1. Clinical Cases

2. 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

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

5. Pulmonary Oedema Perihilar haze Kerley B Lines Alveolar Oedema
Enlarged Heart

6. Kerley B Lines in detail

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

9. 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?

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

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

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

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

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

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

19. Pneumoperitoneum
Free gas under diaphragm
= perforated viscus

20. Other examples of Pneumoperitoneum

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

23. Mediastinal Lymph node enlargement
Probable Lymphoma

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

26. Bilateral Hilar Lymph node enlargement
Sarcoidosis

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

29. Multiple bilateral pulmonary masses
…multiple metastases
until proven otherwise

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

32. 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

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

35. 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

36. CASE 11 20 year old, sudden onset of extreme breathlessness

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

39. CASE 12 20 year old, sudden onset of extreme breathlessness

41. Normal!

42. 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?”