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2/14/2019
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Jong H. Yun, MD
Department of Radiology
Kaiser Permanente San Diego
CXR Interpretation Review anatomy of the chest.
Evaluate how anatomy determines the appearance of pathology.
Review common and interesting abnormalities of the chest.
Wilhelm RÖntgen German physicist
Discovered X-rays in 1895
First Nobel Prize in physics in 1901
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Wilhelm RÖntgen First medical X-ray image:
wife’s hand
Early Chest Radiographs
Radiographics 1991; 11 : 325-332
Early X-ray tubes weak
Several minutes for exposure
Heart and lungs blurred due to motion
Chest Fluoroscopy Cryptoscope –
fluorescent screen
Radiation source posterior to the patient.
Operator looked at chest through a cryptoscope.
Radiographics 1991; 11 : 325-332
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CXR Anatomy – PA viewHeart borders
Aorta
Pulmonary trunk
Aorto-pulmonary window
SVC
Fissures
CXR Anatomy – lateral view
Heart borders
Spine
Posterior costophrenic angles
CXR Anatomy – PA view
courses.lumenlearning.com
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CXR Anatomy – lateral view
CXR Anatomy – lateral view
Which lobes are next to the heart?
Which lobes are next to the diaphragms?
PA vs AP (portable) CXR
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Blind spots on CXR
Keep an eye on the “I”
Basic lines and tubes
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en.wikipedia.org
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PICC tip in azygous vein
S/P PICC placement. Line will not flush.
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PICC looped in left brachiocephalic vein
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en.wikipedia.org
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Status post central line placement
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Endotracheal tube
ICU CXR
ICU CXR
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Pt status post bronchoscopy
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Right pneumothorax
ICU patient
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Large left PTX in intubated patient
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Pt with left-sided chest pain
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Left pneumothorax. Subtle shift of trachea, concerning for early tension pneumothorax.
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clinicalgate.com
One-way valve
54 yo M ICU patient
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Tension pneumothoraxEmergent finding
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87 yo male with SOB
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Hydropneumothorax
SOB
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Skin fold
Skin Fold
Pneumonia
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CXR Anatomy
Silhouette sign Described by Dr. Ben Felson
Actually “loss” of silhouette
Outline of a structure in a radiograph is caused by difference in densities between the two structures.
Helps determine if there is a lung abnormality and where it is located.
Silhouette sign Described by Dr. Ben Felson
Actually “loss” of silhouette
Outline of a structure in a radiograph is caused by difference in densities between the two structures.
Air Soft tissue
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Silhouette sign Described by Dr. Ben Felson
Actually “loss” of silhouette sign
Outline of a structure in radiographs is caused by difference in densities between the two structures.
Air Soft tissue Soft tissue
Soft tissue
Fever and cough
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Pores of Kohn Small holes between
alveoli
Allows air, fluid, and bacteria to move between alveoli
Flow stops at the pleura
vet.uga.edu
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Right middle lobe pneumonia
Prior study
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Right middle lobe pneumonia
Prior study
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Right middle lobe pneumonia
27 yo F with cough and fever
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Lingular pneumonia
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44 yo female with fever
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Lingular pneumonia
81 yo male with SOB
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Left upper lobe consolidation and/or atelectasis
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Another Patient
2018 2009Same Patient
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Fat pad mimicking lingular PNA
36 yo F with fever, cough
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Right lower lobe pneumonia
11 yo SOB
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Right lower lobe pneumonia
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41 yo F with fever and cough
Prior Study
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Right lower lobe pneumonia
54 F with cough, fever
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Right upper lobe pneumonia
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18 yo M with cough
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Left lower lobe pneumonia
55 yo with cough and fever
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Left lower lobe pneumonia(obscured on PA view)
30 yo F with asthma
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Artifact caused by overlying soft tissue density
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Patient with chest pain
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Pectus excavatum simulating right middle lobe pneumonia
79 you female, cough for 3 weeks
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Tuberculosis
66 yo male with weight loss
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Tuberculosis
86 M with cough, known PNA
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Prior study
DDX: AbscessCavitary neoplasm
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21 yo M with congenital abnormality
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Infected sequestration
Patient with SOB
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Congestive Heart Failure
Post treatment
Batwing Sign
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Pt with abdominal pain
Lymphoma
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Pt with abdominal pain
Lung cancer
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46 yo F with chest pain
Another Patient
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Lymphadenopathy (Sarcoidosis)
80 yo F with history of lung cancer
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Prior Study
Lymphadenopathy (lung cancer)
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64 yo M with chronic cough
Eye on the “I”
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Abnormal density in right lung apex
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79 yo male with recent abdominal surgery
Prior study
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Intra-abdominal free air from recent surgery
52 yo F with axillary mass
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Lymphoma
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69 yo M
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Aortic aneurysm
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75 yo male with cough
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Pericardial calcification
58 yo male with positive PPD
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Findings c/w known history of ankylosing spondylitis
88 yo F, no history provided
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1 week later
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Right shoulder dislocation
48 M with chest pain
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Left shoulder dislocation
70 yo F status post pacemaker placement
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Left pneumothorax
62 yo M with dry cough for 1 year
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Tuberculosis
Post treatment
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89 yo M with history of TB
83 yo M with SOB
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82 yo F with SOB
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Tuberculosis patients treated with collapse lung therapy Goal is to deprive the tuberculosis from the oxygen
needed to survive
84 yo M with cough with occasional blood
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Lung cancer
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Known history of situs inversus
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Thank you
