test of x-ray for 6 c. - elearning.sumdu.edu.ua

Test_of_X-ray_for_6_c..docxОлена Костянтинівна Редько

2015

3

ЗмістКлючові терміни:

Ключові терміни: 3

Ключові терміни:

Case A:, Case B:, Case C:, Case D:, Case E:, Case F:, Case G:, Case H:, Case I:, Case J:, Case K:,Case L:, Case M:, Case N:, Case O:, Case P:, Interpretation of Case BTest your skill in reading these 32 pediatric chest radiographs.

Many of these have subtle findings. Unfortunately, subtle findings become even lessobvious when they are displayed on a computer monitor. They are reproduced here asbest as possible. You may need to darken the room lights and adjust the contrast andbrightness on your monitor to appreciate some findings.

PART 1Case A:This is a 15-month old male with fever, coughing, and tachypnea.View Case A.

Interpretation of Case ABilateral central pulmonary infiltrates, but most marked in the right middle and left lower lobes. Theleft

lower lobe infiltrate is best seen on the lateral view inferiorly over the spine. The lungs are hyperaerated.Impression: Right middle and left lower lobe infiltrates.Case B:This is a 3 year old female whose parents do not speak English well. Her chief complaint is coughing

and difficulty breathing. There is mild bilateral stridor on exam. Her cough sounds slightly bronchospastic,but

not barking in nature.View Case B.


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Interpretation of Case BNo infiltrates are noted. The right side is more lucent (darker) compared to the left. This is subtle and

may be difficult to appreciate unless you step back and view the CXR from a distance. The righthemidiaphragm is slightly higher than the left hemidiaphragm, however, it should be higher than this.Both these findings suggest right sided hyperexpansion. More clinical history through a translatorindicated that she was jumping on a bed while eating some food (thought to be meat), when she beganchoking. Since that time, she has experienced respiratory difficulty.

Further radiographs revealed bilateral air trapping. Bronchoscopy revealed bilateral bronchial peanutfragment foreign bodies.

Impression: Right sided hyperexpansion and air trapping. Possible bronchial foreign body.Case C:This is a two week old male infant who arrived in the E.D. with a history of noisy breathing and

worsening respiratory distress. VS T36.7, P160, R60, BP 100/70. His color is dusky. His oxygen saturationis 86% in room air. Oxygen is applied and his color improves. His oxygen saturation is now 96%. He hasdiminished breath sounds bilaterally. There are moderately severe retractions.

View Case C

Interpretation of Case CThere is hyperlucency of the left chest with a mediastinal and cardiac shift to the right. Although this

may look like a tension pneumothorax, realize that such a large tension pneumothorax would generallybe associated with hypotension, bradycardia, and persistent hypoxia (despite supplemental oxygen).

Since this infant appears to have good cardiovascular function and his oxygenation improved withsupplemental oxygen, one should not immediately jump to evacuating the left chest since he is currentlystable.

After carefully reassessing the situation and reexamining the CXR, it is evident that lung markings arepresent in the left chest. This represents a hyperexpanded lobe. The hyperexpansion is so severe that itcompresses the remaining left lung and pushes the heart and mediastinum to the right, compressingthe right lung as well.

Impression: Left upper lobe hyperexpansion with mediastinal shift. Congenital lobar emphysema.Case D:


This is a 3-month old female with fever and coughing.View Case D.

Interpretation of Case DThis is a dark film. It is best read using a hot light. To maximize visibility on the computer monitor, turn

off the room lights and adjust the contrast and brightness controls on your monitor to maximize imagequality.

There is a faintly visible infiltrate in the right upper lobe. Subtle findings may be more difficult toappreciate on dark films.

Impression: Right upper lobe infiltrate.Case E:This is a two month old male with a history of a VSD (taking digoxin) arriving in the E.D. for a possible

seizure. His parents witnessed an episode of body stiffness, jerking of all extremities, and upward rollingof his eyes lasting one minute. An ambulance brought him to the E.D.

His exam was significant for a harsh grade III/VI systolic murmur. His lungs were clear. He was alertand active, and no neurologic abnormalities could be detected. He promptly had another generalizedseizure in the ED which lasted five minutes. An IV could not be started during the seizure. After theseizure, he was not drowsy. An IV was started, and he was given IV lorazepam and phenobarbital.

View Case E.

Interpretation of Case EThere is cardiomegaly with slightly prominent pulmonary vascularity suggesting a left to right shunt.

An unexpected finding was the absence of a thymic shadow that one would expect to see in a 2-monthold. A prominent thymus is usually visible in the upper mediastinum on the AP or PA view. On the lateralview, the space anterior and superior to the heart is usually occupied by the thymus in this age group.However, in this child, the thymic space is occupied by lung tissue.

His laboratory studies were significant for hypocalcemia. Although his clinical presentation resembleda classic seizure, in retrospect, the hypocalcemia suggests that these episodes were symptomatictetany.

Impression: Cardiomegaly and absence of the thymic shadow. In conjunction with the VSD andhypocalcemia, this is most consistent with DiGeorge syndrome (thymic and hypoparathyroid aplasia orhypoplasia).

Case F:This is a 16 year old male presenting to the emergency department with moderately severe acute

wheezing. His oxygen saturation is 95% in room air. He is noted to be wheezing. He is given an albuterolaerosol and he is noted to improve, but his degree of aeration is still somewhat poor. He complains ofmild chest pain.

View Case F.


Interpretation of Case FBoth lungs are hyperaerated. There are vertical air densities seen in the upper mediastinum extending

up into the soft tissues of the neck. This is evidence of air dissecting against the left border of the cardiacsilhouette. There is no evidence of pneumothorax.Impression: Pneumomediastinum.In a pneumomediastinum, the lateral view will often show air dissecting along the trachea or free air

may be visible in the space anterior to the heart in the thymic region. In this case, free air in the thymicregion is visible, but it may be difficult to see it on your computer monitor. There are vertical oblique airdensities in the thymic space anterior and superior to the heart on the lateral view. Darken the room andadjust the contrast and brightness on your monitor to see it best.

Case G:This is a 10 year old male who came to the E.D. with a history of coughing and fever. Poor breath

sounds were noted on the left.View Case G.

Interpretation of Case GThe left lung is consolidated. This atelectasis results in a mediastinal shift to the left. There are air

bronchograms evident over the left lung. On the original film, there is a suggestion of a 1.5cm ylindricalforeign body in the left mainstem bronchus. Further history revealed that he had "swallowed" a plastic

bullet several days ago.Impression: Consolidation of the entire left lung with the suggestion of a foreign body in the left

mainstem bronchus.Case H:This is an 11-month old female with a history of a previous pneumonia, who now presents with fever

and coughing. Mild wheezing and rales are noted on auscultation.View Case H.


Interpretation of Case HThere are small interstitial central pulmonary infiltrates.Impression: Small interstitial central pulmonary infiltrates most consistent with a viral pneumonia.Case I:This is a 6-week old male infant. His parents brought him to the E.D. because of coughing and

congestion. He had a 20 minute episode of frequent coughing, but now seems to be better. He is feedingwell. There is no history of fever or cyanosis. His vital signs are normal. Oxygen saturation is 100% inroom air. Auscultation is clear.

View Case I.

Interpretation of Case IThe upper mediastinum shows the usual prominent thymus for this age. The thymic shadow is larger

on the infant's right than on his left. There is a density in the right upper lobe, but it is obscured by thethymus. Part of this density appears to be from the scapula, but on close inspection, there are densitiessuggesting infiltrates aside from the thymus and the scapula in the right upper lobe.

Impression: Right upper lobe infiltrate or partial atelectasis.Case J:This is an 18-month old female with a history of prematurity and mild bronchopulmonary dysplasia.

She arrives in the emergency department with a history of fever, coughing, and difficulty breathing.Coarse breath sounds and mild wheezing are noted on auscultation.

View Case J.


Interpretation of Case JThere is a small area of atelectasis in the right middle lobe. This is best seen on the lateral view as an

oblique flattened wedge shaped density over the heart. Instead of the normal triangular shape of theright middle lobe, it appears to be flat and compressed indicating atelectasis.

Impression: Right middle lobe atelectasis.Case K:This is a 5-week old infant with a history of fever and coughing. He arrives in the emergency

department with severe respratory distress. His initial CXR shows a small pneumonia. He is thought tohave a staph aureus pneumonia because of his severe condition. He requires mechanical ventilation inan intensive care unit. During his second day of hospitalization, he suddenly

becomes severely cyanotic, bradycardic, and hypotensive. He has good breath sounds bilaterally.This portable CXR (AP only) is obtained.View Case K.

Interpretation of Case KThere is a lucency visible surrounding the heart; representing air dissecting into the pericardium.Impression: PneumopericardiumPneumopericardium is usually a serious emergency since it results in sudden cardiac tamponade.

Immediate pericardiocentesis is required. This is a highly complication prone procedure since it maylacerate the heart and even if it temporarily relieves the tamponade, more air will continue toaccumulate in the pericardial space resulting in recurrent tamponade.

Because of reaccumulation of air, inserting a plastic catheter into the pericardium using an IV catheterover needle or the Seldinger technique, may be more effective at preventing reaccumulation of air andtamponade. If a surgeon is immediately available, a pericardial window procedure may be moreefficacious immediately following pericardiocentesis.

Case L:This is an 11-year old female with a history of fever and coughing for 5 days. VS T39.1 (oral), P122, R

20, BP 107/76. Oxygen saturation 99% in room air. Auscultation is significant for moist rhonchi in the leftbase.


View Case L.

Interpretation of Case LThere is a patchy infiltrate at the left lung base. This is seen on the lateral view obliquely over the heart

and on the PA view as haziness in the left lower lung. The prominence of the right perihilar region isprobably due to rotation. Note the asymmetry of the spinal column and the ribs. This rotation exposesmore of the right hilum in the radiograph, making it appear more prominent.

Impression: Patchy area of consolidation at the left lung base.Case M:This is a 12-year old female complaining of a headache and productive cough. Onset of fever last night

to 39 degrees. Rales are noted in the left base.View Case M.

Interpretation of Case MThere are infiltrates in the right middle and left lower lobes. The right middle lobe infiltrate is blurring

the right heart border. It can also be seen on the lateral view as streakiness over the heart. The left lowerlobe infiltrate is best seen on the lateral view posteriorly on the diaphragm. It can also be seen on the PAview as haziness in the lower lung on the left. The infiltrate in the right middle lobe was noted two yearsago on a previous radiograph, and the possibility of a chronic infiltrate was raised.

Impression: Right middle and left lower lobe infiltrates.Case N:This is a 9-year old male with a history of fever, headache, nausea, and coughing.View Case N.


Interpretation of Case NThere is a circular density in the right lung. This is the superior segment of the right lower lobe.

Although this has the appearance of a mass, it is most likely an infectious process.Impression: Spherical consolidation in the right lower lobe (round pneumonia).Case O:This is a 20-year old male who arrives in the E.D. complaining of difficulty breathing. He also describes

some mild chest pain. He is a poor historian, but does admit to smoking crack cocaine earlier in the day.Auscultation reveals a "friction rub" that occurs in synchrony with his heart rate. His pulses and perfusionare good.

View Case O.

Interpretation of Case OOn the PA film, air is seen dissecting along the superior mediastinum bilaterally. These vertical air

densities extend up into the soft tissues outside the pleural cavity. There is also air superimposed overthe inferior aspect of the aortic arch. The lateral view shows air densities demarcating the thymus.

The lateral view also shows vertical air densities outlining the trachea.Impression: Pneumomediastinum.Pneumomediastinum is commonly associated with substance abuse and other activities that involve a

valsalva maneuver. The "friction rub" that was auscultated was not really a friction rub. This grating soundcalled Hamman's Sign is associated with pneumomediastinum.

Case P:This is a 17-month old female with a history of fever and coughing. She is crying on exam making

auscultation difficult. Oxygen saturation is 98% in room air.View Case P.


Interpretation of Case PThere is a small subtle infiltrate in the left costophrenic angle. This is best seen on the PA view as an

increased density where the ribs cross each other in the left lower lung near the costophrenic angle.Impression: Small infiltrate in the left costophrenic angle.PART 2Case A:This is a 16-month old male with coughing,wheezing, and tachypnea.View Case A.

Interpretation of Case ANo acute infiltrates are seen. There is a faint vertical lucency paralleling the right mediastinal border

see only on the PA view. No other vertical air densities are seen. This may be an artifact or this patientmay have a small pneumothorax or a pneumomediastinum. A pneumomediastinum usually has othervertical air densities over the upper mediastinum on the PA view and over the thymic space on thelateral view. In this case, the thymic space is normal.

Impression: Right mediastinal lucency. This is mostly likely an artifact or possibly, a small rightpneumothorax or pneumomediastinum.

Case B:This is a 9-month old male with fever and coughing.View Case B.

Interpretation of Case BThis film is dark. Turn down the room lights and adjust the brightness and contrast on your screen.There is an area of density best seen on the lateral view posteriorly just above the diaphragm over the


inferior vertebral body. This represents consolidation at the medial aspect of the left lung baseposteriorly. On the lateral view, these vertebral bodies should progressively darken (become blacker) asyou proceed inferiorly (T1 to T12). If one the vertebral bodies appears whiter than it should be, this isoften due to an overlying soft tissue density such as an infiltrate or consolidation.

Impression: Subsegmental consolidation of the posterior segment of the left lower lobe.Case C:This is a 2-month old female who is wheezing.View Case C.

Interpretation of Case CThe diaphragms are flattened indicating bilateral hyperaeration. The lateral view demonstrates this

best. Both diaphragms have lost the usual dome appearance. They are both flattened obliquely.Additionally, the lateral view shows the increased AP diameter. In small

children, hyperaeration (flattened diaphragms) are best demonstrated on the lateral view as seenhere.

There may be slight accentuation of the central lung markings suggesting a viral pneumonia.Impression: Hyperaeration with accentuated central lung markings.Case D:This is a 15-month old male with fever and coughing.View Case D.

Interpretation of Case DThere is a density in the right upper lobe. This is not due to the scapula since the other side does not

have this appearance. This is a patchy area of consolidation in the posterior portion of the right upperlobe.

Impression: Partial right upper lobe consolidation.Case E:This is a 6-week old female presenting with fever and cold symptoms. Her temperature is 39 degrees

rectally. She is feeding well.Exam VS T39.1 (rectal), P125, R45, BP 75/35, oxygen saturation 98% in room air. She is alert and

active. She is not toxic and not irritable. AF flat and soft. TM's normal. Oral clear. Neck supple. Heartregular without murmurs. Lungs are probably clear, but there may be some wheezing. Abdomen benign.

View Case E.


Interpretation of Case EThe lungs are hyperaerated. The diaphragms are flattened (most notably, on the lateral view). There is

a density in the right upper lobe seen best on the PA view. The scapula can be visualized distinctly fromthis density. This is an area of consolidation or atelectasis in the posterior segment of the right upperlobe. This density is also evident on the lateral view in the superior posterior region.

Impression: Hyperaeration of the lungs with an area of consolidation or atelectasis in the posteriorsegment of the right upper lobe.

Case F:This is a 3-year old male with fever and coughing.View Case F

Interpretation of Case FThere is a patchy area of consolidation in the posterior portion of the left lower lobe. The lateral view

best demonstrates this as a density over the inferior vertebral bodies. As stated earlier, the appearanceof the vertebral bodies should darken as one proceeds inferiorly. Note that the two most inferior vertebralbodies above the diaphragm are whiter than the vertebral bodies above them. This is due to an overlyingconsolidation that is clearly outlined when examining the radiograph carefully. This density is locatedbehind the heart making it difficult to see on the PA view. However, an increased streakiness (density) isseen over the left inferior lateral heart border.

Impression: Segmental area of consolidation in the posterior portion of the left lower lobe.Case G:This is a 3-year old male with fever and coughing. He is tachypneic. Crackles are heard on the left. No

wheezing is heard, but he has a bronchospastic cough. There is no past history of asthma.View Case G.


Interpretation of Case GThe central markings are accentuated. The lungs are otherwise clear.Impression: Accentuated lung markings.Case H:This is a 3-year old male with a history of a fever and coughing for one week. Rales are heard on the

right.View Case H.

Interpretation of Case H:The central markings are definitely accentuated. There is an infiltrate in the right middle lobe.Impression: Bilateral central and right middle lobe infiltrates.Case I:This is a 14-month old female with a past history of severe prematurity and chronic lung disease. She

now has fever, coughing, and wheezing.View Case I.


Interpretation of Case IThe pulmonary outflow tract is prominent. The central markings are accentuated and fluffy, more so

on the right. This is evident on the PA view. However, the lateral view also demonstrates increasedmarkings and fluffiness around the hilum. These findings are consistent with chronic lung disease andpossibly suggestive of pulmonary hypertension.

Impression: Accentuation of the central markings. Chronic lung disease (bronchopulmonarydysplasia) and possible pulmonary hypertension.

Case J:This is an 14-month old male with a history of coughing and fever.View Case J.

Interpretation of Case JThe PA view demonstrates a density in the left upper lobe. The lateral view demonstrates a triangular

density in the upper lung and a flat density positioned obliquely over the heart. The upper density is anarea of consolidation in the posterior apical segment of the left upper lobe. The lower density over theheart is a consolidation of the lingula. Note that the PA view does not demonstrate any densities on theright in the area of the right middle lobe. An infiltrate in the lingula usually obscures the left heart border(not so obvious in this case).

Impression: Left upper lobe and lingula consolidation.Case K:This is a 4-month old with respiratory distress and diminished breath sounds on the right.View Case K.

Interpretation of Case KPA inspiratory and expiratory views are shown here. The inspiratory view demonstrates

hyperexpansion of the right hemithorax. The right hemithorax is blacker than the left. The righthemithorax is also bigger than it should be. Lung markings are evident throughout both lungs makingthis incompatible with a pneumothorax. The expiratory view shows satisfactory emptying of the left lung,but persistent hyperexpansion of the right lung.

The diagnosis of foreign body is considered, but the typical age group for a bronchial foreign body is 2years and above. This child's past history is significant for complaints of abnormal breathing in the past.

Closer examination of the radiographs on the right show a density in the upper medial hemithorax(small density compressed against the upper mediastinum). This is probably a compressed right upperlobe.

Impression: Hyperexpansion of the right middle and right lower lobes raising the possibility of anobstruction in the intermediate right bronchus.

This child is ultimately found to have a congenital lobar emphysema of the right middle lobe.Case L:This is a 4-month old female with a history of fever and coughing.View Case L.


Interpretation of Case LThe PA view looks fairly normal except for blurring of the left medial diaphragm. The lateral view

demonstrates an infiltrate superimposed over the inferior aspect of the spine just above the diaphragm.The vertebral bodies inferiorly should be blacker than the vertebral bodies above them. In this case, theinferior vertebral bodies are whiter indicating the presence of an overlying soft tissue density. It is hard toappreciate any infiltrate on the PA view since it is behind the heart on the left.

Impression: Small infiltrate in the posterior portion of the left lower lobe.Case M:This is a 6-week old female with a history of fever and cold symptoms.View Case M.

Interpretation of Case MThere is a faint density in the right upper lobe on the PA view. The lateral view also demonstrates this

density in the upper lung posteriorly. The diaphragms are flattened indicating hyperaeration.Note the spherical density overlying the middle portion of the right clavicle. This is callus formation of a

healing right clavicle fracture. Healing clavicle fractures in this age group are usually due to fracturesoccurring during birth. While most of these are diagnosed on routine examination at birth, some of theseare not. Such a finding on a chest radiograph may be the first

indication of a clavicle fracture. This problem is benign and does not require any special care at thispoint. Consider the possibility of child abuse if the history or the appearance of the fracture does notsuggest that it was caused by the birthing process.

Impression: Hyperaeration of the lungs with an area of consolidation or atelectasis in the posteriorsegment of the right upper lobe. Healing right clavicle fracture.

Case N:This is a 17-month old male with a history of fever, coughing, and respiratory distress.View Case N.


Interpretation of Case NThere is an obvious consolidation of the right upper lobe. Although both costophrenic angles are

sharp, note the abnormal contour of the right hemidiaphragm.The diaphragm should have a domed appearance (normal) or a flattened appearance (hyperexpanded

lungs). But the right hemidiaphragm here has an unusual contour where it is flat medially, then it sharplydips downward laterally. The diaphragms should normally be highest in the middle (domed appearance)or highest medially (flattened appearance).

Impression: This patient's PA radiograph demonstrates a substantial consolidation of the right lungwith an abnormal diaphragm contour. Although the lateral aspect of the diaphragm is not truly thehighest point of the diaphragm, this is still suspicious for a pleural effusion. Subsequent radiographs ofthis patient's lungs demonstrated the presence of a pleural effusion.

Looking back at the lateral view, the posterior costophrenic angle may be blunted suggesting a pleuraleffusion, however, this is where the film is cut off, thus, this appearance may be an artifact.

Case O:This is a 2-month old male with fever, noisy breathing, and tachypnea. His breath sounds are slightly

coarse.View Case O.

Interpretation of Case OThe PA view demonstrates moderate cardiomegaly and accentuation of the central markings. These

findings are most consistent with early congestive heart failure rather than a viral pneumonia. This PAview is slightly rotated making this radiograph more difficult to interpret. The prominent right side of theheart, was initially felt to be due to the rotation. However, it is too large to be due to rotation alone.

Impression: Early congestive heart failure. An echocardiogram confirmed the presence ofcongestive heart failure due to congenital heart disease.Case P:This is a 3-year old male with frequent colds who now presents with fever and coughing.View Case P.


Interpretation of Case PThe PA view shows both lower lung fields to be denser than the upper lung fields. This is more evident

on the left than on the right. The apex of the heart is displaced outward suggesting the possibility of earlycongestive heart failure.

However, in this instance, the findings above are all due to a slightly suboptimal inspiratory effort.Because of the poor inspiration, the central markings are crowded. The diaphragm is at the level of the9th rib. Ideally, the 9th posterior rib should be above the diaphragm.

Impression: No definite acute cardiopulmonary disease. Borderline suboptimal inspiration.


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