STANDARD CASES

CASE 1

A 70 year old male who lives in a residential home presents to ED with increasing confusion. He has a productive cough and a fever. He has a past medical history of hypertension, angina and mild cognitive impairment. He has a 25 pack year smoking history. On examination, he has saturations of 89% in air, and is febrile with a temperature of 38.8°C. There is dullness to percussion and coarse crackles in the right upper zone. A chest X-ray is requested to assess for possible pneumonia or collapse.

REPORT – RIGHT UPPER LOBE CONSOLIDATION

Patient ID: Anonymous

Projection: PA

Penetration: Adequate – vertebral bodies just visible behind heart Inspiration: Adequate – 8 anterior ribs visible

Rotation: Not rotated

AIRWAY

The upper trachea is central. The lower trachea is displaced to the right by the aortic arch.

BREATHING

There is heterogeneous air space opacification in the right upper zone. This has a relatively well defined inferior margin, which is likely to represent the horizontal fissure. There is a focal area of increased opacification in the right upper zone, which may represent focal consolidation or an underlying mass. The remainder of the lungs are clear. The lungs are not hyperinflated.

The pleural spaces are clear.

Normal pulmonary vascularity.

CIRCULATION

The heart is not enlarged.

The heart borders are clear.

There is unfolding of the thoracic aorta, which displaces the lower trachea to the right.

The mediastinum is central, not widened, with clear borders. There is a well- defined density projected over the lower mediastinum, which is in keeping with a hiatus hernia.

Normal size, shape, and position of both hila.

DIAPHRAGM + DELICATES

Normal appearance and position of hemidiaphragms.

No pneumoperitoneum.

The imaged skeleton is intact with no fractures or destructive bony lesions visible.

The visible soft tissues are unremarkable.

EXTRAS + REVIEW AREAS

ECG electrodes in situ.

No vascular lines, tubes or surgical clips.

Lung Apices: Heterogeneous right apical consolidation. Normal left apex

Hila: Normal

Behind Heart: There is a retrocardiac density, which represents a hiatus hernia

Costophrenic Angles: Normal

Below the Diaphragm: Normal

SUMMARY, INVESTIGATIONS & MANAGEMENT

This X-ray demonstrates heterogeneous right upper zone consolidation in keeping with pneumonia. The consolidation has a relatively abrupt inferior margin in keeping with the horizontal fissure, indicating this is right upper lobe pneumonia. A focal opacity in this region may represent focal consolidation or a mass. Incidentally, there is also a hiatus hernia.

Initial blood tests may include FBC, U/Es, blood cultures, and CRP. A sputum culture may also be taken.

The patient should be treated with appropriate antibiotics for community- acquired pneumonia, and a follow-up chest X-ray performed in 4-6 weeks to ensure resolution. The antibiotics may be oral or intravenous depending on the severity of pneumonia (CURB-65).

If the focal opacity in the right upper zone does not resolve then a CT of the chest and abdomen with IV contrast would be appropriate to assess for a lung tumour. It would also be useful to review previous imaging and case notes to see if there was an abnormality at this site before.

CASE 2

A 71 year old female presents to ED with chest pain and breathlessness. She had a left total hip replacement 2 weeks ago. She is a non-smoker. On examination, she has saturations of 91% in air and is afebrile. Lung fields are resonant throughout, with good air entry bilaterally. A chest X-ray is requested to assess for possible pneumonia, collapse, effusion or pulmonary embolism.

REPORT – PLEURAL EFFUSION

Patient ID: Anonymous

Projection: PA

Penetration: Adequate – vertebral bodies just visible behind heart

Inspiration: Adequate – 6 anterior ribs visible

Rotation: Not rotated

AIRWAY

The trachea is central.

BREATHING

There is blunting of the right costophrenic angle in keeping with a small pleural effusion. A small area of heterogeneous opacification is visible in the adjacent lung.

The lungs are otherwise clear. They are not hyperinflated.

The left-sided pleural space is clear.

Normal pulmonary vascularity.

CIRCULATION

The heart is not enlarged.

The heart borders are clear.

There is mild unfolding of the thoracic aorta.

The mediastinum is central, not widened, with clear borders.

Normal size, shape, and position of both hila.

DIAPHRAGM + DELICATES

The lateral aspect of the right hemidiaphragm is obscured. Normal position and appearance of the left hemidiaphragm.

No pneumoperitoneum.

The imaged skeleton is intact with no fractures or destructive bony lesions visible.

The visible soft tissues are unremarkable.

EXTRAS + REVIEW AREAS

No vascular lines, tubes, or surgical clips.

Lung Apices: Normal

Hila: Normal

Behind Heart: Normal

Costophrenic Angles: Blunting of right costophrenic angle. Normal left costophrenic angle.

Below the Diaphragm: Normal

SUMMARY, INVESTIGATIONS & MANAGEMENT

This X-ray demonstrates a small right pleural effusion with minor associated consolidation. This may reflect pneumonia with a parapneumonic effusion. The other main differential, especially given recent surgery, is a pulmonary embolism with infarction (consolidation) and an effusion.

Supplementary oxygen should be given.

Initial blood tests may include an arterial blood gas, FBC, U/Es, LFTs, blood cultures, coagulation, and a CRP. Sputum cultures would also be helpful. D-dimer is unlikely to be helpful given the recent surgery. A CT Pulmonary Angiogram should be considered.

Treatment with either antibiotics or low molecular weight heparin will be guided by the results of above investigations.

CASE 3

A 60 year old female presents to her GP with fatigue, weight loss and wheeze. There is no significant past medical history. She is a non-smoker. On examination, she has saturations of 99% in air and is afebrile. There is wheeze in the right upper zone. A chest X-ray is requested to assess for malignancy or COPD.

REPORT – LUNG AND HILAR MASSES

Patient ID: Anonymous

Projection: PA

Penetration: Adequate – vertebral bodies just visible behind heart

Inspiration: Adequate – 7 anterior ribs visible

Rotation: The patient is slightly rotated to the right

AIRWAY

The trachea is central after factoring in patient rotation.

BREATHING

There is a right upper zone mass projected over the anterior aspects of the right 1st and 2nd ribs. There are multiple small pulmonary nodules visible within the left hemithorax.

The lungs are not hyperinflated.

There is pleural thickening at the right lung apex. Normal pulmonary vascularity.

CIRCULATION

The heart is not enlarged.

The heart borders are clear.

The aorta appears normal.

The mediastinum is central, and not widened. The right upper zone mass appears contiguous with the superior mediastinum.

The right hilum is abnormally dense. It also appears higher than the left. Normal size, shape and position of the left hilum.

DIAPHRAGM + DELICATES

Normal appearance and position of the hemidiaphragms.

No pneumoperitoneum.

The imaged skeleton is intact with no fractures or destructive bony lesions visible.

The visible soft tissues are unremarkable.

EXTRAS + REVIEW AREAS

No vascular lines, tubes, or surgical clips.

Lung Apices: Right apical pleural thickening

Hila: Dense right hilum, normal left hilum

Behind Heart: Normal

Costophrenic Angles: Normal

Below the Diaphragm: Normal

SUMMARY, INVESTIGATIONS & MANAGEMENT

This X-ray demonstrates a large, rounded right upper lobe lung lesion associated with multiple smaller nodules. This is highly suspicious of a right upper lobe primary lung cancer with lung metastases. The dense right hilum is suspicious for hilar nodal disease. The significance of the right apical pleural thickening is not clear.

Initial blood tests may include FBC, U/Es, CRP, LFTs, & bone profile.

A staging CT chest, and abdomen with IV contrast should be performed.

The patient should be referred to respiratory/oncology services for further management, which may include biopsy and MDT discussion. Treatment, which may include surgery, radiotherapy, chemotherapy, or palliative treatment, will depend on the outcome of the MDT discussion, investigations, and the patient's wishes.

CASE 4

A 55 year old male presents to ED with a 2 week history of a productive cough and shortness of breath. There is a history of gastro-oesophageal reflux. He is a non-smoker. On examination, he has saturations of 100% in air and is afebrile. Lungs are resonant throughout, with good bilateral air entry. A chest X-ray is requested to assess for possible pneumonia, effusion or collapse.

REPORT – HIATUS HERNIA

Patient ID: Anonymous

Projection: PA

Penetration: Adequate – vertebral bodies just visible behind heart

Inspiration: Adequate – 6 anterior ribs visible

Rotation: The patient is slightly rotated to the left

AIRWAY

The trachea is central after factoring in patient rotation.

BREATHING

The lungs are clear.

They are not hyperinflated.

The pleural spaces are clear.

Normal pulmonary vascularity.

CIRCULATION

There is a mass projected centrally over the lower mediastinum/heart. An air- fluid level is visible.

The heart is not enlarged.

The heart borders are clear.

The aorta appears normal.

The mediastinum is central, not widened, with clear borders. Normal size, shape, and position of both hila.

DIAPHRAGM + DELICATES

Normal appearance and position of the hemidiaphragms.

No pneumoperitoneum.

The imaged skeleton is intact with no fractures or destructive bony lesions visible.

The visible soft tissues are unremarkable.

EXTRAS + REVIEW AREAS

No vascular lines, tubes, or surgical clips.

Lung Apices: Normal

Hila: Normal

Behind Heart: Retrocardiac opacity with an air-fluid level

Costophrenic Angles: Normal

Below the Diaphragm: Normal

SUMMARY, INVESTIGATIONS & MANAGEMENT

This X-ray demonstrates a retrocardiac opacity with an air-fluid level consistent with a moderately sized hiatus hernia. The lungs are clear.

Initial blood tests may include FBC, U/Es, and CRP to look for possible infection.

Treatment may be required if the gastro-oesophageal reflux disease is symptomatic, otherwise no treatment for the hiatus hernia is necessary.

CASE 5

A 54 year old man presents to ED with acute shortness of breath. He has a background of ischaemic heart disease and has a 20 pack year smoking history. On examination, he is apyrexial, with saturations of 90% in air. HR is 100 bpm with a RR of 22. There is dullness and inspiratory crackles in both lower zones. The JVP is raised 4cm. A chest X-ray is performed to look for pulmonary oedema.

REPORT – PULMONARY OEDEMA

Patient ID: Anonymous

Projection: AP Erect

Penetration: Adequate – vertebral bodies just visible behind heart

Inspiration: Adequate – 6 anterior ribs visible

Rotation: The patient is mildly rotated to the right

AIRWAY

The trachea is central.

BREATHING

There is interstitial opacification throughout both lungs. Prominent pulmonary vessels within the upper lobes are in keeping with upper lobe venous diversion.

The lungs are not hyperinflated.

The pleural spaces are clear.

CIRCULATION

The heart appears enlarged although its size cannot be accurately assessed on an AP X-ray.

The heart borders are clear.

There is unfolding of the thoracic aorta.

The mediastinum is central, not widened, with clear borders.

The hila are enlarged, which is likely vascular in origin, but they are in a normal position, with no increased density.

DIAPHRAGM + DELICATES

There is blunting of the costophrenic angles in keeping with small pleural effusions. The hemidiaphragms are otherwise normal.

No pneumoperitoneum.

The imaged skeleton is intact with no fractures or destructive bony lesions visible.

The visible soft tissues are unremarkable.

EXTRAS + REVIEW AREAS

No vascular lines, tubes, or surgical clips.

Lung Apices: Upper lobe venous blood diversion

Hila: Enlarged

Behind Heart: Normal

Costophrenic Angles: Blunting consistent with small effusions

Below the Diaphragm: Normal

SUMMARY, INVESTIGATIONS & MANAGEMENT

This X-ray demonstrates features of heart failure (cardiomegaly, interstitial opacification, upper lobe venous diversion and small pleural effusions).

U/Es should be performed to assess renal function, as well as FBC to look for any associated anaemia. An ECG would be helpful to look for any new electrical changes. An ECHO would allow assessment of the left ventricular function. The patient should be managed for acute pulmonary oedema/heart failure. A repeat chest X-ray can be used to help monitor response to treatment.

CASE 6

A 50 year old female presents to the ED with shortness of breath. She also reports weight loss of 10 kilograms in the last month. She has an 80 pack year smoking history. On examination, she is cachexic, has saturations of 100% in air, and is afebrile. The lungs are resonant throughout, with good air entry bilaterally. There is tar staining of the fingernails. A chest X-ray is requested to assess for possible malignancy.

REPORT – RIGHT LOWER LOBE COLLAPSE

Patient ID: Anonymous

Projection: PA

Penetration: Under penetrated – vertebral bodies not visible behind heart

Inspiration: Adequate – 7 anterior ribs visible

Rotation: Not rotated

AIRWAY

The trachea is deviated to the right.

BREATHING

There is a homogeneous triangular shaped opacity in the medial aspect of the right lower zone that involves the right retrocardiac area, in keeping with the sail sign. The right hemithorax appears smaller than the left indicating volume loss. The left lung appears hyperexpanded with some coarsening of the bronchovascular markings.

The lungs are otherwise clear.

The pleural spaces are clear, apart from mild bilateral apical pleural thickening.

Normal pulmonary vascularity.

CIRCULATION

The heart is not enlarged.

The heart borders are clear.

The aorta appears normal.

The mediastinum is displaced to the right.

The right hilum is difficult to identify and probably depressed. Normal size, shape, and position of the left hilum.

DIAPHRAGM + DELICATES

The right hemidiaphragm is indistinct, indicating right lower lobe pathology.

Normal position and appearance of the left hemidiaphragm.

No pneumoperitoneum.

The imaged skeleton is intact with no fractures or destructive bony lesions visible.

The visible soft tissues are unremarkable.

EXTRAS + REVIEW AREAS

ECG clips in situ.

No vascular lines, tubes, or surgical clips.

Lung Apices: Mild apical pleural thickening

Hila: Right hilum is difficult to identify and probably depressed. Normal left hilum

Behind Heart: Increased right retrocardiac opacification

Costophrenic Angles: Normal

Below the Diaphragm: Normal

SUMMARY, INVESTIGATIONS & MANAGEMENT

This X-ray shows a right lower lobe collapse (increased triangular opacity medially in the right lower zone which obscured the right hemidiaphragm – sail sign). There is resultant right-sided volume loss with probable depression of the right hilum. No definite mass can be seen but given the history, malignancy is the most concerning differential. Other differentials for collapse include mucus plugging and an inhaled foreign body.

Initial blood tests may include FBC, U/Es, LFTs, bone profile, CRP, ESR and TFTs. A CT chest with IV contrast should be performed to assess for an underlying tumour. A CT of the abdomen will usually also be acquired at the same time to enable lung cancer staging.

The patient should be referred to respiratory/oncology services for further management, which may include biopsy and MDT discussion. Treatment, which may include surgery, radiotherapy, chemotherapy, or palliative treatment, will depend on the outcome of the MDT and the patient's wishes.