1. HOW READ CHEST XR -8
ANAS SAHLE ,MD

2. Brief review

3. POSITION
PA AP
QUALITY
ROTATION PENETRATION INSPIRATION
LESION
OPACI
OPACITY
Homo
Heterogenous Wellill defined Zone
Centralperiph Silhouet
eral sign
TY Necrotic
PATCHY
MEDIASTINAL
NODULE Central deviasionwided
MASS COSTO-PHRENIC ANGEL
Freeoblitern
CAVITARY
OTHER
INFILTIRATION Bone soft tissuediaphragm

4. Consolidation
Infection
causes Non-infection causes
Broncho-
WEGNER Cardiac
Pneumonia Lymphoma alveolar COP Sarcoid
disease failure
carcinoma

5. Solitary Pulmonary Nodule(SPN)
• Is
• Single.
• Discrete.
• intrapulmonary density.
• < 3cm in diameter.
• completely surrounded by aerated lung.
• DDX:
• Bronchogenic ca.
• Solitary metastasis.
• Granuloma (infectioninflamation).
• Benign lung tumor(hamartoma).
• Round pneumonia.
• Round atelectasis.
• AVM.

6. Solitary Pulmonary Nodule(SPN)
Appearance
Margin Calcification cavitation
Comparison with a
Size
previous x-ray to >8mm
<8mm
Assess growth over
time. Location
Upperhillar zone Lowerbasesup-pleural
Associated abnormalities
Lymph node enlargement Rib destruction/erosion

7. Nodule Mass
Nodule Mass
• Well defined opacity it s • Well defined opacity more
diameter up to 3cm. than 3cm.
• The most common is: • The most common is:
– Tuberculoma – Bronchgenic CA
– Hamartoma – Hydatid cyst
– Bronchogenic CA – metastases
– Hydatid cyst
– Metastases
– AVM

33. Cavitary lesion
Air-fluid level Air only
Wall thickness
Straight Wavy Thick Thin
site
ruptured
Irregular inner Regular inner
Abscess Hydatid wall wall
Peripheral Central
cyst
Cavitating Chronic Emphesematous
pneumatocele
neoplasm abscess bulla

34. Case-1
• A 40-year-old man with a history of substance abuse and HIV
infection is seen in the ER with complaints of:
• fever,
• weight loss,
• production of foul-smelling sputum,
• and shortness of breath for 2 wk.
• On physical exam he is :
• tachypneic
• has clubbing of his digits.
• Lung exam reveals:
• diffuse rhonchi
• and an area of egophony with whispering pectoriloquy in the
right chest posteriorly.
• ABGs reveal PaO2 of 59 mm Hg on room air.

35. CASE-1
What is the most likely
diagnosis?
a. Pneumococcal
pneumonia
b. PCP pneumonia
c. Lung abscess
d. Squamous cell
carcinoma

36. POSITION •PA CXR
QUALITY •Good Technical Quality
•Round opacitiy with air-fluid level
•In right upper zone near hilum
LESION •Ill-defined linear opacity surrond it
•Central trachea and mediasteinal.
MEDIASTINAL
ANGELS •Free costo-phrenic angels.
OTHER •No

37. Case-2
• A 60-year-old man with a history of COPD and old TB is seen with
• mild hemoptysis and chronic cough.
• He is HIV negative and has been ill for about 2 wk.
• Vital signs: pulse 110 bpm; temperature 101°F; respirations
24/min; blood pressure 108/70 mm Hg.
• No skin lesions are noted.
• Laboratory data: Hb 14 g/dL; HCA 42%; WBCs 8.7/μL; BUN 24
mg/dL; creatinine 0.8 mg/dL; sodium 131 mEq/L; potassium 4.3
mEq/L.
• ABGs on RA: pH 7.37; PCO2 43 mm Hg; PO2 87 mm Hg.
• Sputum tests reveal numerous AFB-positive organisms on smear.
• Spirometry shows an obstructive ventilatory impairment with
marginal reversibility.

38. Case-2

39. POSITION •PA CXR
QUALITY •Poor Technical Quality
•Cavitary lesion
•In right upper zone
LESION
•Central trachea and mediasteinal.
MEDIASTINALHilum
•Right hilum pulled upward
ANGELS •Disappear .
•No
OTHER

40. Case-2
• the most likely diagnosis is
– a. Lung abscess
– b. Non-TB mycobacteria
– c. Actinomycosis
– d. Aspiration pneumonia

41. Case-3
• A 60-year-old man with a past history of
smoking for 30 years (he stopped 3 years ago,
prior to cardiac bypass surgery).
• is admitted with cough and mild hemoptysis.
• He is afebrile with no shortness on breath.
• Physical exam is negative except that the lung
exam reveals rhonchi in the left upper lung
zone.

42. Case-3

43. POSITION •PA CXR
QUALITY •Poor Technical Quality
•Well defined round density
•(mass lesion)
LESION •7*11cm.
•In left para-hilar area.
•Obscured aortic
•Right deviated trachea.
MEDIASTINALHilum
ANGELS •Disappear .
•No
OTHER

44. Case-3
• The finding/abnormality most likely to occur
with the lesion seen on the CXR:
• Serum calcium of 13.6 mg/dL.
• b. Sputum positive for fungal elements
• c. Increased D-dimer levels.
• d. Koilonychia.

45. Case-4
• A 38-year-old city worker presents with fever,
chills, and cough with left-sided chest pain 2
days after the Mardi Gras festival.
• She denies any hemoptysis, weight loss, or
chronic illness.
• Past history is unremarkable.
• On physical exam, she has a BMI of 32;
temperature is 101°F.
• She was observed to have splinting of her
right side during the inspiration.

46. Case-4

47. POSITION •PA CXR
QUALITY •Poor Technical Quality
•Well defined round density
•(mass lesion)
LESION •3*2,5 cm.
•In right middle zone.
•Cardiomegaly .
MEDIASTINALHilum
ANGELS •Hazy .
•No
OTHER

48. Case-4
• 1.The most likely diagnosis is:
• a. Bronchogenic carcinoma
• b. Round pneumonia
• c. Alveolar sarcoidosis
• d. Fungus ball
• 2. Associated findings may include:
• a. Hyponatremia
• b. Increased ACE levels
• c. Hypercalcemia
• d. Clubbing

49. Case-5
• A 62-year-old female smoker presents with a
history of “pneumonia” 6 wk ago.
• She has been on multiple antibiotics, and
although she feels relatively better now,
• her CXR remains unchanged.

50. Case-5

51. POSITION •PA CXR
QUALITY •Poor Technical Quality
•Ill defined mass-like density
•Behined heart shadow
LESION •7*4 cm.
•Silhoutte descending aorta.
•Central tracheamediastinum .
MEDIASTINALHilum
ANGELS •Hazy .
•No
OTHER

52. Case-5
• The next step in the management of this
patient will include:
• a. Change of antibiotics
• b. Sputum for TB
• c. Flexible bronchoscopy.
• d. Open lung biopsy