The right hilum Figures B and C are axial and coronal images through the mediastinum and hilum. Note large nodes N. This patient has lymphoma. The extrapleural space, a potential space, lies between the rib cage and the adherent parietal pleura. Each produces characteristic radiographic signs of disease, with the usual overlapping of signs. This is called the costophrenic sulcus or angle. The lateral costophrenic sulcus is also fairly deep.
The bullet, almost spent, just penetrated his chest wall and dropped harmlessly into the pleural space. In Figure B lateral film , the bullet is clearly in the costophrenic angle. In Figure C supine film , several days later, the bullet has shifted in the pleural space. In Figure A, the lateral costophrenic sulcus is normal.
Additional fluid tracks up the pleural space, forming a meniscus, as shown in Figure C. Figures A, B, and C are all the same patient. If there is a discrepancy between them, believe the lateral. Figure and Figure are of the same patient. Compare each set of PA and lateral examinations. The true diaphragm lies in normal position, but is obscured by a parallel layer of free fluid.
In the upright position, free fluid often collects between the lung base and the top of the diaphragm. In radiology, however, gravity can be a friend. What view would be most helpful in proving that Figure A has a subpulmonic effusion? The free fluid has redistributed to the dependent side of the left pleural cavity, between the lung and chest wall. Figure C, a CT scan, shows a gravitydependent pleural effusion layered posteriorly E.
On the left, the stomach bubble is normally separated from the lung base by only the thin diaphragm. Figure shows the normal distance between the stomach and the lung arrow.
In Figure , the apex of each diaphragm is in the mid clavicular line. What are the signs of pleural effusion on the right? There is also fluid in a major fissure arrow. How would you confirm suspicions on the PA image? The erect PA requires greater than mL; the erect lateral, 75 mL; the decubitus, greater than 5 mL; the supine, more than several hundred milliliters.
Now you know. Does the name Pavlov ring a bell? See Figure A, an example of loculated pleural fluid. There is a second smaller loculation as well. Compare this with the free effusion of Figure C. It may look like a lung mass.
Remember, the beam must be parallel to the fissure to see it. The two loculated collections in the major fissure B and C are completely sharp only in the lateral projection. On the frontal image, portions of the major fissure pseudotumors are indistinct. Figure B shows the pleural air against the edge of the consolidated upper lobe arrow. There are no lung markings in the air-filled pleural space.
There is also air in the subcutaneous tissues arrowhead. In Figure A, we see what two signs of pneumothorax? Note the subpulmonic air. Figure B shows air anterior to the lung on a CT scan of a supine patient. In Figure , we see the pleural line and air in the pleural space, signs of pneumothorax. The ribs on that side may be further apart. Learn the clinical signs so that you can diagnose and treat it without an x-ray.
Signs include rapid onset of respiratory failure, decreased breath sounds, deviated trachea, and jugular venous distention. There is fluid in the lower pleural space, air in the upper pleural space, and an air-fluid level. The air bubble in the stomach is elevated, indicating diaphragmatic elevation because the lung has been removed.
Lesions that arise in structures within or bordering the extrapleural space e. If none is visible, it may be difficult to separate the two. The convex margin facing the lung is sharp, and the borders are tapered obtuse angle with chest wall. The lesion looks similar to encapsulated fluid see Figure A. The rib fractures arrowheads in Figure indicate the extrapleural origin.
What are the three patterns seen with free pleural effusions seen on an erect film? II 1 peripheral hyperlucency intrapleural air 2 visceral pleural line or edge III Figures A and B are supine x-rays of a young woman who was in an auto accident.
Every beginner should be able to recognize the cardiovascular structures, cardiomegaly, and left heart failure. If you can, you will be ahead of most of your peers.
Two medical students spotted a bear while walking in the woods. Student 1 took out sneakers from his backpack and put them on. On the left side, there are four bulges moguls to you skiers.
They are: 1. The right ventricle does not form a lateral border on the frontal view. Label the cardiovascular structures on the lateral Figure B. Review the following: A. Measure the horizontal width of the heart and divide it by the widest internal diameter of the thorax.
The normal cardiothoracic ratio is less than 0. Oversimplified, but useful. For a given patient, an increase of greater than 1 cm in cardiac diameter from a prior film is a more reliable index of cardiac enlargement than the cardiothoracic ratio. In general, a radiologist with a ruler is a radiologist in trouble, but these measurements work fairly well on erect, inspiratory PA radiographs. The upper left heart border bulges laterally arrow on Figure A and posteriorly arrow on Figure B.
Compare with Figures A and B. On the lateral view, the left heart border moves inferoposteriorly. The aorta is so tortuous that even the aortic arch is visible. In the frontal projection, the normal right heart protrudes slightly to the right of the spine, and an enlarged heart protrudes further to the right soft science, at best. In the lateral projection, the right heart enlarges anteriorly and superiorly.
The normal right heart contacts the lower one third of the sternum, whereas the enlarged right heart contacts the lower one half. In a supine patient, what happens to blood flow? This is called cephalization or vascular redistribution. Cephalization, not heart size, is the key to diagnosing elevated left heart pressure.
Compare Figure A and Figure B until cephalization is absolutely clear. A shunt e. The patient in Figure B is in left heart failure. There is enlargement of the upper lobe vessels cephalization. This is mild left heart failure because the vessel margins remain distinct i. Which patient has prominent upper lobe vessels as a result of an atrial septal defect?
Figure A shows mild left heart failure. The upper and lower lobe vessels are equal, and there is no edema. Fluid thickens the interlobular septa, causing short lines perpendicular to the pleural surface. Figure C is a close-up of Kerley B lines arrows in a different patient. With alveolar edema, the pulmonary vessels may not be visible. In addition: A. Kerley also described A and C lines.
He was obviously a splitter, rather than a lumper. We will not worry about A and C lines. Figure is a CT scan of Kerley B lines arrows.
With interstitial edema, crackling rales are audible. With alveolar edema, rales are audible. Is there cephalization? Is there edema? Is there a pleural effusion? There are no significant signs of left heart failure. Figure , a CT scan of a different patient, shows a pericardial effusion P , bilateral pleural effusions, and left lower lobe consolidation atelectasis. Echocardiography, CT, and MRI accurately depict pericardial effusions, but echocardiology is most cost-effective.
Clinical Pearl: Marked generalized enlargement of the cardiac silhouette, with no or mild signs of left heart failure, is most likely due to pericardial effusion.
Cardiomyopathy and multivalvular heart disease may have a similar radiographic presentation. These should be evaluated on every x-ray before your standard search. You are done. There is no review quiz. Take a break! When you come back, challenge yourself to the dozen great quiz cases in the last section. The CD on the back cover is worth a look.
Principles are as important as facts. If you master the principles, you can make up the facts. You learn better when you know your goals. Follow your cases. Like sex, learning is better if you are actively involved. When you read, talk back to the author. Be skeptical. Reinforcement is essential for acquiring knowledge. See a case, look it up; read an article, find a case or ask a question. Reward is important for learning.
Show off what you know. Brag a little. Speak up in class. Different people learn best by different methods. Figure out your own best method and cater to it, whether it be reading, listening, observing, or doing, or a combination of these.
They are as rare as great students. Quick retrieval of once-acquired information is crucial. The home computer is ideal but other good retrieval methods are available. Create your own personal modification and keep improving it. Divide your study time into prime time, work time, and sleepy time.
Biorhythms vary widely among students, so develop your own study schedule. Felson, B. Read the history. Then, and only then, answer all questions before you turn to the answers on the next page. Many patients have several abnormalities that you can combine to arrive at a diagnosis. Metal nipple markers have been placed to distinguish nipples, which sometimes show on x-rays, from real pulmonary nodules. Is the lung abnormal?
Are there any changes to suggest pleural effusion? What type of surgery did the patient have? Diagnosis: Can you combine the history and x-ray findings to suggest a diagnosis?
Yes, below the right nipple marker, where the ribs cross, there is a pulmonary nodule. The costophrenic angles are sharp. The stomach bubble sign is absent. Diaphragms are normally shaped. The right shoulder has been amputated. A systematic approach helps avoid embarrassing misses. Diagnosis: Patient had a shoulder amputation, most likely for cancer.
The nodule is most likely a pulmonary metastasis. The amputation was for osteosarcoma. Aristotle to open her mouth. Describe the lesion in detail. Diagnosis: Put the x-ray findings and history together for a logical diagnosis. There is a mass or focal alveolar consolidation with a central cavity, air-fluid level.
Diagnosis: This is a lung abscess in an epileptic who probably aspirated during a seizure. Tuberculosis, another reasonable possibility, is usually more indolent. Aspiration most often involves the gravity-dependent portions of the lung in a supine patient posterior segments of the upper lobes and the superior and posterior basal segments of the lower lobes. Identical paper clips mark the entrance and exit wounds.
Describe the major radiologic findings of the left hemithorax. Are proximal air bronchograms visible? The police tell us that he was shot from the front. Is the entry wound midline or left-sided? Remember, they are identical paper clips. The left hemithorax is opaque laterally. The partially aerated lung is visible medially.
The air bronchogram on the left tells us that the major airways are open. There is no central endobronchial obstruction, and the surrounding lung is almost airless water density.
This is an AP supine film, so the anterior clip would be magnified. Because identical paper clips were used, the bullet must have entered the left chest magnified clip and exited in the midline. Diagnosis: Left hemothorax from gunshot wound. Relaxation atelectasis. Increased pressure in left hemithorax causing contralateral mediastinal shift. Fiction has to be believable.
Figure Q-4A was obtained shortly after admission. There is a drain in the right pleural space laterally. Describe the lung abnormalities. Several hours later, he became more short of breath. Figure Q-4B shows what additional finding? Bilateral dense consolidation, air bronchograms, silhouette signs of diaphragms, blunt right costophrenic angle. Diagnosis: Pneumonia.
Tension pneumothorax on right—air in pleural space, low right diaphragm, heart shifted to the left. Figure Q-5A is a baseline image obtained 10 months earlier. Figure Q-5B is the current image. Explain the discrepancy. Ten months later, there have been striking changes Figure Q-5B.
The left lung is more lucent. There has been a left mastectomy. The breast is missing, and there are clips in the axilla. There is less soft tissue on the left, so there is less absorption of radiation. The right costophrenic angle is blunt and there is a small meniscus. The right diaphragm also has changed shape subpulmonic effusion.
Diagnosis: Pericardial effusion and right pleural effusion caused by metastatic breast cancer. It causes a silhouette sign of what three cardiovascular structures? Is there an abnormality visible on the lateral film? Diagnosis: Formulate a differential diagnosis.
Density in retrosternal clear space, between sternum and trachea. This is a large anterior and middle mediastinal mass on the left. The lateral radiograph shows the mass predominantly in the anterior mediastinum. The silhouette sign indicates anterior mediastinum left atrium and middle mediastinum pulmonary artery, aortic knob. This mass is too low. Thoracic aortic aneurysm. The ascending thoracic aorta is on the right and looks normal i.
Terrible lymphoma. This is usually lobulated and bilateral. Thymoma and Teratoma are the best choices. Large masses commonly cross mediastinal boundaries. This was a thymoma. What forms the sharp lower edges of their lesions? The minor fissure is the sharp lower border. The upper lobe is consolidated, and the middle lobe is well aerated. There is no air bronchogram. Diagnosis: Patient A has a carcinoma obstructing the right upper lobe bronchus i.
Patient B has alveolar infiltrate or airspace consolidation with patent airways as a result of a community-acquired pneumonia. His file contains an x-ray done 6 months earlier, when he was asymptomatic Figure Q-8C. What has happened to the heart size in the 6-month interval? What has happened to the pulmonary vessels? How do the costophrenic angles compare? What accounts for the right mid lung densities? The heart is bigger. The pulmonary vessels are bigger and slightly less sharp as a result of interstitial edema.
There is fluid in the right costophrenic angle. Fluid trapped in the major and minor fissures pseudotumors. Figure Q-8B shows the markedly thickened fissures. Diagnosis: The patient is in left heart failure congestive heart failure. Figures Q-9A and Q-9B are admission x-rays. What is the diagnosis on admission? Two days later, the patient developed increasing dyspnea.
In Figure Q-9C, how have the lungs changed? Emphysema chronic obstructive pulmonary disease. Hyperinflated, sparse upper lobe markings. Left diaphragm silhouette sign, dense retrocardiac area, elevated left diaphragm compare position of stomach bubble. Diagnosis: Left lower lobe consolidation—most likely atelectasis. Pneumonia probably would take longer to develop.
It is in the right lower lobe. This indicates hyperinflation, probably chronic obstructive pulmonary disease 4. Diagnosis: What is his cardiac diagnosis most likely? Diagnosis: What explains his acute symptoms?
Diagnosis: mild left ventricular failure explains dyspnea for days. Diagnosis: Free air under the diaphragm from perforated ulcer explains sudden chest discomfort and fever. Trachemys scripta—terrapin turtle Dr. Timothy T. Klostermeier of Wilmington, Ohio, nursed the sick turtle back to health with daily subcutaneous shots of tetracycline for 2 weeks. Radiology ;; with permission.
Goodman, M. You are done! For those looking for more unknown cases, board review cases, and a few other goodies, there is a CD in the back cover. A Abdomen gas-containing structures of, 38f, 39, 40f, 41 on computed tomography, 62f, 63 search pattern for, 40f, 41 Abscess, pulmonary, f, Accessory fissures, 80f, 81, 82f, 83 Acini, 50f, 51, f, See also Alveoli Acute alveolar disease. See Alveolar filling disease Adenopathy hilar, f, , f, mediastinal, f, Adhesive atelectasis, Air in lung, 19, 20f, 21, 66f, 67, 86f, See also Air bronchogram sign pleural.
See Pneumothorax subcutaneous, f, subpulmonic, f, under diaphragm, 54f, 55 Air bronchogram sign, — absence of, f, , , f, definition of, , f, , in alveolar filling disease, f, , in left lower lobe collapse, f, in left lower lobe pneumonia, f, interpretation of, f, model analogue of, f, on computed tomography, f, through cardiac shadow, f, vs.
See also Silhouette sign Air trapping, expiratory film for, 14f, 15 Air-fluid level, f, after lung removal, f, in hydropneumothorax, f, in pneumonia, f, Alveolar edema, f, Alveolar filling disease, 50f, 51, 52f, 53, f, , f, acute, diffuse interstitial disease and, f, focal, f, lobar sites of.
See Consolidation multifocal, f, on computed tomography, 6f, 67, f, signs of, f, , , Alveoli, 50f, 51, 52f, 53, f, air in, 66f, 67, edema of, f, filling of, f, See also Alveolar filling disease Aneurysm, aortic arch, f, Anterior mediastinum, f, , See also Mediastinum mass of, f, Anteroposterior AP view, 2f, 3, 16f, 17 Aorta ascending in left heart enlargement, f, in mediastinal search, 45, 45f in right upper lobe consolidation, 96f, 97 on computed tomography, 58f, 59, 91, 91f, f, on lateral x-ray, 38f, 39, 90f, 91, f, , f, on normal x-ray, 36f, 37, f, descending in left heart enlargement, f, in left lower lobe consolidation, 95 in mediastinal search, 45, 45f mediastinal location of, f, , f on computed tomography, 58f, 59, 91, 91f, f, on lateral x-ray, 90f, 91, f, , f, on normal x-ray, f, post-traumatic pseudoaneurysm of, f, three-dimensional view of, 28f, 29 Aortic knob arch aneurysm of, f, in mediastinal search, 45, 45f on computed tomography, 26f, 27, 58f, 59, 90f, 91, f, on lateral x-ray, 38f, 39, f, , f, on normal x-ray, 36f, 37, 38f, 39 Apical lordotic position, 17 Artifacts, 4f, 5 Ascending aorta.
See Aorta, ascending Aspiration, of abscess, f, of pin, 84f, 85, 85f Atelectasis, , f, See also Collapse adhesive, bandlike, f, cicatricial, f, hypoventilation, f, mechanisms of, mediastinal shift and, f, obstructive central, f, , , f, peripheral, passive relaxation , , f postoperative, f, resorptive, structure shift in, f, , f, Atrial septal defect, f, Atrium.
See also specific lobes air-filled. See Air bronchogram sign contrast-aided examination of, , f, dilation of, f, , f, f, focal air trapping in, 14f, 15 obstruction of, f, , f, See also Collapse on computed tomography, 60f, 61, f, right main stem, 60f, 61 tumor of, f, Bronchus intermedius, , f Bullae, f, Bullet, in pleural space, f, C Calcification aortic arch, f, in granulomatous infection, f, on oblique view, 6f, 7 Cancer lung.
See Lung cancer metastatic, f, , f, Cardiac cycle, magnetic resonance imaging of, 30f, 31 Cardiac shadow, air bronchogram through, f, Cardiac silhouette, See also Heart Cardiothoracic ratio, f, Cardiovascular disease, — See also Heart Carina, 36f, 37, 38f, 39, 45, 45f on computed tomography, 64f, 65 Catheter, 4f, 5, f, Cavitary mass, f, , f, Central venous catheter, 4f, 5, f, Cephalization, f, Chronic obstructive pulmonary disease COPD , 20f, 21, f, , f, See Heart failure Consolidation.
See also Alveolar filling disease left lower lobe, 94f, 95 left upper lobe, 96f, 97, , f, lingula, 92f, 93, f, , f, multifocal, right lower lobe, 94f, 95, f, , f, , , f, f, right middle lobe, 78f, 79, 92f, 93, 94f, 95, f, , f, right upper lobe, 68f, 69, 69f, 96f, 97, f, , f, Contrast media bronchial, , f, CT, 26f, 27, 56f, 57 esophageal, f, COPD.
See Chronic obstructive pulmonary disease COPD Coronal plane, 64f, 65, 69, 69f Costophrenic sulcus angle , 36f, 37, 38f, 39, f, shallow blunt , f, , , , f Cross-sectional imaging, 22f, 23— See also Computed tomography; Magnetic resonance imaging; Ultrasonography axial, 22f, 23 coronal, 22f, 23 oblique, 22f, 23 sagittal, 22f, 23 CT.
See Alveolar filling disease density of, 20f, 21 fissural, 74f, 75, f, , f, , f, pericardial, , f, , f, pleural. See Pleural effusion subpulmonic, f, , f, , Fluoroscopy, 17 Foreign body, aspiration of, 84f, 85, 85f Fracture, rib, f, G E Echocardiogram, 32f, 33 pericardial effusion on, f, Edema alveolar, f, interstitial, f, Effusion pericardial. See Pericardial effusion pleural. See Pleural effusion Electrocardiogram lead, f, Emphysema, 20f, 21, f, , f, See also Pleural effusion Hyperinflation, f, compensatory, Hyperlucency, f, Hypoventilation atelectasis, f, I Inferior accessory fissure, 80f, 81, 84f, 85 Inspiration, 11, 12f, 13 Interlobular fissure, 70f, 71 Interstitium, 50f, 51, 66f, 67, f, acute disease of, , chronic disease of, diffuse disease of, f, , f, , alveolar consolidation and, 67, 67f, f, edema of, f, focal disease of, f, on computed tomography, 66f, 67, 67f thickening of, f, , f, Intrafissural effusion, 74f, 75, f, , f, , f, Intrapleural air.
See Left lower lobe; Right lower lobe Lung s abscess of, f, air in, 19, 20f, 21, 86f, See also Air bronchogram sign alveoli of. See Alveoli atelectasis. See Atelectasis blackness of, 12f, 13, 14f, 15, 27 bronchus of. See Bronchus bronchi collapse of.
See Collapse consolidation in. See Consolidation density of, 86f, 87 fissures of. See Fissure s interstitium of. See Interstitium lobes of. See Left lower lobe; Left upper lobe; Lingula; Right lower lobe; Right middle lobe; Right upper lobe mass of, f, See also Lung cancer cavitary, f, , f, fissural fluid simulation of, , f hilar, f, , f, , f, size of, f, vs. See Fissure s , major oblique Mass mediastinal. See Mediastinum, mass of over spine, f, pulmonary, f, See Magnetic resonance imaging Multiple myeloma, f, Muscle, density of, 86f, 87 N Nasogastric tube, f, Neural tumor, , f Nodule s.
See also Mass metastatic, f, multiple, f, on computed tomography, f, , f, right upper lobe, f, size of, f, Normal chest x-ray, 37— See also specific structures O Oblique views, 6f, 7, 16f, 17 Obstructive atelectasis central, f, , , f, peripheral, Obstructive pulmonary disease, chronic COPD , 20f, 21, f, , f, Pleura mediastinal mass displacement of, on computed tomography, 59, 59f parietal, 71 visceral, 60f, 61, 71 Pleural effusion air-fluid level with, f, case study of, f, encapsulated loculated , , f, fissural, 74f, 75, f, , f, , f, in heart failure, , f, mediastinal shift and, f, on computed tomography, f, on lateral decubitus view, 8f, 9, f, on supine view, f, , f, on ultrasonography, 32f, 33 shallow blunt costophrenic angle and, f, , f, , f subpulmonic, f, , f, , white lung with, f, Pleural space cavity , 71, f, air in.
See Pneumothorax bullet in, f, fluid in. See Pleural effusion Pneumonia, 79 air-fluid level in, f, case study of, f, , f, left lower lobe, 98f, 99, f, right lower lobe, f, right middle lobe, f, silhouette sign and, 98f, 99, f, Pneumothorax, 10f, 11 air-fluid level with, f, lung collapse and, f, on decubitus film, 10f, 11 on expiratory film, 17 on supine view, f, , f, tension, f, , f, Portable x-ray, 2f, 3, f, Posteroanterior PA view, 1, 2f, 3, 4f, 16f, 17 inspiratory vs.
View detailed clinical images covering all the image types you'll see on the boards including digital quality radiographs and an introduction of PET imaging, plus more advanced imaging such as CT and MRI than ever before. Test your skills and simulate the exam experience with updated content aligned with the new MCQ-format Board exam for easy preparation and review. Benefit the from more robust interactive offerings in an e-book format? Expert Consult eBook version included with purchase.
This enhanced eBook experience allows you to search all of the text, figures, references, and videos from the book on a variety of devices. Download e-Book Pdf. The glass is just too big. From geekswithblogs. Figure shows an air-fluid level arrow in a cavitary right upper lobe pneumonia. Compare with Figure , where there is no fluid in the cavities.
Granulomas frequently calcify. Figure A shows a nodule in the left mid lung. Figure B shows the same healed scar granuloma on CT. Clinical Pearl: Heavy calcification is an important sign of benign disease in the lung. Healed tuberculosis and histoplasmosis are the most frequent causes of lung granulomas. The adjacent hilar lymph nodes often calcify Figure B.
If the lung is hyperin- flated, it becomes hyperlucent because a fixed amount of tissue is spread over a larger volume. If the interstitium is destroyed e. Bullae or sparse markings replace normal branching vessels Figure A.
The AP diame- increased ter is increased i. In real life, these nice neat patterns of lung disease often overlap. However, this approach provides a way of organizing your descriptions to form a differential diagnosis.
The patient has what generalized lung disease? Use all mass, bulla, ciga- the information on the film! Mediastinal diseases can be difficult to detect on chest x-ray because most diseases are of soft tissue density and are surrounded by other soft tissue structures. Mediastinal lesions may cause local or diffuse widening; displace, compress, or invade adjacent structures; or cause a silhouette sign with adjacent structures.
The lateral view is often helpful for localization. Which is likely due to tumor? Which is likely due to hemorrhage? Figure B hemorrhage is diffuse 10 10 A mediastinal mass displaces the medial pleura toward the lung. This helps to silhouette locate the mass. Note mediastinal tracheal displacement and marked narrowing arrows. There are several methods of dividing the mediastinum.
None is perfect because structures and diseases often cross these artificial divisions. In Figure , an imagi- nary line separates the anterior I and middle mediastinum II. On the lateral x-ray, the upper portion is the heart area of the retrosternal clear space. It fills the retrosternal anterior clear space. Compare with Figure B. Big White is discussed in Chapter Figures A and A show a thymic mass in the same patient. Generally, it is difficult to differentiate one anterior mediastinal mass from another on the chest x-ray.
CT is often helpful in delineating boundaries. In Figure B, CT shows a homogeneous anterior mediastinal thymic mass with sharp margins, just anterior to the ascending aorta. Figure B is a CT scan showing the enlarged lymph nodes to the right of and anterior to the trachea T , in the middle mediastinum. The trachea is not compressed.
Middle mediastinal adenopathy is most often due to sarcoido- sis in young patients and lung cancer in older patients. Figures A and B show an air-containing mass behind the heart. Figure C is a lateral view of a barium swallow esophagram showing the large hiatal hernia stom- ach above diaphragm. Primary tracheal lesions are rare, but keep your eye on the trachea because it is often deviated or narrowed by adjacent lesions.
The descending aorta usually sits anterolateral to the anterior margin of the vertebral bodies. In Figure A, an aneurysmal aortic arch projects as a mass. Note the calci- fied atherosclerotic intima of the aortic arch upper arrow. The tortuous descending aorta is lateral to the heart lower arrow. Figure B shows the tortuous descending aorta arrow overlapping the spine.
A feeding tube shows the normal course of the esophagus—a middle mediastinal structure. More simply, the posterior mediastinum edge of the vertebral is the paravertebral area. Figure , an MRI image, shows a neural tumor.
The vertebral body V is intact, but a soft tissue mass M protrudes through the neural foramen into the posterior mediastinum. The descending aorta x is normal.
Clinical Pearl: Most posterior mediastinal masses are from the nerves or their coverings e. Multiple myeloma and metastatic spine diseases are more common in older patients. In Figure B, the CT scan shows fluid blood surrounding the aortic arch. Figure C is a multiplanar reconstruction of the aorta, showing a post-traumatic pseudoaneurysm arrow. They taper as they course pulmonary vessels peripherally.
Normal hilar nodes are not visible on the chest arteries, veins x-ray. In Figure , there is bilateral hilar adenopathy. The hila are lumpy because of the enlarged nodes. Clinical Pearl: The most common cause of a hilar mass is adenopathy or an adjacent tumor. The chest x-ray is reasonably sensitive in detecting mediastinal lesions. Additional imaging usually is required to characterize the abnormality. There are many different examinations to choose from.
It is often helpful to check with the radiologist. You may even get different answers from different radiologists. The right hilum Figures B and C are axial and coronal images through the medi- astinum and hilum.
Note large nodes N. This patient has lymphoma. The extrapleural space, a potential space, lies between the rib cage and the adherent parietal pleura. Each produces characteristic radiographic signs of disease, with the usual overlapping of signs.
This is called the costophrenic sulcus or angle. The lateral costophrenic sulcus is also fairly deep. The bullet, almost spent, just penetrated his chest wall and dropped harmlessly into the pleural space. In Figure A upright film , the bullet in the posterior costophrenic angle appears to lie in the abdomen. In Figure B lateral film , the bullet is clearly in the costophrenic angle.
In Figure C supine film , several days later, the bullet has shifted in the pleural space. In Figure A, the lateral costophrenic sulcus is normal. Additional fluid tracks up the pleural space, forming a meniscus, as shown in Figure C. Figures A, B, and C are all the same patient.
If there is a discrepancy between them, believe the lateral. Figure and Figure are of the same patient. Compare each set of PA and lateral examinations.
The true diaphragm lies in normal position, but is obscured by a parallel layer of free fluid. In the upright position, free fluid often collects between the lung base and the top of the diaphragm.
In radiology, however, gravity can be a friend. What view would be most helpful in proving that Figure A has a subpulmonic effusion? The free fluid has redistributed to the dependent side of the left pleural cavity, between the lung and chest wall.
Figure C, a CT scan, shows a gravity- dependent pleural effusion layered posteriorly E. On the left, the stomach bubble is normally elevated separated from the lung base by only the thin diaphragm. In Figure , the apex of each diaphragm is in the mid clavicular line. In Figure A, the left costophrenic angle is A. What are the signs of pleural effusion on the right?
There is also fluid in a major fissure arrow. The costophrenic angle may be shallow or show a 3. How would you confirm suspicions on the PA image? Clinical Pearl: Every student wants to know how much fluid one can see on a radiograph. The erect PA requires greater than mL; the erect lateral, 75 mL; the decubitus, greater than 5 mL; the supine, more than several hundred milliliters.
Now you know. Does the name Pavlov ring a bell? See Figure A, an example of loculated pleural fluid. There is a second smaller loculation as well. Compare this with the free effusion of Figure C. It may look like a lung mass. Remember, the beam lateral must be parallel to the fissure to see it. The two loculated collections in the major fissure B and C are completely sharp only in the lateral projection.
On the frontal image, portions of the major fissure pseudotumors are indistinct. Figure B shows the pleural air against the edge of the consolidated upper lobe arrow. There are no lung markings in the air-filled pleural space. There is also air in the subcutaneous tissues arrowhead.
In Figure A, we see what two signs inferiorly of pneumothorax? Note the hyperlucent pleural space subpulmonic air. Figure B shows air anterior to the lung no lung markings ; vis- on a CT scan of a supine patient. In Figure , we see the pleural line and air in the pleural space, signs of pneumothorax. The ribs astinum on that side may be further apart. Clinical Pearl: Rapid decompression of a tension pneumothorax can be lifesaving. Learn the clinical signs so that you can diagnose and treat it without an x-ray.
Signs include rapid onset of respiratory failure, decreased breath sounds, deviated trachea, and jugular venous distention.
There is fluid in the lower pleural space, air in the upper pleural space, and an air-fluid level. The air bubble in the stomach is elevated, indicating diaphragmatic elevation because the lung has been removed. Lesions that arise in structures within or bordering the extrapleural space e. If none is extrapleural visible, it may be difficult to separate the two.
Figure illustrates an extrapleural lesion. The convex margin facing the lung is sharp, and the borders are tapered obtuse angle with chest wall. The lesion looks similar to encapsulated fluid see Figure A. The rib fractures arrowheads in Figure indicate the extrapleural origin. How extrapleural; expansile did you decide? What are the three patterns seen with free pleural effusions A. Every beginner should be able to recognize the cardiovascular structures, cardiomegaly, and left heart failure.
If you can, you will be ahead of most of your peers. Two medical students spotted a bear while walking in the woods. Student 1 took out sneakers from his backpack and put them on. On the left side, there are four bulges moguls to you skiers.
They are: 1. The right ventricle does not form a lateral border on the frontal view. Label the cardiovascular structures on the lateral Figure B. Review the following: A. On the frontal view, the left atrial appendage is normally C. Determining cardiac enlargement is easy.
Measure the horizontal width of the heart and divide it by the widest internal diameter of the thorax. The normal cardiothoracic ratio is less than 0. Oversimplified, but useful. The 0. These measurements 0. For a given patient, an increase of greater than 1 cm in cardiac diameter from a prior film is a more reliable index of cardiac enlargement than the cardiotho- racic ratio.
In general, a radiologist with a ruler is a radiologist in trouble, but these measurements work fairly well on erect, inspiratory PA radiographs. The upper left heart border bulges laterally arrow on Figure A and posteriorly arrow on Figure B.
Compare with Figures A and B. On the lateral view, the left heart border moves inferoposteriorly. The aorta is so tortuous that even the aortic ascending aorta arch is visible. In the frontal projection, the normal right heart protrudes slightly to the right of the spine, and an enlarged heart protrudes further to the right soft science, at best. In the lateral projec- tion, the right heart enlarges anteriorly and superiorly.
The normal right heart contacts the lower one third of the sternum, whereas the enlarged right heart contacts the lower one half. In a supine patient, what happens to blood flow? This is called cephalization or vascular redistribution.
Cephalization, not heart size, is the key to diagnosing elevated left heart pressure. Compare Figure A and Figure B until cephalization is absolutely clear. Clinical Pearl: Left heart failure and mitral valve stenosis are the most frequent causes of redistribution or cephalization.
A shunt e. The patient in Figure B is in left heart failure. There is enlargement of the upper lobe vessels cephalization. This is mild left heart failure because the vessel margins remain distinct i. Which patient has prominent upper lobe vessels as a result of an atrial septal defect?
Figure A shows mild left heart failure. Figure B shows moderate heart failure in the same patient as in Figure A with large but hazy upper lobe vessels and prominent interstitium. Fluid thick- ens the interlobular septa, causing short lines perpendicular to the pleural surface. Figure C is a close-up of Kerley B lines arrows in a different patient.
With alveolar edema, the pulmonary vessels may water density lung not be visible. In addition: A. Moderate failure causes indistinct vessel margins as a B. Kerley also described A and C lines. He was interlobular septa obviously a splitter, rather than a lumper. We will not worry about A and C lines.
Figure is a CT scan of Kerley B lines arrows. Clinical Pearl: With cephalization alone, lung auscultation is usually normal. With interstitial edema, crackling rales are audible.
With alveolar edema, rales are audible. Is there cephalization? Is there edema? Is there a pleural effusion? There are no significant signs of left heart failure. Figure , an echocardiogram, shows a large pericardial effusion P. Figure , a CT scan of a different patient, shows a pericardial effusion P , bilateral pleu- ral effusions, and left lower lobe consolidation atelectasis. Echocardiography, CT, and MRI accurately depict pericardial effusions, but echocardiology is most cost-effective.
Clinical Pearl: Marked generalized enlargement of the cardiac silhouette, with no or mild signs of left heart failure, is most likely due to pericardial effusion. Cardiomyopathy and multivalvular heart disease may have a similar radiographic presentation. These should be evaluated on every x-ray before your standard search. The central venous pressure catheter is in the B. You are done.
There is no review quiz. Take a break! When you come back, challenge yourself to the dozen great quiz cases in the last section. The CD on the back cover is worth a look. Principles are as important as facts. If you master the principles, you can make up the facts. You learn better when you know your goals. Follow your cases. Like sex, learning is better if you are actively involved.
When you read, talk back to the author. Be skeptical. Reinforcement is essential for acquiring knowledge. See a case, look it up; read an article, find a case or ask a question.
Reward is important for learning. Show off what you know. Brag a little. Speak up in class. Different people learn best by different methods. Figure out your own best method and cater to it, whether it be reading, listening, observing, or doing, or a combina- tion of these. They are as rare as great students. Quick retrieval of once-acquired information is crucial. The home computer is ideal but other good retrieval methods are available.
Create your own personal modification and keep improving it. Divide your study time into prime time, work time, and sleepy time. Biorhythms vary widely among students, so develop your own study schedule. Felson, B. Read the history. Then, and only then, answer all questions before you turn to the answers on the next page. Many patients have several abnormalities that you can combine to arrive at a diagnosis. Metal nipple markers have been placed to distinguish nipples, which sometimes show on x-rays, from real pulmonary nodules.
Is the lung abnormal? Are there any changes to suggest pleural effusion? What type of surgery did the patient have? Diagnosis: Can you combine the history and x-ray findings to suggest a diagnosis?
Yes, below the right nipple marker, where the ribs cross, there is a pulmonary nodule. The costophrenic angles are sharp. The stomach bubble sign is absent. Diaphragms are normally shaped. The right shoulder has been amputated. A systematic approach helps avoid embarrassing misses. Diagnosis: Patient had a shoulder amputation, most likely for cancer.
The nodule is most likely a pulmonary metastasis. The amputation was for osteosarcoma. Aristotle to open her mouth. Describe the lesion in detail. Diagnosis: Put the x-ray findings and history together for a logical diagnosis. There is a mass or focal alveolar consolidation with a central cavity, air-fluid level.
Diagnosis: This is a lung abscess in an epileptic who probably aspirated during a seizure. Tuberculosis, another reasonable possibility, is usually more indolent. Aspiration most often involves the gravity-dependent portions of the lung in a supine patient posterior segments of the upper lobes and the superior and posterior basal segments of the lower lobes. Identical paper clips mark the entrance and exit wounds.
Describe the major radiologic findings of the left hemithorax. Are proximal air bronchograms visible? The police tell us that he was shot from the front. Is the entry wound midline or left-sided? Remember, they are identical paper clips. The left hemithorax is opaque laterally. The partially aerated lung is visible medially. The air bronchogram on the left tells us that the major airways are open. There is no central endobronchial obstruction, and the surrounding lung is almost airless water density.
This is an AP supine film, so the anterior clip would be magnified. Because identical paper clips were used, the bullet must have entered the left chest magnified clip and exited in the midline. Diagnosis: Left hemothorax from gunshot wound. Relaxation atelectasis. Increased pressure in left hemithorax causing contralateral mediastinal shift. Fiction has to be believable.
Figure Q-4A was obtained shortly after admission. There is a drain in the right pleural space laterally. Describe the lung abnormalities. Several hours later, he became more short of breath. Figure Q-4B shows what additional finding? Bilateral dense consolidation, air bronchograms, silhouette signs of diaphragms, blunt right costophrenic angle. Diagnosis: Pneumonia. Tension pneumothorax on right—air in pleural space, low right diaphragm, heart shifted to the left.
Figure Q-5A is a baseline image obtained 10 months earlier. Figure Q-5B is the current image. Explain the discrepancy. Ten months later, there have been striking changes Figure Q-5B. The left lung is more lucent. There has been a left mastectomy. The breast is miss- ing, and there are clips in the axilla. There is less soft tissue on the left, so there is less absorption of radiation. The right costophrenic angle is blunt and there is a small meniscus.
The right diaphragm also has changed shape subpulmonic effusion. Diagnosis: Pericardial effusion and right pleural effusion caused by metastatic breast cancer. It causes a silhouette sign of what three cardiovascular structures? Is there an abnormality visible on the lateral film? Diagnosis: Formulate a differential diagnosis. Density in retrosternal clear space, between sternum and trachea. This is a large anterior and middle mediastinal mass on the left.
The lateral radiograph shows the mass predominantly in the anterior mediastinum. The silhouette sign indicates anterior mediastinum left atrium and middle medi- astinum pulmonary artery, aortic knob. This mass is too low. Thoracic aortic aneurysm. The ascending thoracic aorta is on the right and looks normal i. Terrible lymphoma. This is usually lobulated and bilateral. Thymoma and Teratoma are the best choices. Large masses commonly cross mediastinal boundaries. This was a thymoma.
What forms the sharp lower edges of their lesions? How did you know? The minor fissure is the sharp lower border. The upper lobe is consolidated, and the middle lobe is well aerated.
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