OSPE UNMANNED STATION

CHEST X RAY INTERPRETATION

Patient presented with a 5 day history of productive cough, high grade fever and fatigue.

Bronchopneumonia - multiple small nodular & consolidation of the right upper lobe which is
reticulonodular on both lungs. separated by confined inferiorly by the horizontal fissure - lobar
normal lung parenchyma pneumonia

Diagnostics: blood & sputum culture, nasal swap, ↑ crp ↑ esr ↑ pct, ↓ PaO2 treatment: amoxicillin for 5
days

56 year old patient presented with Short history of progressive shortness of breath

A homogenous opacification in the right lower tracking along the lateral chest wall. The right costophrenic
angle is obliterated with a meniscus - right sided pleural effusion

collection of fluid in the pleural space. Fluid gathers in the lowest part of the chest, according to the
patient's position. If the patient is upright when the X-ray is taken, then fluid will surround the lung base
 forming a 'meniscus' – a concave line obscuring the costophrenic angle and part or all of the
hemidiaphragm.

Management: treat underlying cause and therapeutic thoracocentesis

Transudate Exudate

It occurs when there is an increase in hydrostatic
pressure or a decrease of capillary oncotic pressure.
Examples: cardiac failure, nephrotic syndrome,
cirrhosis: hepatic trauma, asbestos exposure.
It occurs due to the increase in permeability of the
microcirculation or alteration in the pleural space
drainage to lymph nodes.
Examples:bronchial carcinoma, pulmonary embolism,
infarction, pneumonia tuberculosis, mesothelioma
lymphoma.
 72 year old male hypertensive presented with acute shortness of breath (SO2 72%)

Pulmonary edema :-

Features useful for broadly assessing pulmonary edema on a plain chest radiograph include:

• upper lobe pulmonary venous diversion (stag's antler sign)

• increased cardiothoracic ratio for assessing for an underlying cardiogenic cause or
association

Features of pulmonary interstitial edema:

• peribronchial cuffing and perihilar haze

• septal (Kerley) lines due to lymphatic engorgement (edema). occur when
pulmonary capillary wedge pressure reaches 20-25 mmHg
• thickening of interlobar fissures

features of pulmonary alveolar edema:

• air space opacification classically in a batwing distribution

• may have air bronchograms
• pleural effusions and fluid in interlobar fissures

management: diuretics (furosemide), opoids, iv nitroglycerin, nesiritide, dopamine, nifedepine

 Kerley A - interlobular septa, thick & coarse, (2-6 cm), cross
normal vascular markings and extend radially from the hilum.

Kerley B - subpleural interlobular septa, thin, in the periphery of

the lung, perpendicular to the pleural surface and extend out to
it.

Kerley C - short lines which do not reach the pleura (i.e. not B or
D lines) and do not course radially away from the hila

34 year old male admitted in the intensive care unit (ICU) for head injury develops hypoxia

Lobar lung collapse - right lower lobe triangular opacity, obscuring right hemidiaphragm.
Mild mediastinal shift towards right side, mild crowding of right lower ribs
- Most often collapse of most or all of a lobe is secondary to bronchial obstruction
causing resorptive atelectasis.
Etiology:

luminal - aspirated foreign material mucus plugging endobronchial mass misplaced

endotracheal tube

mural - lung cancer

extrinsic - compression by adjacent mass

 25 year old male presented with acute shortness of breath

pneumothorax usually appreciated on erect chest radiographs, visible visceral pleural edge is
seen as a very thin, sharp white line.

no lung markings are seen peripheral to this line peripheral space is radiolucent compared to
the adjacent lung. Lung may completely collapse. Mediastinum should not shift away from the
pneumothorax unless a tension pneumothorax is present. Subcutaneous emphysema and
pneumomediastinum may also be present.

Management: needle aspiration

45 years old female presented with Progressive 50 years old female presented with exercise
intolerance and shortness of breath. dyspnea.

This case is an echocardiographically proven massive pericardial effusion presenting with the
"water bottle sign" on chest radiography. The fluid-filled pericardial sac casts a cardiac
silhouette that resembles an old-fashioned leather water bottle. Patient with a previous mitral
valve repair demonstrates marked cardiomegaly.

58 year old male, smoker, presented with fever, productive cough for 3 days (SO2 96%)

1- interpret x ray
a. Hyper-inflated lungs (>10 ribs posteriorly)
b. flattened diaphragm
c. Hyper-lucency through lung fields bilaterally
d. narrow mediastinum.
e. alveolar infiltrations in both lungs
 f. dextrocardia, a right-sided aortic knuckle, a right-sided gastric air bubble and left-
sided liver.
2- what is your diagnosis? COPD
3- Discuss other investigations needed for professional evaluation of the patient?

Spirometry: Key finding - FEV1/FVC < 70% after bronchodilator inhalation. Post bronchodilator
test to determine reversibility of bronchoconstriction, pulse oximetry to assess for indications of
oxygen therapy, ABG for hypoxemia and hypercapnia, serum a-1 antitrypsin for any
deficiencies.

4- How to manage that patient?

Cessation of tobacco use, encourage physical activity, recommend immunizations

(pneumococcal, influenza, covid-19, zoster,Tdap) screen for comorbidities such as
cardiovascular disease & give long acting beta agonist (salmeterol), mucolytics (N-
acetylcysteine), a1-antitrypsin augmentation therapy.