Session 2 Homework

1. Assess the CXR first for quality: rotation, inspiration and penetration
(“RIP”)
2. Interpret the CXR
3. Make your diagnosis

Case 1:
67 yo F w/ 40 pack years of smoking, complains of left arm swelling and increasing
SOB while climbing the stairs. She also notices that her voice is "gravelly".
Pexam: vitals stable. Left arm slightly bigger than right. Left pupil smaller than
right.

1. Rotation: The right clavicle appears closer to the spine indicating the patient is rotated
left shoulder back. Inspiration is good nine ribs are visible on the right hands side.
Penetration is good details are clear.
2. The airway is shifted somewhat to the right but this is most likely due to rotation.
Cardiac silhouette is normal does not appear to suffer from cardiomegaly but limited due
to single ap x-ray. The right diaphragm appears normal the left is elevated significantly.
There is a mild consolidation/opacification in the left upper lobe. There is soft tissue
swelling on the left arm and left side of the lung near consolidation The great vessels
have a normal course. Hilar region not congested.
3. Pancoast tumor with lymphatic congestion most likely non-small cell cancer secondary
to patients smoking history. The left pupil contraction is due to Horner’s syndrome, loss
of sympathetic stimulation due to compression of stellate ganglion, voice changes are due
to compression of recurrent laryngeal nerve, and hemidiaphragm disfunction/paralysis is
due to disruption of the Phrenic nerve.
Case 2:
56yoM, ex-smoker with progressive difficulties performing his job as a bus driver.
The past 2 days, he was unable to sleep due to breathing issues when he lies in his
bed.
Pmed hx: lumber pain and sciatica controlled with conservative mgt.
ROS: increasing upper back pain.
Pexam: mod distress w/. HR 120, RR28, normotensive
neck: trachea appears midline
Cor: tachy
Lungs: reduced breath sounds on left

You ordered a STAT CXR with a wet read.

1. Clavicles are even rotation is normal, inspiration is good 8-9 ribs on right, penetration
is good details clear.
2. The trachea is deviated to the right, cardiac silhouette and left diaphragm are obscured
by large left pleural effusion. Clear deafferentation between pleural effusion a small
apical segment of aerated lung. Mediastinal and tissue shift along with airway shift.
3. Patient has a large left pleural effusion with mass effect and tracheal deviation.
Case 3:
72yoF w/ 2 days of feeling weak where now she gets out of breath with 1/2 flight of
stairs. Also she is unable to lie flat. Never smoked.
Pmed hx: recently dx of ovarian CA after w/u of her vague abd c/o. About to
consider treatment options.
Pexam: RR 24, normotensive
Lungs: reduced breath sounds on right
Abd: distended and tender abdomen, shifting dullness

1. Rotated right side forward, inspiration adequate 8 ribs on left, penetration is good
details clear.
2. No tracheal deviation, large right sided pleural effusion, clear meniscus sign, left side
of lung is clear with normal cardiac silhouette and diaphragm can not comment on heart
size as right border obscured. Possible mediastinal shift.
3. Large right sided pleural effusion with no tracheal deviation but possible mediastinal
shift.
You perform a procedure. You ordered a follow up CXR.
What was this procedure? Chest tube for drainage visible in right lung.
Any complications? Right sided pneumothorax though no signs of tension.

1. Rotation normal, inspiration adequate, penetration good.

2. Airway midline, large but now draining pleural effusion on the right, with drain still in
lung. Pneumothorax with collapsed lung visible above meniscus of draining right pleural
effusion. No signs of mediastinal shift.
3. Insertion of chest tube drainage which caused a simple pneumothorax no signs of
tension.
Case 4:
32yoF who never smoked, history for mild asthma, previously well controlled with
inhalers, recently ran out of her inhaler. She presented to the emergency
department after several hours of coughing and difficulty in breathing, with a
shorter history of rapid onset of unilateral chest pain and worsening shortness of
breath.
Pexam: HR 90, BP 120/80, RR 18
Peak Expiratory Flow (PEF) is 70% of predicted
She is able to speak in full sentences.
She undergoes an admission CXR below.
nces

Pt was given nebulizers and steroids where she improved. However, she then
gradually became more short of breath and tachycardic. A second X-ray was
acquired.
What is your diagnosis now?
What clinical and physical signs may you expect to find?
What do you advise?