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...