Abnormal Chest X-Rays

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• Please click on any of the images below to enlarge •




An Enlarged Heart

Left atrial enlargement

Follow the left mediastinal border down. The first 'hump' is the aortic knuckle. The second is the left hilum. An enlarged left atrium appears as a third 'hump' in the sequence. Also note the apparent double heart border caused by the enlarged left atrium.

Left atrial enlargement

Left ventricular enlargement

Increased CTR/CTD.

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Vascular Abnormalities

Coarctation of the aorta

The classical x-ray finding of this condition is the presence of rib-notching caused by the development of collateral vessels.

Right-sided aortic arch

The aortic knuckle is usually on the left, however in this image is deviated to the right side. Follow the heart borders to determine the path of the aorta.

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Lobar Collapse

Left lower lobe collapse

PA view
- 'sail' sign along left heart border

Left lower lobe collapse

Lateral view

Left upper lobe collapse

PA view
- 'veil' over left lung

Left upper lobe collapse

Lateral view

Right middle lobe collapse

PA view
- blurred or obscured and 'indistinct' right heart border

Right middle lobe collapse

Lateral view
- triangular 'wedge' seen

Right upper lobe collapse

PA view
- horizontal fissure raised

Right upper lobe collapse

Lateral view

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Pneumothorax

Simple pneumothorax

The affected side looks less vascular (ie. more black). Look carefully for the outline of the lung.

Tension pneumothorax

The affected side looks considerably less vascular, with the lung field enlarged (hyper-expanded) and the trachea deviated away from the affected side. In reality, this x-ray should not have been taken, as the diagnosis should have been made on clinical grounds and treated immediately! The emergency treatment of a tension pneumothorax involves inserting a large-bore venflon into the 2nd intercostal space, in the mid-clavicular line.

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Infections of the Lung

Lobar Pneumonia

A localised focus of consolidation can be seen. Look carefully for the presence of air-bronchograms (consolidation around bronchioles) to differentiate the consolidation of infection from fluid (eg. in pulmonary oedema).

Air Bronchogram

These can be difficult to spot. Air-bronchograms are essentially consolidation around bronchioles, and appear as small round black areas surrounded by white consolidation.

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Effusions

Pleural effusion

This classically features a fluid level (that is curved, ie. with a 'meniscus') and obliteration of the costophrenic angle on the affected side.

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Chronic Lung Disease

Emphysema

Markedly increased lung volume and flattened diaphragms.

Emphysema

Sarcoidosis

This condition features bilateral hilar lymphadenopathy, non-caseating granulomata and apical fibrosis. Causes of apical fibrosis:

-Extrinsic allergic alveolitis
-Sarcoid
-Coal workers pneumoconiosis
-Histiocytosis X
-Ankylosing spondilysys
-Tuberculosis

Fibrosis - basal

Causes of basal fibrosis:

-Rheumatoid arthritis
-Asbestosis
-Scleroderma
-Cryptogenic fibrosing alveolitis
-Other (drugs eg. bleomycin, nitrofurantoin, amiodarone)

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Malignancy

Lung cancer

Look carefully for small opacities that shouldn't be there.

Lung cancer

Bronchoaelveolar cell carcinoma.

Breast cancer

Note the presence of scoliosis, and the absence of the left breast shadow. If you look closely at the region of the missing left breast shadow, you may note the destruction and subsequent absence of a section of rib. Breast cancer can result in both lytic and sclerotic (blastic) bone lesions. Contrast this with the more sclerotic bone lesions seen with prostate cancer, and the more lytic lesions seen with lung cancers.

Non-Hodgkin's Lymphoma

Note the enlarged mediastinal nodes.

Bone lesion

Rib destruction as a result of bony metastasis.

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Other

Dextrocardia

Always check the 'L' and 'R' labels of the film! Associated with situs inversus (abdominal viscera the 'wrong way round' - note the right-sided gastric bubble), and Kartagener's syndrome (defective dynein protein leading to ciliary dysmotility and recurrent infections with bronchiectasis).

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Breast implants

Bilateral prosthetic implants.

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Acknowledgement: revise4finals would like to thank Dr Niall Moore (John Radcliffe Hospital, Oxford) for providing images and explanations used in this section.



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