Clinical Cases. For each case, there is first a slide with some history –Think about a likely differential diagnosis, based on the clinical information.

Clinical Cases

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

CASE 1

Elderly male, 2 previous myocardial infarctions, presents with crushing

central chest pain radiating to jaw and left

arm, and extreme breathlessness

Pulmonary Oedema

Kerley B Lines

Enlarged Heart

Alveolar Oedema

Perihilar haze

Kerley B Lines in detail

CASE 2

70 year old man. Left pneumonectomy three

years ago for lung cancer.

Admitted with haemoptysis, weight loss

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?

Lung cancer recurrence

Thick walled 8cm cavityRight mid/lower zone

CASE 3

40 year old man. 3 month history of increasing

breathlessness. Reduced left chest expansion and

stony dull percussion note.

Left Pleural Effusion

Mediastinum pushed over to right

White-out

No diaphragm visible

CASE 4

30 year old, acute onset of breathlessness and pleuritic chest pain.

Afebrile.

Right Pneumothorax

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

CASE 5

55 year old alcoholic with severe abdominal pain.

Tender +++ epigastrium with guarding and

rebound

Free gas under diaphragm= perforated viscus

Pneumoperitoneum

Other examples of Pneumoperitoneum

CASE 6

74 year old female. 2 month history of

progressive weight loss, malaise, drenching night sweats and itch. She has

found a lump in her neck.

Mediastinal Lymph node enlargement

Probable Lymphoma

CASE 7

26 year old female. 3 month history of malaise.

Shiny, painful rash on shins and red, dry eyes.

Bilateral Hilar Lymph node enlargement

Sarcoidosis

CASE 8

65 year old. Admitted for elective surgery (inguinal

hernia repair). No past history. Smoker. Recent weight loss and cough.

Multiple bilateral pulmonary masses

…multiple metastases until proven otherwise

CASE 9

19 year old motorcyclist.Involved in high speed

road traffic incident.

Multiple left posterior rib

fractures (flail segment)

Surgical emphysema left lateral chest wall

Pulmonary contusion left lung (secondary

to trauma) – compare left with right side

CASE 10

55 year old man. 6 month history of progressive

breathlessness and a dry cough. No haemoptysis.

Fibrosing Alveolitis

Generalised increased interstitial shadowing, particularly in mid/lower

zones

Loss of clear cardiac and mediastinal

contours

CASE 11

20 year old, sudden onset of extreme breathlessness

Bilateral Pneumothoraces

Red arrows denote lung edge. Note no lung markings lateral to

this.

CASE 12

20 year old, sudden onset of extreme breathlessness

Normal!

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?”