Moodle Course

Medical Imaging
Chest X Ray: General
• Horizontal Fissure
• X Kerley A/B lines
• The lesion is in the left lower • Mass is in right middle lobe
lobe.
• The right side is normal.
• Mass is in the left upper lobe,
lingular segment
• Nipple Shadows • Cavity
• X coin lesion / opacity / nodule /
mass
 The lung apices are the apical segments of the right
upper and the left upper lobes respectively, the other
• Pleural effusion • Granuloma common locations for tuberculosis are indeed apical
segments of both the right lower and the left lower lobes

• X consolidation • X describe this as calcified

• X foreign body / bronchogenic
cyst
Infiltrative Airways Diseases
• Ground Glass Opacities • Reticulonodular pattern
• X reticulonodular pattern • X ground glass opacities
• If patient has lymphopenia, we
should suspect PCP (X TB /
nCoV)
• Also a reticulonodular pattern • Silicosis
• X streaky infiltrates / infiltrative
pattern
• Sarcoidosis
Pulmonary Infections
• Air bronchogram • Since L. heart border is present, we know that LUL
/ lingula is not involved.
• R air bronchogram.
• Since it conforms to airway anatomy more t, it is a
bronchopneumonia rather than lobar pneumonia.
• With these combined it is known • Pulmonary aspergillosis
as a lobar consolidation
• X multifocal consolidation
• Pulmonary tuberculosis • Fibronodular pattern of
• X melioidosis / mucormycosis / tuberculosis
brucellosis / atypical pneumonia • X miliary tuberculosis
• LUZ fine nodular pattern
• Tuberculosis > pneumoconiosis
• Miliary tuberculosis (prone to
haematogenous spread)
• Systemic military tuberculosis
affects the CNS to present as
choroidal tubercles on
fundoscopy and seizures when
meningitis has resulted.
• It also causes
hepatosplenomegaly.
• It does not present with retinal
haemorrhages.
• Chronic fibrotic changes due to previous RUL
infection.
• X RUL atelectasis / Right upper lobectomy /
cavitation due to infection / apical pleural
thickening
• Causes R mediastinal shift • This patient admitted having
• Other pathology: calcification of airways, tramlines previous tuberculosis.
• We cannot determine from the
CXR whether there is
reactivation of tuberculosis.
• Send sputum for AFB smear and
culture.
• Pleural calcification and
thickening (most likely cause:
old TB empyema)
• RLZ consolidation
• Left lung abnormalities:
• X pneumothorax bronchiectasis (tramlines), and
emphysema.
• X unfolding of aorta
• In the absence of a meniscus and
a fluid level, we distinguish
between a consolidation and a
pleural effusion by ultrasound of
the thorax. NOT decubitus XR /
percussion/ chest drain.
• Pleural thickening • Pleural Plaques
• Dense calcification not conforming to lobar/fissure
anatomy but seems living the pleura likely the
result of previous pleuritic and formation of pleural
plaques. Spirometry shows restrictive pattern
• May be due to old empyema / old TB empyema /
asbestosis / old haemothorax
• Parts of the ribs were resected in a thoracoplasty.
• X rib fracture / inward bending of ribs
• Rarely indicated nowadays.
• Used to be a treatment for empyema / tuberculous
empyema / bronchopleural fistula
• S/E of thoracoplasty: collapse and pleural thicken
Lung Atelectasis
• RUL collapse resulting in pulling
up of horizontal fissure
• LUL collapse. Unlike the right
side, there is no horizontal
fissure in left lung, thus left
upper lobe will collapse in
antero-posterior dimension just
like folding up on top of the
oblique fissure
• Blunted posterior costophrenic • L costophrenic angle is blunted.
angle Since there is no meniscus, it is
• X aortic dissection / rib fracture / an atelectasis.
vertebral collapse / cardiomegaly • Of the L LOWER LOBE.
• Elevation of L hemidiaphragm
• L mediastinal shift
• X apical pleural thickening (outer edge)
• Left upper lobe collapse giving rise to ill-defined
opacity
• The same patient
• # = hilar lymphadenopathy
• X aspiration of foreign body
• Next step: fibreoptic bronchoscopy
• Silhouette sign with right heart
border indicating RML collapse
• No completely horizontal fluid
level, X hydropneumothorax
• The same patient
• Right lower lobe collapse
• Since costophrenic angle is sharp, unlikely to be
pleural effusion
• DX: lobar pneumonia (S. pneumoniae / K.
pneumoniae)
• Flat waist sign (flattening of
countours of aortic knob)
• Suggests LLL atelectasis
• Juxtaphrenic peak sign is due to
retraction of the diaphragm.
• Given that the patient has stage
IV RCC, the CXR may represent
a lymphangitis carcinomatosis i.e.
pulmonary metastasis.
• In this sense, the juxtaphrenic
sign is due to nerve metastasis
causing phrenic nerve paralysis.
Obstructive Airway Disease
• Hyperinflation is another abnormality.
• Emphysema (a radiological finding) (X COPD: a
clinical syndrome) (note that enlarged left atrium is
not a finding of emphysema)
• The patient complained of dyspnea and another XR
was taken
• Most worrying condition: cor pulmonale with
pulmonary oedema (X bilateral pleural effusion)
Miscellaneous Lung Diseases
• Pulmonary embolism • Pneumothorax
• Possible causes: recent tracheostomy, ruptured
cavity, neoplasm
• Early chest drain is always warranted
• Cannonball Lesions (due to
metastasis from extrapulmonary
cancers)
• X patchy consolidation
• Bronchus intermedius, which will further divide into middle
and lower lobe bronchi • This patient had a diagnosis of acute
• Other abnormalities: hyperinflation and peribronchial
myeloid leukaemia last year with
thickening clinical remission following systemic
• X Kerley A and B lines chemotherapy and with HSCT done 6
months ago. The baseline CXR before
transplantation was clear. He
complained of progressive dyspnea for
the past two months.
• The most likely pathology is
bronchiolitis obliterans syndrome, a
part of GVHD.
• Expected features on HRCT:
• Reduced attenuation (black lung)
• Mosaic attenuation pattern
• Reduction of pulmonary vasculature in
black lung
• Ground glass opacity
• Possible complications:
• Bronchiectasis
• Pneumothorax
• Pneumomediastinum
• You were consulted on this chest X-ray of a patient
just admitted to the Adult Intensive Care Unit with
severe respiratory failure and the intensivist is
preparing for mechanical ventilator support.
• The CXR shows ground glass opacities and patchy
infiltrates.
• X cannonball lesions and miliary nodules.
• After ventilator support, CT of this patient showed
peripheral consolidation.
• ARDS as characterized by acute onset of
respiratory failure with severe hypoxemia and
bilateral diffuse infiltrates on chest X-ray in the
absence of left atrial hypertension.
• Hydropneumothorax may be • Another pneumothorax
caused by traumatic chest
tapping or lung entrapment
syndrome (X pneumonitis,
pneumonia)
Extrapulmonary Diseases
• Cardiomegaly (CTR > 0.5) • Cardiomegaly is another
• X hyphoscoliosis abnormality
• “*”=Enlargement of left atrium • You suspect that the patient is
• “$”= right pulmonary artery suffering from a pulmonary
vascular disease. Auscultation of
the heart revealed a long,
rumbling cardiac murmur heard
for most of systole and diastole
in the second left interspace near
the sternum.
• DX: PDA
• Proneness to development of
infective endocarditis or SBE as
the right to left cardiac shunting
will give bypass to the filtering
action of pulmonary parenchyma.
Must rule out if patient has fever.
• Elevation of L hemidiaphragm • Aortic aneurysm
• X prominent gastric bubble / • X unfolding of aorta
depressed R hemidiaphragm
• May be due to phrenic nerve
palsy or eventration of
hemidiaphragm
• Blunted costophrenic angle (?)
• Enlarged hilar vessels
• Cardiomegaly
• X hyperinflation, upper lobe diversion
• We call this pruning of vessels due to PAH
• Rib fracture • Subcutaneous emphysema
• Roundish, attached to
mediastinum, solitary
• X homogenous
• DX: teratoma (X thymoma, lung
abscess, lung cyst)
• Another lymphangitis
carcinomatosis
• X sputum retention, amyloidosis
Tubes, Drains and Devices
• Hickman catheter
• Has two ports of entry
• Another abnormality: bilateral
basal peribronchial thickening
• Chest tube drainage • Left upper lobectomy (?)
• X thoracentesis, PTNB, or
pleurodesis
Computed Tomography
• A lung window for showing
pulmonary parenchyma.
• Both CTs show a pneumonia
since it is in the lower lobes.
• A mediastinal window for
mediastinal structure, rib cage
and soft tissues.
• X lung window
• CT angiogram sign is suggestive • Mosaic pattern signifies air
of bronchoalveolar carcinoma or trapping, usually in obstructive
lymphoma airway diseases e.g. asthma
• Honeycomb lung • RUL and LUL involvement
• X septal thickening, X honeycombing
• DDX: asthma and bronchiolitis obliterans, X
emphysema.
• Peripheral consolidation • Diffuse panbronchiolitis showing
tree-in-bud appearance
• Pruning of vessels due to PAH
Miscellaneous Data
Interpretation
• Flow volume curve
• Descending limb shows scooped
appearance i.e. obstructive