flat diaphragm
B. Vertical heart
C. Blebs
D. Increased retrosternal air
E. Increased A-P diameter

7. Next semester:
PCM2 Hands on Radiology Workshop: Reading a CXR
Small group sessions in February 2019
Use what you have learned this semester from CXR weekly lessons, this exam, and my PCM2 lectures “Systematic Approach to CXR Pathology”
TCM2 Radiology Exam on Neurology and Abdominal imaging pathology in April 2019 (Pass fail, preceded by review session)
More information to follow later

8. CXR image characteristics and patient positioning

9. Is this a PA or AP film?

10. Quality characteristics
PA vs. AP (upright vs supine)

11. Scapula projecting overlapping lung fields
AP Anterior posterior
Scapula 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)
Heart bigger
PA Posterior Anterior
Scapula does not overlap lung fields
Clavicles projecting over upper chest
Air fluid levels in abdomen or chest
Penetration/exposure normal

12. Is this film centered?
Yes No

13. Not centered. Patient rotated to his right
Draw a line along the central spinous process
Draw a line along the medial end of clavicles
Distance between medial end of right clavicle and midline longer than on left
Right ribs longer than left

14. Appropriate. Can see vessels in lungs and can see spine behind heart
Overpenetrated. Overexposed. Too dark. Lungs look completely black. Too many xrays reaching xray plate.
Appropriate. Can see vessels in lungs and can see spine behind heart
Underpenetrated. Underexposed. Lungs and heart too white. Cannot see spine behind heart. Too few xrays reaching xray plate.

15. Proper inspiration: right diaphragm should be between 9th and 10th posterior ribs
How to count ribs

16. CXR anatomy

17. Arrow: AP aortico pulmonary window (concave space between aortic knob and main pulmonary artery)

18. Transverse (horizontal or minor) fissure on the right
Scapula

19. Lung pathology

20. Types of focal lung abnormalities
Consolidation
Mass
Cavity

21. Consolidation Triangular density RUL of lung
Air bronchogram (arrows) are hallmark of alveolar/ airspace disease or consolidation
Bronchi become visible because of density contrast between normal air in bronchi and abnormal fluid in surrounding alveoli
Consolidation may be secondary to pneumonia (no volume loss) or atelectasis (volume loss, elevation right minor fissure, as shown here)

22. Radiographic Signs Silhouette Sign
Loss of silhouette (outline, shadow) is abnormal and indicates that there is airless, consolidated lung adjacent to that structure.
Left heart border obscured = lingula consolidation
Know which heart borders are obscured with consolidation in which lobes of the lung.
(“Consolidation”)

23. Silhouette Sign
Right heart border obscured= right middle lobe consolidation (arrows)

24. Atelectasis = Collapse of all or part of lung
Left upper lobe lobe atelectasis
There is density in left upper lung
Left upper mediastinal border obscured (silhouette sign)
Forward shift of oblique/major fissure on lateral CXR (arrows) indicates loss of LUL lung volume. Therefore atelectasis rather than pneumonia.
Clinical history will also help distinguish atelectasis (hypoxia, no fever) from pneumonia (fever and cough)

25. Normal positions major and minor fissures.
Fissures are not normally seen unless outlined by abnormal lung.
Sharply demarcated, straight borders

26. Resorptive Atelectasis
Triangular density
Loss of lung volume. Minor/horizontal fissure is elevated (arrows).
Right upper lobe (Silhouette sign, right upper mediastinal border obscured)
Types of atelectasis: resorptive (endobronchial obstruction); adhesive (loss of surfactant); relaxation (loss of negative pressure in pleural space).
Know which fissures become elevated in atelectasis
(“Atelectasis”)

27. Right lower lobe lung Resorptive atelectasis.
Right lower lobe lung density but right heart margin still visible, therefore right lower lobe and not middle lobe.
Atelectasis because major or oblique fissure is pulled down.
Resorptive because most likely due to endobronchial obstruction

28. Adhesive atelectasis
Diffuse bilateral confluent lung opacities are consistent with ARDS in this patient with tracheostomy tube.
Lungs become atelectatic due to diffuse loss of surfactant = adhesive atelectasis.

29. Complete collapse (resorptive atelectasis) of left lung
white-out of left hemithorax with signs of lung volume loss on left (mediastinal shift to left, crowding of left ribs) indicating that it is due to atelectasis
Usually due to obstruction of bronchus from mucus plug or, in a child, foreign body
DDx for this appearance on CXR is left pleural effusion, but there would be signs of increased rather than decreased volume in left hemithorax

30. Types of solitary round lesions in lung
Solitary pulmonary nodule in right lower lobe of lung
Distinct, sharply demarcated borders
Lung masses: Larger than 3 cm
Solitary lung nodules: 1-3 cm
Lung nodules < 1 cm
This lesion could be cancer or benign tumor

31. What kind of lesion is this?
Mass
Consolidation
Congestion
Cavity
Diffuse interstitial disease

32. Cavity
Arrow points to dense mass with central lucency (black area), indicating air in the center
Cavity signifies lung abscess or necrotic (dead tissue) tumor
If in lung apex, also consider TB.

33. Cavitary lung mass with air fluid level (flat line with air on top and fluid on bottom because of gravity). Ddx lung abscess vs. lung tumor
Necrotic lung tumor. Months long history of weight loss, hempotysis.
Lung abscess. Weeks long history of pneumonia, fever, cough.

34. Alveolar vs. interstitial lung disease. Your choice?
Diffuse alveolar disease (confluent density over broad area)
Diffuse interstitial disease (Lines)

35. Acute Diffuse Alveolar Disease secondary to pulmonary edema or ARDS
Soft fluffy densities over broad area Butterfly distribution (central, near hila, bilaterally symmetric)
Air bronchogram

36. Acute diffuse alveolar disease can be due to many causes. Your choice?
Pulmonary edema
Pulmonary hemorrhage
Influenza
Adult respiratory distress syndrome

37. Pulmonary Edema from Congestive Heart Failure
Diffuse bilateral soft fluffy densities
“Batwing” or “Butterfly” distribution
Air bronchogram (arrowheads)
Cardiomegaly supports pulmonary edema rather than ARDS or hemorrhage
Influenza is interstitial, not airspace, disease

38. Congestive Heart Failure Vascular Phase
First phase: Cephalization of pulmonary blood flow (more to upper lobes than normal)

39. Congestive Heart Failure Interstitial Phase
Second phase. Kerley B lines (Interstitial, short straight lines that extend to pleural surface)

40. Congestive Heart Failure Alveolar Phase
Third phase
Basal and bilateral “batwing” densities close to hila
Pleural effusions
Cardiomegaly

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

42. Diffuse Interstitial Disease Miliary Tuberculosis
Reticulonodular (lines and dots)
Ground glass / hazy density
Miliary nodules < 5mm

43. 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

44. Pathology of pleura

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

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

47. Unilateral White Out Left lung collapse/ateletasis
Mediastinal shift to left, ipsilateral side
Left hemithorax volume smaller than right
Left pleural effusion
Mediastinal shift to right, contralateral side
Left hemithorax volume larger than right

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

49. Left Pneumothorax Air in pleural cavity
Loss of normal lung vascular markings in periphery of chest
Visible pleural/lung interface
Relaxation atelectasis
Mediastinal shift to contralateral side
Enlarged hemithorax

50. Mediastinum and tubes and lines

51. Anterior Mediastinal Widening Abnormal soft tissue in paratracheal and supracardiac areas
Mediastinal nodes
Mediastinal mass
Aortic aneurysms
Normal comparision

52. 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 or feeding tube
(“Tubes and lines”)

53. ETT tube A: ET tube, B: NG (enteric) tube, C: Central line
ETT tip should be between carina and suprasternal notch (T1 vertebral body level)

54. Feeding tube positioning
Correctly positioned tube with tip at junction fourth duodenum and jejunum. Duodenum is C shaped.
Improperly positioned tip in right lung