Test yourself: X-thorax
Case Study 1.
A 24-year-old man presents to his GP with general malaise and dyspnea
complaints present for 2 days.
History of asthma.
A chest X-ray is made (fig. 1).
Figure 1. PA and lateral chest X-ray.
A dense line is seen in the left lung apex (= visceral pleura). Lung vessel markings are absent peripheral of this line.
Pneumothorax in left lung apex.
♦ Figure 1. Answer: Pneumothorax in left lung apex.
Case Study 2.
A 55-year-old man presents to the Emergency Assistance department with complaints of acute dyspnea and pain when breathing.
Lab: leukocytes 20, CRP 250.
History of hypertension, smoking
A chest X-ray is made (fig. 2)
Figure 2: PA and lateral chest X-ray.
No consolidations are visible in the lungs. The heart contours and diaphragmatic domes are sharply delineated. A rind-shaped lucency can be seen at right subdiaphragmal. The lucency does not have the configuration of an intestinal structure.
Intra-abdominal free air. Gastric perforation was found in the OR. Note: acute abdominal problems can sometimes present as a pulmonary problem. The above patient was very sick and each movement (also breathing!) was very painful.
♦ Figure 2. Answer: intra-abdominal free air.
Case Study 3.
A 41-year-old man presents to his GP with general malaise and complaints of dyspnea. The dyspnea has been present for a few weeks, but for three days now patient has also had a fever (Temp 38.3).
History: rheumatoid arthritis, sinusitis.
Figure 3. PA and lateral chest X-ray
A consolidation can be seen on the PA image on the transition from the lower to the middle fields. The right heart contour and the right hemidiaphragm are sharply delineated (so NO silhouette sign). There is no obvious air bronchogram.
A consolidation projecting over the heart can be seen on the lateral image. The consolidation borders on the right major fissure at back.
In combination with the clinical history, this picture is consistent with pneumonia of the middle lobe.
♦ Figure 3. Answer: middle-lobe pneumonia.
Case Study 4.
A 20-year-old woman presents to her GP with complaints of dyspnea and fever.
The patient has just returned from a holiday in Spain.
Figure 4. PA and lateral chest X-ray.
You can not see clearly through the heart on the PA image. The heart contour and diaphragmatic dome are clearly visible.
Note that the lower thoracic vertebrae are denser (= whiter) than the vertebrae above them (normally, vertebrae become less dense in the caudal direction). The consolidation in the lower fields contains a number of air bronchograms. The level corresponds with the level on the PA image, therefore this is the left lower lobe.
Pneumonia left lower lobe.
♦ Figure 4. Answer: Pneumonia left lower lobe.
Case Study 5.
A 35-year-old man has had ‘complaints of tightness on the chest’ for years and would like to know the cause. Patient has no fever at the time of presentation.
History: smoking ++, alcohol +.
Figure 5. PA and lateral chest X-ray.
Prominent hili are noticed on the PA image. Neither the left and right pulmonary artery are clearly distinguishable.
The lateral image has more dense structures at the hilar side than can be explained by normal anatomy.
No abnormalities in the lung fields. Lung vessel markings are normal (so no interstitial lung disease).
The spherical hilar configurations are consistent with mediastinal/hilar lymphadenopathy. No distinction can be made between a pathologically enlarged lymph node and a space occupying lesion.
Biopsy of one of the lymph nodes revealed non-cheesy granulomas. Diagnosis: sarcoidosis.
♦ Figure 5. Answer: mediastinal/hilar lymphadenopathy in sarcoidosis.