Case Book For The Medical Students Guide To The Plain Chest Film

Handout for VMS II Course: Disease, Diagnosis and Therapeutics
Case Book for
The Medical Student's Guide to the Plain Chest Film
Edwin F. Donnelly, M.D., Ph.D.

Associate Professor of Radiology and Radiological Sciences Vanderbilt University Medical Center
2009 Version
Copyright 2008-2009 Edwin F. Donnelly, M.D., Ph.D. All rights reserved. No part of this publication can be reproduced or distributed without the written permission of the author.
This version of the document has been optimized for viewing on the computer, not printing. The image resolution has been lowered to keep the lesize down. These images will not appear correct if printed.
Contents
Contents Preface 1 White Belt Cases 2 Yellow Belt Cases 3 Orange Belt Cases 4 Purple Belt Cases 5 Blue Belt Cases 6 Green Belt Cases 7 Brown Belt Cases 8 Black Belt Cases
i iii 1 23 43 63 87 107 129 153
ii
Preface
This collection of cases is designed to be a companion to the new (2009) edition of my Medical Students Guide to the Plain Chest Film. The Guide instructs the student on the systematic evaluation of the plain chest lm using the clavicle method. I have collected here a series of graduated plain frontal chest lms for the student to not only practice his or her chest lm interpretation skills, but also to improve.
How not To Use These Cases

There is one way that you can spend a lot of time with these cases and really not improve your chest lm interpretation skills at all. That way is to casually look at each lm and then go right away to the text describing the case. The overwhelming majority of your learning comes at the exact point where you force yourself to make a decision about what you think is going on in the lm. By just casually looking at the lm, not thinking too much about, not forcing yourself to make a conclusion, and then just reading my description, you will delude yourself into thinking that you are progressing when in fact you are making no progress at all.
How To Learn To Read Chest Films

If your goal is to improve your skills at reading chest lms, you are in luck because, if you utilize these cases properly, you become much better. The rst thing you should do is come up with a systematic method for evaluating a plain chest lm. For a long time I told students iii
that it doesnt matter what method they use, as long as it is systematic. I still feel that is true, but so many students have requested that I just tell them a method that I have nally given in and developed the clavicle system. Whether you use that method or some other, your should rst read my Medical Students Guide to the Plain Chest Film because it not only describes the clavicle method in great detail, but it also goes through all of the major categories of abnormalities that you will nd on these lms. Once you have been through the Guide, then you should look at these cases. The best way to use these cases is to treat each one as if it is a lm on one of your patients and it is your responsibility to extract as much information as possible from the lm. Look at the lm and analyze it with your systematic method. Then consider all of the ndings that you have found, and decide what problems are present. Remember, there may be multiple problems present and there may be ndings that, while abnormal, are not really signicant. Once you have made a rm commitment to what you think is going on in the lm, then you should read my description. I go through every step of the clavicle system for each lm and then I summarize the major abnormalities and their signicance at the end of the discussion. The cases gradually get more dicult as you progress through the colored belt system. For each of the eight belt levels there are eight related cases, for a total of 64 cases in all. This collection is not meant be comprehensive that is, it is not designed to cover all of the abnormalities you will encounter on your patients lms, but rather it is intended to give you practice and experience in a variety of increasinglydicult types of cases. By the time you nish the Guide and all of these cases, you will have developed a strong foundation upon which you will continue build for the rest of your career.
iv
Group
White Belt Cases
White Belt Cases

he cases here are designed to be extremely easy and to illustrate some basic concepts in the interpretation of plain chest lms. You should use a systematic approach to analyze each of these lms. When you look at these, imagine that each lm corresponds to a patient of yours and think about what the ndings of that chest lm would mean for your patient. Is further imaging required? Is a diagnostic or therapeutic procedure indicated? Is the lm normal?
1 White Belt Cases
Case 1
history: 24 year-old presents to the emergency department with a cough.
Case 1
Correct You would verify that it is the correct patient and lm. Life Support No devices. Anatomy: Airways Airways normal, minor ssure not well seen. Bones All appear normal. Contours All appear normal. Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces All interfaces are well-preserved. Categorize No abnormal patterns. Limitations None, excellent quality lm. Extra Look Trachea, hila and hidden areas all appear normal.
Notice that a normal trachea does deviate slightly to the right when it goes by the aortic arch. This is a normal PA chest radiograph. As you encounter abnormal cases in the book, it may be useful to refer back to this image to remind you of what normal looks like.
1 White Belt Cases
Case 2
history: 54 year-old presents to the emergency department with chest pain.
Case 2
Correct You would verify that it is the correct patient and lm. Life Support No devices. Anatomy: Airways Airways normal, minor ssure not well seen. Bones All appear normal. Contours All appear normal. Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces All interfaces are well-preserved. Categorize No abnormal patterns. Limitations None, excellent quality lm. Extra Look Trachea, hila and hidden areas all appear normal.
This is a normal portable, AP chest radiograph. Because the lm is taken with a shorter source-to-object distance and because the heart is farther from the detector on a AP lm, there may be some magnication of the heart and vascular pedicle, but often, as in this case, theres still no question that everything is normal.
1 White Belt Cases
Case 3
history: 44 year-old presents to the emergency department with a fever.
Case 3
Correct You would verify that it is the correct patient and lm. Life Support No devices. Anatomy: Airways Airways normal, minor ssure not well seen. Bones All appear normal. Contours All appear normal. Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces The right heart border shows a silhouette sign. Categorize There is a subtle but real increased, uy opacity
in the right mid to lower lung eld. The appearance is that of alveolar ooding.
Limitations None, excellent quality lm. Extra Look Trachea, hila and hidden areas all appear normal.
The combination of an alveolar ooding pattern with that of a silhouette sign along the right heart border indicates that there is something lling the alveolar spaces in the right middle lobe. The simple dierential diagnosis is blood, pus, water or cells. We would think about hemorrhage (blood) if there were something in the patients medical history that would suggest a tendency towards bleeding in general (thrombocytopenia, etc.) or towards pulmonary hemorrhage specically (such as Goodpastures, Wegeners, Lupus, etc.). We would generally think about pulmonary edema (water) if the pattern were symmetrical and perihilar and if there were an appropriate history. Edema often, but
1 White Belt Cases
not always, also has enlargement of the heart and vascular pedicle. We would think about tumor (cells) such as bronchoalveolar cell carcinoma or lymphoma if the pattern were persistent despite treatment with antibiotics. In this case, even without the history of fever, the most likely (and, incidentally, correct) conclusion is that the patient has a pneumonia in the right middle lobe.
Case 4
history: 45 year-old found down, brought by ems to the emergency department and admitted to the icu where several life support devices were placed.
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1 White Belt Cases
Case 4
Correct You would verify that it is the correct patient and lm. Life Support There are four specic hardware devices that have
been placed. Make sure you at least see all of them before reading further. (1) There is an endotracheal tube in place with its tip below the level of the clavicular heads. Without a reference scale, you cannot make an actual measurement from the picture given here, but if you could you would nd that it is 3 cm above the carina. Ideally it should be between 4 and 5 cm, so it could be pulled back slightly. (2) There is a nasogastric tube, and though its tip goes just o the bottom of the lm, the side-port marker is well-seen and is clearly below the diaphragm, so it is ne. (3) There is a pulmonary artery catheter (dashed line in the gure) which has been placed from a femoral approach. Its tip is just at the right hilum and is ne. (4) There is an intraaortic counter-pulsation balloon. Only its tip (white line in the gure) is visible on the lm, but the balloon itself (white dashes) extends well into the abdomen. The tip of the balloon pump needs to be distal to the origin of the left subclavian artery, or else the balloon may obstruct the left subclavian artery (and thus, the vertebral artery). The tip of this balloon is a little lower than normal. Overlying ekg leads and the external portions of tubes are generally not even worth mentioning unless they might be mistaken for an internal hardware device.
Anatomy: Airways The airways appear normal. The minor ssure is much more prominent than normal.
Bones All appear normal. Contours See below.
11
Case 4 Zoom to illustrate hardware. A. Original image. B. The black dashes overlie the femoral pulmonary artery catheter, the short white line overlies the tip of the intra-aortic balloon pump. The white dashes show the course of the balloon pump, even though it is not visible on the image.
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1 White Belt Cases
Vascular The heart and the vascular pedicle appear slightly larger
than normal, though neither is denitely abnormal. It is dicult to nd an airway/artery pair because of the parenchymal opacities.
Interfaces The central hilar vessels show a silhouette sign. The

other interfaces are well-preserved.
Categorize There is a uy, bilateral, symmetrical and central

parenchymal pattern. It is the pattern of the alveolar ooding.
The hilar vessels are obscured by the parenchymal opacities. Again we are faced with an alveolar pattern, but this time we see that it is easy to conclude that what we are seeing is alveolar pulmonary edema. First, the pattern itself is symmetric and perihilar. In addition, the heart and vascular pedicle appear subjectively larger than normal. The reason the minor ssure is seen so well is that there is uid within it (pleural uid) and adjacent to it (subpleural uid). The clinical history as well as the fact that the patient needed both the pulmonary artery catheter and the intra-aortic balloon pump support the diagnosis of alveolar pulmonary edema from congestive heart failure.
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Case 5
history: 58 year-old smoker with hemoptysis.
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1 White Belt Cases
Case 5
Correct You would verify that it is the correct patient and lm. Life Support No devices. Anatomy: Airways Airways normal, minor ssure not well seen. Bones There is orthopedic hardware seen over the left
shoulder, but it is not all within the eld of view. There are also old, healed rib fractures seen bilaterally.
Contours All appear normal. Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces All interfaces are well-preserved except for the areas
obscured by the large white opacity near the right hilum.
Categorize There is a large, solid white opacity which falls into

the nodule category, but would be classied ocially as a mass because of its size (greater than 3 cm in diameter). The mass is not a perfect sphere, being somewhat lobulated in shape. There is also a small round lucency seen near the center which could represent some cavitation.
Limitations None, excellent quality lm. Extra Look Trachea, left hilum and hidden areas all appear
normal. The right hilum is obscured by the large mass. This is a large lung cancer. Other entities, including some infections and abscesses can have this kind of appearance, but the general thought is that any mass (i.e., bigger than 3cm) is cancer until proven otherwise. In this case, lung biopsy for tissue diagnosis was obtained, and ct and pet scans were also obtained to aid in staging.
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Case 6
history: 37 year-old who comes to the emergency department acutely short of breath.
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1 White Belt Cases
Case 6
Correct You would verify that it is the correct patient and lm. Life Support No devices. Anatomy: Airways The trachea shifts slightly to the left.
out than those on the left. The minor ssure is not seen at all (nor is the right lung, for that matter).
Bones The ribs on the right side appear more spread Contours The heart is shifted to the left and the right
diaphragm is displaced downward slightly.
Vascular Heart and vascular pedicle are normal in size.

vessels are seen on the right.
No
Interfaces The right heart border is completely obscured. Categorize There is a large right-sided pneumothorax (mustknow pattern).
Limitations None, excellent quality lm. Extra Look The amount of tracheal shift is similar to that of
the rest of the mediastinum. The right hilum cannot be seen at all. No abnormalities are seen in the hidden areas. This patient has a large right pneumothorax. The other ndings suggest that this may be a tension pneumothorax. Of particular concern are the complete collapse of the right lung, the shift of the mediastinum, the inferior displacement of the right hemidiaphragm and the spreading
17 of the ribs on the right side. This is the kind of nding that needs to be seen right away, and it is because of ndings like this that you should always make sure you look at any lm you order. Imagine what would happen if this lm got lost in the radiology department for several days.
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1 White Belt Cases
Case 7
history: 85 year-old with long-standing pulmonary symptoms.
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Case 7
Correct You would verify that it is the correct patient and lm. Life Support No devices. Anatomy: Airways Airways normal, minor ssure not displaced. Bones All appear normal. Contours Central pulmonary arteries appear too large,
peripheral vessels are diminished.
Vascular The heart and vascular pedicle are normal, but the
central pulmonary arteries are enlarged. The peripheral vessels are diminished.
Interfaces All interfaces are well-preserved. Categorize The lungs are hyperinated in the emphysema pattern
(must-know pattern). There are some areas of vascular crowding in the lung bases (atelectasis pattern) as well.
Limitations None, excellent quality lm. Extra Look Trachea and hidden areas all appear normal.
The hila appear too large, but this is because of the enlarged pulmonary arteries. This is a patient with severe centrilobular emphysema. This patient is markedly hyperinated. The atelectasis in the lung bases represents more normal lung parenchyma which is actually being compressed by the more-severely emphysematous lung tissue above it. The enlargement of the pulmonary arteries is quite common and is a manifestation of secondary pulmonary hypertension related to the emphysema.
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1 White Belt Cases
Case 8
history: 45 year-old patient in the hospital recovering from recent abdominal surgery.
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Case 8
Correct You would verify that it is the correct patient and lm. Life Support No devices. Anatomy: Airways Airways normal, minor ssure not well seen. Bones All appear normal. Contours Both hemi-diaphragms are partially obscured
and the costophrenic angles are blunted.
Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces There are new soft-tissue interfaces seen laterally in
both lungs near the costophrenic angles. In addition, the normal interface between the hemidiaphragms and the lung are gone.
Categorize The is a homogeneous white pattern seen laterally

over the lung bases. This represents uid in the pleural space (must-know pattern).
Limitations None, excellent quality lm. Extra Look Trachea, hila and hidden areas all appear normal,
though it is dicult to see through the diaphragm in this case because of the uid. There are bilateral pleural eusions with associated volume loss in the lung bases. Pleural eusions are common, especially in hospitalized patients. Sometimes portable lms such as this one can underestimate the size of the eusions, since uid does not always go to the costophrenic angles as it does in this case.
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1 White Belt Cases
Group
Yellow Belt Cases
Yellow Belt Cases

or these cases, imagine that you are an intern covering hospital patients at night. Part of your duty is to check on the chest lms of those patients who had life support devices placed earlier in the evening, but the lms didnt get taken until after everyone else (including all the radiologists!) left. Unfortunately, the resident checking the patients out to you didnt give you any useful history on any of them. For all of these, consider not only what the abnormality on the lm is, but what you should do about it.
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2 Yellow Belt Cases
Case 1
history: Patient checked out to you with the instructions to check cxr.
25
Case 1
Correct You would verify that it is the correct patient and lm. Life Support There is an endotracheal tube with its tip in good
position at the level of the clavicular heads. There is also a nasogastric tube that has a large loop in cervical esophagus and its tip in the thoracic esophagus.
Anatomy: Airways Airways normal, minor ssure normal. Bones All appear normal. Contours All appear normal. Vascular The heart and vascular pedicle are mildly enlarged, but
part of this may be due to the portable technique. In any case, there is clearly no pulmonary edema.
Interfaces All interfaces are well-preserved. Categorize Lung volumes are slightly lower than normal but
there are no other abnormalities.
The problem is the coiled nasogastric tube. There are really two reasons this is a problem. The rst is that the tube does not reach the stomach (remember, both the tip and the side port should be in the stomach, in this case neither is) so there is no way that the tube can do its job. The other problem is that the loop of tubing will act as an irritant in the patients throat and increase the risk of aspiration. The tube should be repositioned.
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2 Yellow Belt Cases
Case 2
27
Case 2
Correct You would verify that it is the correct patient and lm. Life Support There are three internal devices. Make sure you
have identied all of them before reading further. The rst is an endotracheal tube with its tip in good position at the level of the clavicular heads. The second is a left subclavian catheter with its tip just at the level of the svc. Both of these devices are ne. The third is a feeding tube which has a giant loop in its course and which then goes into the trachea, down the right mainstem bronchus and then well into the lower lobe bronchus.
Anatomy: Airways Airways normal, minor ssure normal. Bones All appear normal. Contours See below. Vascular The heart and vascular pedicle are enlarged. None of
the pulmonary vessels appear enlarged, though, and there is no pulmonary edema.
Interfaces There is a silhouette sign along the left hemidiaphragm. Categorize There is increased opacity in the left lung base. This
opacity comes from the crowding of vessels and is a sign of atelectasis. There is also some elevation of the right hemidiaphragm, also a sign of atelectasis.
Limitations The patient is rotated towards the right quite a

bit. This can be conrmed by remembering that the spinous processes (very posterior) should project midway between the
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2 Yellow Belt Cases

heads of the clavicles (very anterior). Here the spinous processes overlap the left clavicular head.
Extra Look Trachea appears normal. The atelectasis described

above is seen through the heart. The hila are not well seen because of the widened vascular pedicle and the patient rotation. The main problem is the feeding tube in the airway. This needs to be corrected immediately and certainly before the tube is used for feeding the patient. The nding of atelectasis in the lung bases is extremely common in hospitalized patients and often occurs because of mucus plugging or poor depth of inspiration.
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Case 3
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2 Yellow Belt Cases
Case 3
Correct You would verify that it is the correct patient and lm. Life Support There is an endotracheal tube in the esophagus.
The patient is on a trauma (spine) board.
Anatomy: Airways Airways normal, minor ssure not well seen. Bones There is a fracture of the right third rib (laterally).
Contours The left mediastinal contour is abnormal,

with loss of the normal denition of the aortic knob and main pulmonary artery.
Vascular The heart is mildly prominent, but the vascular pedicle

appears very wide.
Interfaces All interfaces are well-preserved. Categorize The lung parenchyma looks normal. Limitations The lateral portion of the left lung base is excluded
from the image.
Extra Look Trachea, right hilum and hidden areas all appear normal. The left hilum is not seen because of the widened mediastinum. This patient has clearly suered a recent trauma, which would explain the rib fracture. The widening of the mediastinum is concerning for blood, and further evaluation, usually with ct scanning, is needed to see if there is a vascular injury or a spinal fracture which might cause
31 the bleeding. The endotracheal tube in the esophagus is actually a normal nding in this case, because it represents a Combitube, which is a dual-lumen (see the two lumens?) tube that can be used for ventilation whether it is in the esophagus or trachea. This type of tube is useful for patients with dicult airways or where environmental conditions may be less than ideal (such as a trauma).
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2 Yellow Belt Cases
Case 4
33
Case 4
Correct You would verify that it is the correct patient and lm. Life Support There is a left subclavian central line with its tip
in the superior vena cava (good position).
Anatomy: Airways The trachea deviates slightly to the right. The

minor ssure appears normal.
Bones All appear normal. Contours The left hemidiaphragm is displaced inferiorly. The aortic knob and main pulmonary artery are not well seen. The mediastinum is shifted to the right.
Vascular The heart and vascular pedicle are normal in size,

though they are shifted to the right. There is no pulmonary edema.
Interfaces The aortic knob and main pulmonary artery show a

silhouette sign.
Categorize There is a moderate-sized pneumothorax on the left.

There are increased opacities resulting from crowded vessels in the left lung (atelectasis pattern).
This is a typical iatrogenic pneumothorax caused by the placement of the left subclavian central line. There is partial collapse of the left lung which causes both the atelectasis pattern seen and the silhouette sign along the aorta and pulmonary artery.
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2 Yellow Belt Cases
Case 5
35
Case 5
Correct You would verify that it is the correct patient and lm. Life Support There is a right-sided chest tube, but it never enters
the thoracic cavity. Both its tip and side-port are lateral to the rib cage.
Anatomy: Airways Airways normal, minor ssure not well seen. Bones All appear normal. Contours All appear normal. Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces All interfaces are well-preserved. Categorize There are streaky black lines outside of the lungs
(help! this isnt one of the patterns). [Two circles over the right lung are artifacts related to external structures.]
The chest tube is malpositioned. The black lines represent air dissecting through the soft tissues of the chest wall (we often call this nding subcutaneous emphysema even though it usually involves much more than just the subcutaneous spaces). This case is a good example of why its important to treat patients and not chest lms. What should you do if this is your patient? Clearly the chest tube that is there should be removed, since its not doing any good where it. Does this patient even need a chest tube? Thats for you (the clinician) to decide.
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2 Yellow Belt Cases
Case 6
37
Case 6
Correct You would verify that it is the correct patient and lm. Life Support There is an ivc lter protruding into the right
atrium.
Anatomy: Airways Airways normal, minor ssure not well seen. Bones All appear normal except for some mild scoliosis which may actually just be how the patient was positioned.
Contours All appear normal. Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces All interfaces are well-preserved. Categorize The lung parenchyma looks normal. Limitations None, excellent quality lm. Extra Look Trachea, hila and hidden areas all appear normal.
The ivc lter has migrated from its normal position (below the renal veins and well below the eld of view on this study) in a very high position where it is actually projecting into the heart.
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2 Yellow Belt Cases
Case 7
39
Case 7
Correct You would verify that it is the correct patient and lm. Life Support There is a left subclavian central line which extends
up into the left ij vein.
Anatomy: Airways Airways normal, minor ssure not well seen. Bones All appear normal. Contours All appear normal. Vascular The heart, vascular pedicle and pulmonary vasculature
are all prominent. This is a good example of a patient with a large circulating vascular volume and some mild pulmonary vascular engorgement (several good examples of vessels larger than their adjacent bronchi).
Interfaces All interfaces are well-preserved. Categorize No abnormal patterns. Limitations None, excellent quality lm. Extra Look Trachea, hila and hidden areas all appear normal.
The left subclavian line is malpositioned (it goes up the ij vein).
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2 Yellow Belt Cases
Case 8
41
Case 8
Correct You would verify that it is the correct patient and lm. Life Support There is an endotracheal tube which goes down the
left mainstem bronchus.
Anatomy: Airways Airways normal, minor ssure not well seen. Bones All appear normal. Contours All appear normal. Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces All interfaces are well-preserved. Categorize There are uy alveolar opacities throughout the
right lung and, to a lesser extent, in the perihilar region of the left lung.
The endotracheal tube is down the left mainstem bronchus. This obviously needs to be corrected because it causes two problems over ventilation of the left lung and non-ventilation (in fact, obstruction) of the right lung. The patient has bilateral pneumonia accounting for the alveolar pattern, but the appearance is no doubt made worse on the right by the obstruction of the airway, leading to some superimposed atelectasis.
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2 Yellow Belt Cases
Group
Orange Belt Cases
Orange Belt Cases

hese cases show more of the basic patterns that you should recognize, but they are slightly more dicult than some of the cases that have been shown before. Work on not only analyzing the lm systematically, but also trying to come up with what you think the single most likely diagnosis is.
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3 Orange Belt Cases
Case 1
history: Patient in the emergency department with shortness of breath.
45
Case 1
Correct You would verify that it is the correct patient and lm. Life Support No devices. Anatomy: Airways Airways normal. The minor ssure has uid
in it.
Bones All appear normal. Contours All appear normal. Vascular The heart and vascular pedicle are normal in size. No
good vessel-airway pairs are seen to evaluate the pulmonary vasculature, but there is an interstitial pattern that could represent interstitial pulmonary edema.
Interfaces All interfaces are well-preserved. Categorize There are linear and irregular shadows (interstitial
pattern). Upon closer inspection, these extra lines can be seen to be septal lines (Kerley lines). (Notice the Kerley B lines). There is also so obscuration of the diaphragm in both lung bases (silhouette sign). There are bilateral pleural eusions.
Limitations None, excellent quality lm. Extra Look Trachea and hidden areas appear normal.
The hila look large, but they are hard to judge on this lm because of all the adjacent opacities.
This is a good example of an interstitial pattern in an acutely-ill patient in the emergency department. The two most-likely diagnoses are
46
3 Orange Belt Cases
interstitial pneumonia and interstitial edema. If the heart and vascular pedicle were enlarged and if there were evidence of pulmonary vascular engorgement, then edema would be the most likely cause. Without these ndings, though, either diagnosis is possible, since patients with an acute mi may show pulmonary edema without the other ndings. Additionally, the presence of the pleural eusions would be unusual for interstitial pneumonia, but typical for pulmonary edema. Generally, the history and physical exam (and lab work) will make it obvious which one is correct. In this case, the patient has interstitial pulmonary edema.
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Case 2
history: Patient in the emergency department with shortness of breath.
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3 Orange Belt Cases
Case 2
Correct You would verify that it is the correct patient and lm. Life Support No devices. Anatomy: Airways Airways normal, minor ssure normal. Bones All appear normal. Contours All appear normal. Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces All interfaces are well-preserved. Categorize There is a left apical pneumothorax (must-know pattern). There is an interstitial pattern.
This case is similar to the previous case in that there is an interstitial pattern in an acutely-ill patient in the emergency department. The dierence here is that there is a pneumothorax and we dont see pleural eusions. Again, history and clinical exam ndings would be most useful to you, but the lack of pleural eusions combined with the very normal heart and vascular pedicle make interstitial pneumonia more likely. In this case the patient had undiagnosed aids and was preventing with pneumocystis carinii (jirovecii) pneumonia (pcp). The pneumothorax occurred because one of the peripheral cysts (not visible) had ruptured.
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Case 3
history: Increasingly-ill patient in the icu
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3 Orange Belt Cases
Case 3
Correct You would verify that it is the correct patient and lm. Life Support There is an endotracheal tube with its tip midway
between the level of the clavicular heads and the carina (too low). There is a left subclavian line (introducer sheath) with its tip in the left brachiocephalic vein. There is a nasogastric tube with both its tip and side port in the stomach.
Anatomy: Airways Airways normal, minor ssure normal. Bones All appear normal. Contours All appear normal. Vascular Heart, vascular pedicle and vasculature appear normal.
There is, however, an interstitial pattern that could represent pulmonary edema.
Interfaces All interfaces are well-preserved. Categorize There is a fairly large pneumothorax on the left (notice that it has apical, lateral, basilar and medial components). There is an interstitial pattern throughout the lungs. On the left, there is also some additional increased opacity which is dicult to classify but which likely represents crowding of the vasculature and septal lines from the volume loss caused by the pneumothorax (atelectasis pattern).
Limitations None, excellent quality lm. Extra Look Trachea and hidden areas all appear normal. The
hila are obscured by the overlying pathology in the lung.
51 Here is yet another interstitial pattern with a fairly normal-appearing heart and vascular pedicle. In this case, the patient is not in the emergency department but in the icu. In this case, the history is crititcal because the patients diagnosis is ruptured cerebral aneurysm, and the edema pattern seen is that of neurogenic edema. The pneumothorax in this case was caused by the line placement. Whether the patient requires a chest tube or not is a clinical decision and cannot be determined based upon this lm. The endotracheal tube should be withdrawn about 2 cm to bring its tip in line with the level of the clavicular heads.
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3 Orange Belt Cases
Case 4
history: 54 year-old internal medicine clinic patient with chronic dyspnea.
53
Case 4
Correct You would verify that it is the correct patient and lm. Life Support No devices. Anatomy: Airways Airways normal, minor ssure not well seen. Bones All appear normal. Contours The diaphragm is displaced inferiorly on
both sides, and it has a scalloped appearance.
Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces All interfaces are well-preserved. Categorize The lungs are hyperinated in what appears to be an
emphysema (must-know) pattern.
This patient has a type of emphysema known as panacinar emphysema. It occurs in patients with a genetic defeciency in alpha-1 antitrypsin. Notice how normal the middle and the apices of the lungs look, while in the bases of the lungs there are far fewer vessels than would normally be seen. This type of emphysema is relatively rare (roughly 1-2 % of all emphysema), but its radiographic appearance is fairly characteristic.
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3 Orange Belt Cases
Case 5
history: 56 year-old internal medicine clinic patient who is short of breath.
55
Case 5
Correct You would verify that it is the correct patient and lm. Life Support There is a left subclavian Portacath with its tip in
the region of the superior vena cava.
Anatomy: Airways The trachea deviates to the right. No airways

are visible on the right side beyond the carina. The minor ssure is not seen.
Bones All appear normal. Contours No anatomic structures can be evaluated on

the right because of the complete loss of air on that side.
Vascular Heart, vascular pedicle and vasculature (at least, what

can be seen of them) appear normal.
Interfaces All interfaces are well-preserved on the left, none can

be seen on the right.
Categorize There is total white-out on the right with shift of the

mediastinum towards the side of the white-out.
Limitations None, excellent quality lm. Extra Look Trachea, hila and hidden areas, where seen, all
appear normal. This is a classic white-out appearance from total atelectasis of the right lung. There are basically two possible etiologies for total whiteout of one side of the chest either total atelectasis from a central
56
3 Orange Belt Cases
obstruction or massive pleural eusion. With total atelectasis, the mediastinum shifts towards the white-out, while with pleural eusion the mediastinum shifts away. A second helpful nding in this case is the cut-o of the airway on the right at the site of the obstruction (right mainstem bronchus). This patient had a lung cancer causing the obstruction.
57
Case 6
history: 61 year-old presents to the emergency department with a cough.
58
3 Orange Belt Cases
Case 6
Correct You would verify that it is the correct patient and lm. Life Support No devices. Anatomy: Airways Airways normal, minor ssure normal. Bones All appear normal. Contours All appear normal. Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces All interfaces are well-preserved. Categorize There is a thick, black line over the right side of the
chest running parallel to the lateral margin of the thorax.
The only abnormality is a skin fold on the right. This should not be confused with a pneumothorax, which could have the same general shape, but would be thin white line.
59
Case 7
history: 54 year-old presents to the emergency department with a fever.
60
3 Orange Belt Cases
Case 7
Correct You would verify that it is the correct patient and lm. Life Support No devices. Anatomy: Airways Airways normal, minor ssure not well seen. Bones All appear normal. Contours All appear normal. Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces All interfaces are well-preserved. Categorize There is a very large mass in the left lung base.
It is partially lled with air and partially with uid (i.e., it is cavitary).
Limitations None, excellent quality lm. Extra Look The large mass is well-seen through the heart and
left hemi-diaphragm, but no other lesions are seen. The two most-likely diagnoses are lung cancer and pulmonary abscess. In this case, the mass turned out to be an abscess.
61
Case 8
history: 12 year-old with leg pain and shortness of breath.
62
3 Orange Belt Cases
Case 8
Correct You would verify that it is the correct patient and lm. Life Support No devices. Anatomy: Airways Airways normal, minor ssure not well seen. Bones All appear normal. Contours All appear normal. Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces All interfaces are well-preserved. Categorize There are multiple, bilateral pulmonary nodules. Limitations None, excellent quality lm. Extra Look Trachea, hila and hidden areas all appear normal.
Look carefully and make sure you can see all of the nodules. Some students notice only the large nodule on the right, but miss all of the other nodules (satisfaction of search). These nodules represent metastatic Ewings sarcoma.
Group
Purple Belt Cases
Purple Belt Cases

gain you are on night duty and you are covering a lot of patients for you colleagues. Again they have given you a series of to do items, including checking on a number of dierent chest lms that have been ordered on these patients. Again it seems they have failed to give you a lot of information about these patients, but it does seem that this group is a little bit more complicated than the last group of patients you were covering at night . . .
63
64
4 Purple Belt Cases
Case 1
history: You are called by the nurse because the line is not function properly.
65
Case 1
Correct You would verify that it is the correct patient and lm. Life Support There is a left subclavian line (port), but the line
stops at the level of the clavicle. There is another segment of tubing projecting over the left side of the chest medially. What is this tubing and where is it? There are also some surgical clips seen on the left, likely in the axilla from prior nodal dissection surgery.
Anatomy: Airways Airways normal, minor ssure not well seen. Bones All appear normal except for an old left 7th rib
fracture seen laterally.
Contours All appear normal. Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces All interfaces are well-preserved. Categorize No abnormal patterns. Limitations None, excellent quality lm. Extra Look Trachea, hila and hidden areas all appear normal.
The line has broken and fragment has traveled down the superior vena cava, into and through the right atrium and is now lodged with its distal end extending into the left pulmonary artery and its proximal end in the right ventricle. The prior lm shows what the line looked like before it broke.
66
4 Purple Belt Cases
Case 1 Port line before it fractured. This lms shows the normal (expected) course, and the tip is just into the right atrium.
67
Case 2
history: Film to check endotracheal tube placement.
68
4 Purple Belt Cases
Case 2
Correct You would verify that it is the correct patient and lm. Life Support There is an endotracheal tube with its tip in good
position at the level of the clavicular heads. There is also a well-positioned nasogastric tube. There are also two unexplained items one that has the density of bone and is seen just lateral to the right heart border and another that has the density of metal and is seen in the stomach, just above the nasogastric tube.
Anatomy: Airways Airways normal, minor ssure normal. Bones All appear normal. Contours There is a calcied circular density seen
within the aortic knob. The other anatomical structures appear normal.
Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces All interfaces are well-preserved. Categorize There is some vascular crowding the lung bases (atelectasis pattern).
Limitations None, excellent quality lm. Extra Look Trachea, hila and hidden areas all appear normal. The unexplained object described above is in the expected location of the right lower-lobe bronchus. There is an aspirated tooth in the right lower-lobe bronchus and there is a swallowed dental lling in the stomach. This patient had presented
69 with severe facial trauma from a motor vehicle accident. The calcied aorta indicates aortic atherosclerosis and the atelectasis in the lung bases is a common nding in hospitalized patients.
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4 Purple Belt Cases
Case 3
history: icu patient with shortness of breath.
71
Case 3
Correct You would verify that it is the correct patient and lm. Life Support There are midline sternal wires and some surgical
clips seen. There are chain sutures in the left lung just above the hilum. There is an endotracheal tube that is a little low. There is a nasogastric tube that goes o the bottom of the lm and appears ne. There are two chest tubes, both coming in anteriorly and going towards the left. There is a right internal jugular line which coils upon itself in the svc.
Anatomy: Airways Airways normal, minor ssure not well seen. Bones All appear normal. Contours See below. Vascular The heart and vascular pedicle are big but there is no
pulmonary edema.
Interfaces There is a silhouette sign along the diaphragm bilaterally and of the left pulmonary artery.
Categorize The opacity in the left lung just above the hilum is a
combination of alveolar ooding and vascular crowding. There are bilateral pleural eusions (must-know pattern).
Limitations None, excellent quality lm. Extra Look All of the hidden areas as well as the hila are
dicult to see on this lm because of the opacities in the lungs. The trachea and central airways appear ne.
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4 Purple Belt Cases
The right IJ line is coiled and needs to be xed. This case represents a typical post-surgical patient in the icu. It illustrates the importance of looking at each life support device individually because it is easy to overlook that one problem if the lm is just looked at as if it were an ink blot. It is also important to recognize that all of the other metallic things seen represent things outside of the patient (the lines are ekg leads while the coil is a part of the ventilator device). These are seen in nearly all icu patients. All of the other ndings above are fairly common post-surgical ndings (including the pleural eusions, basilar atelectasis and combination of post-surgical hemorrhage and volume loss in the left suprahilar region).
73
Case 4
history: icu patient Check line placement.
74
4 Purple Belt Cases
Case 4
Correct You would verify that it is the correct patient and lm. Life Support There is an endotracheal tube in good position.
There is a nasograstic tube which also appears ne. There is a right internal jugular pulmonary artery catheter which has its tip in the left pulmonary artery. The tubing over the base of the heart represents a surgical drain in the pericardial space. There is an intra-aortic balloon counter pulsation pump with its tip into the arch of the aorta.
Anatomy: Airways Airways normal, minor ssure not well seen. Bones All appear normal. Contours See below. Vascular The heart and vascular pedicle are enlarged, the pulmonary vessels are engorged (see the pulmonary artery-bronchus pair seen end-on near the tip of the pa catheter), but there is no pulmonary edema.
Interfaces There is a silhouette sign along the left hemidiaphragm. Categorize There is vascular crowding in the lung bases (atelectasis pattern).
Limitations None, excellent quality lm. Extra Look Trachea and hila appear normal; the area behind
the heart appears opacied and nothing can be seen through the diaphragm.
75 The intra-aortic balloon pump is too high and is obstructing the origin of the left subclavian artery (and thus, the left vertebral artery). It needs to be pulled back. The other ndings represent atelectasis in the lung bases, likely related to bilateral pleural eusions.
76
4 Purple Belt Cases
Case 5
history: 58 year old patient with cough.
77
Case 5
Correct You would verify that it is the correct patient and lm. Life Support There is a single-lead transvenous cardiac pacer
device that comes in from a left subclavian approach. Notice how thinned the pacer lead is as it crosses under the clavicle.
Anatomy: Airways Airways normal, minor ssure not well seen. Bones All appear normal. Contours All appear normal. Vascular The heart is at the upper limits of normal, but the
vascular pedicle and vasculature appear normal.
The pacer wire is frayed and is at high risk of failure.
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4 Purple Belt Cases
Case 6
history: icu patient check line placement.
79
Case 6
Correct You would verify that it is the correct patient and lm. Life Support There are two malpositioned devices, make sure you
see both of them before reading any further. The endotracheal tube goes down the right mainstem bronchus. The feeding tube goes all the way down the esophagus, turns around, comes all the way back up o the top of the lm and actually turns around again such that its tip is just seen at the top of the lm. The right internal jugular line appears ne.
Anatomy: Airways Airways normal, minor ssure not well seen. Bones All appear normal. Contours All appear normal. Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces All interfaces are well-preserved. Categorize There is a pneumothorax on the left (seen laterally
and along the base). There is vascular crowding in the left lung (atelectasis pattern), likely from the pneumothorax.
Three important abnormalities are present: (1) an endotracheal tube down the right mainstem bronchus, (2) a badly-looped feeding tube and (3) a medium-sized pneumothorax. This is another good example of why a systematic approach to the lm is so important for avoiding
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4 Purple Belt Cases
satisfaction of search. You may wonder why the pneumothorax is on the left, while the (presumably) new line is on the right. This commonly occurs when there has been an attempt at line placement on one side that does not go well and then the decision is made to go ahead and put the line in on the other side. The pneumothorax occurred during the failed attempt.
81
Case 7
82
4 Purple Belt Cases
Case 7
Correct You would verify that it is the correct patient and lm. Life Support The endotracheal tube is well-positioned. The
nasogastric tube is not seen as well as you would like, but it does appear to go into the stomach. There are bilateral chest tubes which appear ne. There is a right subclavian introducer sheath, which appears ne with its tip in the subclavian vein. There is also a left subclavian pulmonary artery catheter that has its tip very deep into a lower lobe artery on the right.
Anatomy: Airways Airways normal, minor ssure displaces slightly

inferiorly (atelectasis in the middle lobe).
Bones All appear normal. Contours All appear normal. Vascular The heart and vascular pedicle appear enlarged. There
is also engorgement of the pulmonary vasculature, but there is no pulmonary edema.
Interfaces All interfaces are well-preserved. Categorize There is vascular crowding seen in both lung bases
(atelectasis pattern).
Limitations The lm is a little bit under-penetrated and so the

distal extent of the nasogastric tube is not seen as well as you would like, and the side-port is not seen (could be in the stomach or above the ge junction).
83
Extra Look The trachea appears normal. The hila are obscured
partially by atelectasis. The vascular crowding (atelectasis pattern) is also seen through the heart. The main problem is that the pulmonary artery catheter is so far out that it is at risk of occluding the artery and causing an infarct of the lung. While these catheters can oat out fairly far while taking a pulmonary capillary wedge pressure measurement, at other times they should be retracted back towards the hilum. If they are too far out they may reside in a pulmonary artery whose diameter is not much (if any) bigger than that of the catheter, and all ow through that artery may be obstructed.
84
4 Purple Belt Cases
Case 8
85
Case 8
Correct You would verify that it is the correct patient and lm. Life Support This patient has a tracheostomy. Its canula is at
the level of the clavicular heads. There is also a nasogastric tube which is well-seen and which extends o the bottom of the lm, in good position. There is a right subclavian line which has its tip in the svc, but going through the line is a metallic wire that starts in the middle of the central line and goes down the svc, into the right atrium, loops in the right ventricle, then returns to the right atrium and svc and ultimately points into the right internal jugular vein.
Anatomy: Airways Airways normal, minor ssure not well seen. Bones All appear normal. Contours All appear normal. Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces All interfaces are well-preserved. Categorize No abnormal patterns. Limitations None, excellent quality lm. Extra Look Trachea, hila and hidden areas all appear normal.
The wire seen on this lm represents a guidewire that was used during the placement of the central line. Somehow the guidewire got lost and was left inside the patient.
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4 Purple Belt Cases
Group
Blue Belt Cases
Blue Belt Cases

ou now nd yourself in clinic seeing patients. Many of them have indications for chest x-rays, and you are lucky that you happen to have an x-ray machine right in your clinic. Imagine these are the lms you got today, and that there is no radiologist to overread you.
87
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5 Blue Belt Cases
Case 1
history: 78 year-old who has a cough.
89
Case 1
Correct You would verify that it is the correct patient and lm. Life Support No devices. Anatomy: Airways The trachea deviates to the right. The minor
ssure is not well seen.
Bones All appear normal. Contours All appear normal. Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces All interfaces are well-preserved. Categorize No abnormal patterns. Limitations None, excellent quality lm. Extra Look Trachea deviates because of a mass (dont-miss
lesion); hila and hidden areas all appear normal. This patient has a neck mass on the left. The most common cause is going to be thyroid enlargement from a goiter, but other masses should be excluded (including thyroid cancer and adenopathy).
90
5 Blue Belt Cases
Case 2
history: 72 year-old with chest pain.
91
Case 2
Correct You would verify that it is the correct patient and lm. Life Support The very bottom of an anterior cervical spine fusion
plate is seen at the top of the lm.
Anatomy: Airways Airways normal, minor ssure normal. Bones The posterior left 3rd rib disappears medially. Contours All appear normal. Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces All interfaces are well-preserved. Categorize There is what appears to be a small pleural eusion
at the left lung apex.
There is a lung cancer at the apex of the left lung, invading the left 3rd rib. In this case it is hard to see the tumor itself, but the adjacent pleural eusion (may be pleural thickening or actual tumor itself) is visible.
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5 Blue Belt Cases
Case 3
history: 24 year-old with chronic dyspnea.
93
Case 3
Correct You would verify that it is the correct patient and lm. Life Support No devices. Anatomy: Airways Airways normal, minor ssure not well seen. Bones All appear normal. Contours The central hilar vessels appear large. The
other anatomical structures appear normal.
Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces All interfaces are well-preserved. Categorize No abnormal patterns. Limitations None, excellent quality lm. Extra Look The hila are enlarged. The trachea and hidden
areas appear normal. This is a good example of what to think about when you recognize that the hila are enlarged. The main decision you need to make is whether the enlargement comes from big vessels or from something extra (such as a mass or adenopathy) in the hila. If only one hilum is enlarged, then a mass or adenopathy becomes more likely. When it is both hila, though, the decision is tougher. Often, when the cause is adenopathy, you will be able to see adenopathy in other places (e.g., along the right side of the trachea or below the carina). When the cause is pulmonary arterial enlargement, you may also see enlargement of the right side of the heart. In either case, a lateral view is extremely
94
5 Blue Belt Cases
Case 3 Lateral view. The frontal lm showed large hila. Can you tell from the lateral view whether the problem is adenopathy or enlargement of the central pulmonary arteries?
95
Case 3 Zoom of the lateral view. This zoomed view shows the right pulmonary artery (short black dashes) and left pulmonary artery (long black dashes). These are enlarged. Notice that below the area marked by white dashes (infrahilar window) does not show any abnormal soft tissue density. Adenopathy can often be seen here. helpful because the right and left pulmonary arteries are so well seen on it. Look at the lateral in this case In this case, the lateral view clearly shows that it is the pulmonary arteries themselves that are enlarged (See also the zoomed view). This patient has primary pulmonary hypertension.
96
5 Blue Belt Cases
Case 4
history: 83 year-old man with know prostate cancer.
97
Case 4
Correct You would verify that it is the correct patient and lm. Life Support No devices. Anatomy: Airways Airways normal, minor ssure not well seen. Bones No focal bone abnormalities are present, but
all of the bones appear abnormally dense and there is no dierentiation between the bone cortex and the bone marrow.
Contours There is either something next to the aortic

knob or the aortic knob is enlarged.
Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces There is a silhouette sign along the left hemidiaphragm
and left heart border.
Categorize There are uy opacities in both lung bases, greater

on the left (alveolar pattern).
Limitations None, excellent quality lm. Extra Look Trachea and hila appear normal. Alveolar opacities
are seen through the heart and left hemidiaphragm. The dense bones with loss of the cortico-medullary dierentiation represent diuse metastatic disease to bone. This patient also has leftgreater-than-right basilar pneumonia with an associated pleural eusion (it is the eusion that causes the density near the aortic knob).
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5 Blue Belt Cases
Case 5
history: 32 year-old with cough and fever.
99
Case 5
Correct You would verify that it is the correct patient and lm. Life Support No devices. Anatomy: Airways Airways normal, minor ssure not well seen. Bones All appear normal. Contours There is blunting of the left costophrenic
angle.
Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces All interfaces are well-preserved. Categorize There is an alveolar pattern seen in the left lung base
behind the heart. There is a small left pleural eusion.
Limitations None, excellent quality lm. Extra Look Trachea and hila appear normal. The alveolar pattern is seen only through the heart (dont-miss lesion). This patient has a left lower lobe pneumonia with a small pleural eusion.
100
5 Blue Belt Cases
Case 6
history: 61 year-old with a cough and a known diagnosis.
101
Case 6
Correct You would verify that it is the correct patient and lm. Life Support There is a left subclavian Portacath in good position. You might notice that the catheter is narrowed as it crosses under the clavicle. This line may be starting to weaken there and may ultimately end up breaking o like purple belt case #1.
Anatomy: Airways Airways normal, minor ssure not well seen. Bones The right humerus has an abnormal appearance.
There are extra calcications seen, there are areas of bone erosion and there is a pathological fracture.
Contours All appear normal. Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces All interfaces are well-preserved. Categorize There is a small soft tissue nodule seen in the right
lung (just over the 6th rib).
This patients known diagnosis is sarcoma (synovial cell) of the humerus. The lung nodule represents a metastasis. The pathological fracture of the humerus may represent one of the corner-of-the-lm lesions you are always being warned about (I never said they dont occur).
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5 Blue Belt Cases
Case 7
history: 30 year-old with cough.
103
Case 7
Correct You would verify that it is the correct patient and lm. Life Support No devices. Anatomy: Airways Airways normal, minor ssure not well seen. Bones All appear normal. Contours There are extra bumps along the hila and
right side of the trachea.
Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces All interfaces are well-preserved. Categorize No abnormal patterns. Limitations None, excellent quality lm. Extra Look Trachea and hidden areas appear normal. The
hila are enlarged bilaterally. This patient has bilateral hilar and mediastinal adenopathy. In this case, the extra bump above the right hilum represents adenopathy in the right paratracheal region, while the extra bumps in the hila represent hilar adenopathy. Look at a zoomed view of the lateral lm in this case, and compare it to the same view from case #3 (primary pulmonary hypertension).
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5 Blue Belt Cases
Case 7 Zoom of lateral view. Compare to Case # 3. Notice here that there is a full circle (white dashes) of soft tissue representing adenopathy, while in the case of pulmonary hypertension there was sparing of the infrahilar window because the abnormal density was caused by enlarged pulmonary arteries.
105
Case 8
history: 47 year-old with chest pain.
106
5 Blue Belt Cases
Case 8
Correct You would verify that it is the correct patient and lm. Life Support No devices. Anatomy: Airways Airways normal, minor ssure not well seen. Bones The left humeral head is missing. Contours All appear normal. Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces All interfaces are well-preserved. Categorize No abnormal patterns. Limitations None, excellent quality lm. Extra Look Trachea, hila and hidden areas all appear normal.
Sometimes it is harder to see what is missing than what is present. In this case, a soft tissue sarcoma in the left arm has invaded and eroded most of the left humeral head.
Group
Green Belt Cases
Green Belt Cases

ow that your skills are improving, you are taking on some more challenging cases. You are now working in a cardiology clinic seeing patients with heart and related problems. For each patient, try to come up with as specic a diagnosis as possible.
107
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6 Green Belt Cases
Case 1
109
Case 1
Correct You would verify that it is the correct patient and lm. Life Support No devices. Anatomy: Airways The trachea is slightly o to the right, but
there is no focal bulge and this appearance is likely related to the mild scoliosis.
Bones There is mild scoliosis of the spine. Contours The main pulmonary artery is too large (it is
larger than the aorta). The other anatomical structures appear normal.
Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces All interfaces are well-preserved. Categorize No abnormal patterns. Limitations None, excellent quality lm. Extra Look Trachea, hila and hidden areas all appear normal.
The main pulmonary artery is enlarged from pulmonic stenosis. The enlargement seen represents a post-stenotic dilatation of the artery.
110
6 Green Belt Cases
Case 2
history: Three heart valves have been replaced. Which ones have been replaced and where is the fourth (non-replaced) valve located?
111
Case 2
Correct You would verify that it is the correct patient and lm. Life Support There is a right subclavian dual-lead transvenous
pacemaker with lead tips in the right atrium and right ventricle. There are midline sternal wires and three heart valve replacements.
Anatomy: Airways The trachea deviates to the right, but the patient is rotated towards the right, which would account for this. The minor ssure is not well seen.
Bones All appear normal. Contours The mediastinal contours are dicult to see
because of the enlargement of the heart.
Vascular The heart, vascular pedicle and pulmonary vasculature

all appear enlarged. There is no pulmonary edema.
Interfaces All interfaces are well-preserved. Categorize No abnormal patterns. Limitations None, excellent quality lm. (The lm appears a
little light because it was windowed to make all of the valves easier to see.) Also, the pacemaker does cover up a portion of the lungs, so any abnormalities beneath it would not be seen.
Extra Look Trachea, hila and hidden areas all appear normal.
From superior to inferior, the three replaced valves are the pulmonic, aortic and mitral. The fourth valve, the tricuspid, is near the midline
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6 Green Belt Cases
and would be below all three. Its location is actually known on this lm, too, because the pacemaker lead must pass through it to get from the right atrium to the right ventricle.
113
Case 3
history: 29 year-old with a cough.
114
6 Green Belt Cases
Case 3
Correct You would verify that it is the correct patient and lm. Life Support No devices. Anatomy: Airways The trachea deviates to the left in the mediastinum. Make sure you know why before you read any further. The minor ssure is not well seen.
Bones All appear normal. Contours The aortic arch is on the right side of the
trachea.
Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces All interfaces are well-preserved. Categorize No abnormal patterns. Limitations None, excellent quality lm. Extra Look Trachea, hila and hidden areas all appear normal.
There is a right-sided aortic arch.
115
Case 4
history: Patient with possible pacemaker problem.
116
6 Green Belt Cases
Case 4
Correct You would verify that it is the correct patient and lm. Life Support Coming in from the right side is a peripherallyinserted central venous catheter, with its tip in the svc. There is a left subclavian dual-lead implanted debrillator. One of the lead tips is in the right ventricle, the other is dislodged and free within the right atrium.
Anatomy: Airways Airways normal, minor ssure not well seen. Bones There is an old right clavicular fracture and
there are multiple old left-sided rib fractures (near the debrillator).
Contours There are atherosclerotic calcications in

the aorta.
Vascular The heart is enlarged, but the vascular pedicle and

pulmonary vasculature appear normal.
The right atrial lead is dislodged. Pacer and debrillator leads generally screw into the walls of the right atrium and ventricle. A relatively common problem is for the atrial lead to come out and oat freely in the atrium. Notice how it perfectly parallels the right ventricular lead,
117
Case 4 Corrected atrial lead. Notice how after it has been xed, the atrial lead goes down but then loops back up (white line), where it is then attached to the atrial wall. which is passing through the atrium. Compare to the image taken after the lead had been replaced. In this case, the lateral view also helps because it shows that the loop seen on the frontal view is a gradual loop that goes from posterior to anterior. The subsequent gure compares the lateral view before and after the atrial lead was xed.
118
6 Green Belt Cases
Case 4 Lateral views. A. Dislodged atrial lead (white line). B. Correctly positioned atrial lead (black line) in the same patient.
119
Case 5
history: There are four dierent pacer/debrillator leads on this lm. Where is each one going?
120
6 Green Belt Cases
Case 5
Correct You would verify that it is the correct patient and lm. Life Support There is a left subclavian pacer/debrillator with
a total of 4 leads entering the left subclavian vein.
Anatomy: Airways The trachea is deviated, but the patient is rotated, which would account for this nding. The minor ssure is not well seen.
Bones All appear normal. Contours All appear normal. Vascular The heart is enlarged, but the vascular pedicle and
pulmonary vasculature appear normal.
One of the four leads is not connected to the control pack (you can see that the top side of the control pack has three leads connecting to it, and that there is an additional lead not connected to anything but seen through the control pack). Three of the leads go through the left brachiocephalic vein, into the svc and then into the right atrium. One of those three terminates in the right atrium (notice it curving back upwards), while the other two continue into the right ventricle. It is one of these two ventricular leads that is not connected (intentionally).
121 The more dicult lead to understand is the fourth lead, which goes not into the svc but down the left side of the chest. It is traveling in a persistent left superior vena cava (an anatomic variant). A persistent left svc drains into the coronary sinus. The pacer lead goes into the coronary sinus and then into one of the veins of the heart where it is positioned so that it can be used to pace the left ventricle.
122
6 Green Belt Cases
Case 6
history: Where do the two pacer leads on this lm go?
123
Case 6
Correct You would verify that it is the correct patient and lm. Life Support There is a left subclavian dual-lead transvenous
pacemaker. A single, tiny suture wire is seen near the aortic knob.
Anatomy: Airways Airways normal, minor ssure not well seen. Bones The right 4th and 5th ribs appear abnormally
close to each other. The other bones appear normal.
Contours All appear normal. Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces All interfaces are well-preserved. Categorize No abnormal patterns. Limitations None, excellent quality lm. Extra Look Trachea, hila and hidden areas all appear normal.
The key is to recognize the evidence of prior surgery (the suture wire and the rib deformities on the right). This patient had a d-transposition of the great arteries which was repaired in childhood using the Mustard procedure, so there is a pathway from the svc to the left atrium, which is where these pacer leads are going (the other continues into the left ventricle).
124
6 Green Belt Cases
Case 7
history: 50 year-old with acute shortness of breath.
125
Case 7
Correct You would verify that it is the correct patient and lm. Life Support No devices. Anatomy: Airways Airways normal, minor ssure not well seen. Bones All appear normal. Contours All appear normal. Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces There is a silhouette sign along the left heart border,
all other interfaces are well-preserved.
Categorize There is a uy (alveolar pattern) opacity in the left

lung base.
The alveolar opacity in the left lung base represents a pulmonary infarction from an acute pulmonary embolism. Infarct in the lung manifests itself as hemorrhage, and thus the alveolar pattern. This appearance has been termed Hamptons hump after the person who described it. Classically, a Hamptons hump will be an alveolar pattern that is peripheral and wedge-shaped. The sign is not very common and in reality it can be nearly impossible to distinguish a Hamptons hump from a pneumonia (since both give the same alveolar pattern).
126
6 Green Belt Cases
Case 8
history: 53 year-old with chronic shortness of breath.
127
Case 8
Correct You would verify that it is the correct patient and lm. Life Support No devices. Anatomy: Airways The trachea deviates slightly because the
head is turned; the minor ssure is normal.
Bones All appear normal. Contours The heart and central pulmonary arteries
appear enlarged.
Vascular The heart and vascular pedicle are enlarged. In addition, the central hilar vessels are enlarged. Even the vessels more peripherally in the lungs are too big. There is no pulmonary edema.
The pattern you see is that of high-output or shunt vasculature. Unlike the case of primary pulmonary arterial hypertension (blue belt case #3), here the large hilar vessels continue on as large vessels all the way through the lung. The peripheral vessels look like those of pulmonary vascular engorgement, but the massively-enlarged central pulmonary arteries have developed because of a congenital and uncorrected atrial
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6 Green Belt Cases
septal defect (giving a left-to-right shunt), hence the name shunt vasculature. A similar pattern may be seen patients who do not have a shunt but do have a high output state, such as a chronic severe anemia (thus the name high-output vasculature).
Group
Brown Belt Cases
Brown Belt Cases

ou nd yourself once again covering a bunch of patients at night, but this time you are covering for a surgical service that covers not only postoperative cases but also the trauma service. Your goal is to look at these trauma or post-operative lms and determine what, if any problems, are present.
129
130
7 Brown Belt Cases
Case 1
history: 34 year-old in the trauma bay following a motor vehicle accident.
131
Case 1
There is a right subclavian introducer sheath in place, though it has a mild kink in it as it goes under the clavicle. There is a nasogastric tube which extends into the stomach, but takes a rather wide course and terminates high, almost above the heart.
Anatomy: Airways The trachea deviates to the right. The minor

ssure appears normal.
Bones There are several displaced rib fractures on the

left.
Contours The diaphragm is much higher than normal

on the left. The entire left side of the mediastinum is obscured by either the elevated diaphragm or the opacities in the left lung.
Vascular Heart, vascular pedicle and vasculature, though dicult

to evaluate due to all the adjacent opacities, appear normal.
Interfaces All interfaces are along the left side of the mediastinum
show a silhouette sign.
Categorize There is a left pleural eusion (likely pleural blood

in this case). There is elevation of the left hemidiaphragm with crowding of the vasculature in the left lung base (atelectasis pattern). There is also superimposed uy opacity (alveolar pattern) in the left lung.
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7 Brown Belt Cases
Limitations The lm was obtained with the patient on a spine

(trauma) board, which causes some artifacts, but it is otherwise a good lm.
Extra Look The trachea is deviated to the right and the regions
behind the heart or left side of the diaphragm cannot be seen at all. This is a case of a traumatic rupture in the left side of the diaphragm. What appears to be the diaphragm on that side is actually abdominal contents (including the stomach) passing through the large hole in the diaphragm into the thoracic cavity. The compression from below, along with the pleural eusion/hemorrhage, accounts for the atelectasis, and pulmonary contusion accounts for the alveolar pattern in the left lung.
133
Case 2
134
7 Brown Belt Cases
Case 2
There is a nasogastric tube which deviates to the right as it courses down the esophagus and then terminates in the stomach. The side port is not well seen on this study and could be above the ge junction.
Anatomy: Airways The trachea deviates towards the right. The

minor ssure is displaced inferiorly slightly.
Bones All appear normal. Contours The superior mediastinum appears widened
and there is loss of the normal outline of the aortic knob.
Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces There is a silhouette sign of the aortic knob and pulmonary artery.
Categorize There is very minimal vascular crowding in the right

lung base and mild inferior displacement of the minor ssure (signs of atelectasis).

Extra Look The trachea is deviated to the right. The hila and
hidden areas appear normal.
135 This patient has a traumatic rupture of the thoracic aorta. The worrisome signs are the deviation of the nasogastric tube (a sign of a mediastinal hematoma displacing the esophagus), the widened superior mediastinum and loss of distinctness of the aortic knob (also from the hematoma). In major trauma centers almost all patients from major motor vehicle accidents get ct scans, but it is possible to have this injury in what may have seemed like something less than a major accident and these patients may occasionally be seen non-trauma centers.
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7 Brown Belt Cases
Case 3
137
Case 3
Correct You would verify that it is the correct patient and lm. Life Support The endotracheal tube, nasogastric tube, right subclavian introducer sheath and right sided chest tube all appear ne.
Anatomy: Airways Airways normal, minor ssure not well seen. Bones There are multiple displaced rib fractures on the
left.
Contours The contours of the left side of the mediastinum are all obscured.
Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces There is a silhouette sign of the left heart border as
well as of the aortic knob and main pulmonary artery.
Categorize There is uy opacity seen throughout the left lung

(alveolar pattern) with some sparing of the left costophrenic angle.

Extra Look The airways appear normal. The right hilum appears
normal. The left hilum is obscured by the lung opacity, and the areas behind the heart and left side of the diaphragm show the alveolar process described above.
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7 Brown Belt Cases
This patient has a large pulmonary contusion on the left. Contusion (blood) is one of the causes of an alveolar pattern in trauma patients. Another important cause of alveolar ooding in these patients is aspiration. In this case, though, the overlying rib fractures are a sure sign of where the brunt of the force hit the chest.
139
Case 4
history: 31 year-old in the icu recovering from a recent burn injury.
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7 Brown Belt Cases
Case 4
Correct You would verify that it is the correct patient and lm. Life Support The tracheostomy canula, feeding tube and right
subclavian central line appear ne. Some scattered skin staples related to grafting surgery are also seen.
Anatomy: Airways Airways normal, minor ssure not well seen. Bones All appear normal. Contours The left side of the diaphragm is not seen,
but otherwise the anatomical structures appear normal.
Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces There is a silhouette sign of the left hemidiaphragm. Categorize There are bilateral, peripheral alveolar opacities throughout the lung.
Limitations None, excellent quality lm. Extra Look The trachea is normal but the hila and hidden
areas are obscured by all the opacities. This pattern represent injury edema. Injury edema is a non-cardiogenic pulmonary edema seen in patients with ards. The pattern is typically alveolar and peripheral, but usually always fairly severe as well. The patients are generally quite sick (almost always intubated) and are also at risk for ventilator-acquired pneumonia which can have an identical appearance. It is usually not possible to tell injury edema from diuse bilateral pneumonia, and it is not uncommon for these patients to have both.
141
Case 5
history: 59 year-old, post op lm. What surgery was done and are there any problems?
142
7 Brown Belt Cases
Case 5
Correct You would verify that it is the correct patient and lm. Life Support There are midline sternal wires. There is an aortic
valve replacement. There are well-positioned endotracheal and nasogastric tubes as well as a right internal jugular pulmonary artery catheter. There are also four chest tubes. All four enter anteriorly. Two go straight up the mediastinum and are dicult to see, one goes o to the right laterally and the other to left over the heart.
Anatomy: Airways Airways normal, minor ssure not well seen. Bones All appear normal. Contours There are aortic atherosclerotic calcications. The heart and mediastinum are enlarged. The left side of the diaphragm is not well seen.
Vascular The heart and vascular pedicle are enlarged (though

some of the enlargement seen could be related to the surgery). In addition, there is engorgement of the pulmonary vascular, especially centrally, but there is no pulmonary edema.
Interfaces There is a silhouette sign of the left hemidiaphragm

and left heart border. The hilar interfaces are also lost.
Categorize There is vascular crowding in both lung bases and in

the perihilar regions (atelectasis pattern).
Limitations None, excellent quality lm.
143
Extra Look The basilar atelectasis is seen through the heart and
diaphragm and the hila are obscured by the adjacent atelectasis there. The trachea is normal. This patient has just returned from aortic valve replacement surgery and all of the ndings described are typical and expected.
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7 Brown Belt Cases
Case 6
history: 63 year-old, post op lm. What surgery was done and are there any problems?
145
Case 6
Correct You would verify that it is the correct patient and lm. Life Support There are chain sutures seen in both lungs (suprahilar regions).
Anatomy: Airways Airways normal, minor ssure not well seen. Bones Spinal scoliosis but otherwise normal. Contours The hila are superiorly retracted slightly and
they are obscured. There are some black streaks in the soft tissues over the left shoulder. These streaks represent air in the soft tissues (subcutaneous emphysema). The ascending aorta is too prominent (see along the right side of the mediastinum over the right heart border) but this is a common nding in some older patients.
Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces There is a silhouette sign of both hila from the adjacent
lung opacities.
Categorize In the regions of the chain sutures there is a mixed

pattern of alveolar ooding and vascular crowding (atelectasis).
Limitations None, excellent quality lm. Extra Look The apparent deviation of the trachea comes from
a combination of the scoliosis and patient rotation. These are the typical ndings of a patient who has undergone bilateral lung volume reduction surgery (lvrs). lvrs is done in patients
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7 Brown Belt Cases
with severe centrilobular emphysema that has an upper lobe predominance. This patients surgery occurred 4 days prior to this lm. Immediately following the surgery there were bilateral chest tubes and pneumothoraces present. The pneumothoraces have resolved and the tubes have been pulled, but some air remains in the adjacent soft tissues (an expected nding). The opacities around the chain sutures represent a combination of bleeding and volume loss.
147
Case 7
history: 49 year-old with history of prior surgery. What surgery was done and are there any problems?
148
7 Brown Belt Cases
Case 7
Correct You would verify that it is the correct patient and lm. Life Support There is a right sided Portacath. The line is wellpositioned. The loop actually occurs where the tubing is still in the soft tissues. This line enters the right ij vein and has its tip in the svc.
Anatomy: Airways Airways normal, minor ssure not well seen. Bones All appear normal. Contours All appear normal, though there is an extra soft tissue structure projecting over the right heart border and the right hilum.
Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces All interfaces are well-preserved. Categorize There is what appears to be a mass lesion overlying
the right side of the heart and the right hilum.
This patient has had a prior esophagectomy and gastric pull-through procedure, and all of the ndings seen are expected. The study was performed because of esophageal cancer. What appears to be a mass (or what is sometimes mistaken for a large ascending aorta) is the stomach, which has been pulled into the chest to replace the resected esophagus. The stomachs appearance can change dramatically from lm to lm depending upon how distended it is with food, uids or air.
149
Case 8
history: 42 year old, post device placement. What device was placed and are there any problems?
150
7 Brown Belt Cases
Case 8
Correct You would verify that it is the correct patient and lm. Life Support The device consists of two large-bore tubes extending up from the abdomen. One tip goes towards the left ventricle and the other towards the ascending aorta. There are also midline sternal wires from a prior surgery.
Anatomy: Airways Airways normal, minor ssure not well seen. Bones All appear normal. Contours The main pulmonary artery appears enlarged, but the other anatomical structures appear normal.
Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces There is a silhouette sign of the left hemidiaphragm. Categorize No abnormal patterns. Limitations The lateral portion of the right lung base is not
included in the image (however, note that this lm is labeled 1 of 2. A second lm to include that area had been obtained).
Extra Look Trachea, hila and hidden areas all appear normal.
The device is a left ventricular assist device (lvad). It takes blood from the left ventricle and pumps it into the aorta. The main pump for this device is located in the abdomen. Often these devices are used to keep a patient alive while awaiting heart transplant. You may also see a similar device that has four large-bore tube (a bi-ventricular assist device, bi-vad). The lateral view is included here so you can better see where the tubing goes.
151
Case 8 Lateral view. The inferior tube takes blood from the base of the left ventricle while the superior tube pumps blood into the aorta..
152
7 Brown Belt Cases
Group
Black Belt Cases
Black Belt Cases

ou should congratulate yourself for making it this far through the case book. If you have worked through all of the cases so far, then you really have developed a rm framework upon which you can continue to build your understanding of the plain chest lm. The clavicle system is just one way to analyze lms, and whether you have been using it or your own method, you will soon discover that there is always more to know. Because you have used a disciplined and systematic approach for analyzing lms, however, you will nd that it becomes easy to incorporate knew knowledge into what you are already doing. The cases I have chosen for the black belt level arent necessarily any more dicult than those you have seen already. In fact, many of them are relatively straight-forward. The purpose is to introduce some new concepts so you can practice your skills and learn how to deal with new concepts as you encounter them. This is really where you should be when you nish medical school, and here the black belt represents not
153
154
8 Black Belt Cases
the end of your training, but just the beginning.
155
Case 1
156
8 Black Belt Cases
Case 1
Correct You would verify that it is the correct patient and lm. Life Support No devices. Anatomy: Airways Airways normal, minor ssure not well seen. Bones All appear normal. Contours The diaphragm is elevated bilaterally, but
greater on the left. All of the mediastinal and hilar anatomical contours are at least partially obscured.
Vascular Heart, vascular pedicle and vasculature are dicult to

evaluate because of all of the adjacent parenchymal abnormalities.
Interfaces There is a silhouette sign of most of the mediastinal

borders and of both hemidiaphragms.
Categorize There is a predominantly-linear pattern (interstitial)

throughout the lungs. The severity is greater in the lung bases, but abnormalities are seen everywhere. The abnormal lines do not appear to be normal anatomical septa becoming visible. Instead they are irregular bands which do not correspond to any anatomical structures. In addition, the lung volumes are low and the diaphragm is elevated (atelectasis pattern). There are also small bilateral pleural eusions or areas of thickening of the pleura.
Limitations None, excellent quality lm.
157
Extra Look The trachea appears normal. The hila and hidden
areas are obscured by the abnormal interstitial pattern. This patient has severe pulmonary brosis. The interstitial pattern can be subdivided into two categories the pattern that results from the normally-invisible septa becoming apparent on the lm, and the pattern that results from new, non-anatomical lines. There have been several cases of the former (including interstitial pulmonary edema and interstitial pneumonia). Here is a case of the latter. The linear pattern results from bands of brotic tissue, and the low lung volumes are a consequence of the poor pulmonary compliance due to the stiening of the lungs. While there are many causes and types of pulmonary brosis, this patient has one of the most common (and deadly) that of idiopathic pulmonary brosis (ipf).
158
8 Black Belt Cases
Case 2
history: 24 year-old post bronchoscopy.
159
Case 2
Correct You would verify that it is the correct patient and lm. Life Support No devices. Anatomy: Airways Airways normal, minor ssure not well seen. Bones All appear normal. Contours All appear normal. Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces There is a silhouette sign along the right heart border. Categorize There is an alveolar pattern in the middle lobe. Limitations None, excellent quality lm. Extra Look Trachea, hila and hidden areas all appear normal.
Without the history, this lm could very easily be interpreted as a right middle lobe pneumonia. In fact, though, the alveolar pattern is being caused by residual lavage uid left behind after the bronchoscopy procedure, a very common and expected nding. This case reminds us that the parenchymal patterns can at best give you a broad category of what may be wrong, but that the ultimate diagnosis must come from your additional knowledge about the patients history and other clinical ndings.
160
8 Black Belt Cases
Case 3
history: 29 year-old, post-operative day #1. What surgery was performed and are there any abnormalities?
161
Case 3
Correct You would verify that it is the correct patient and lm. Life Support Skin staples cross the chest transversely and there
are transverse sternal wires present. There are also surgical clips seen in the mediastinum. There are an endotracheal tube, nasogastric tube and right internal jugular pulmonary artery catheter which appear well-positioned. There are also four chest tubes seen (all anterior, two on the left and two on the right).
Anatomy: Airways Airways normal, minor ssure not well seen. Bones All appear normal. Contours All appear normal. There are some black
streaks of air outlining muscle bers in the pectoralis major muscle.
Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces All interfaces are well-preserved. Categorize There is a small left apical pneumothorax. There is
an alveolar ooding pattern seen throughout both lungs.
Limitations None, excellent quality lm. Extra Look Trachea, hila and hidden areas all appear normal
except for the alveolar pattern. This patient has had bilateral lung transplantation. For this surgery, a transverse (rather than midline sternal) approach is used. The air in the pectoralis muscle is an expected and inconsequential post-operative
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8 Black Belt Cases
nding. The alveolar pattern represent reimplantation pulmonary edema, which often occurs within the transplant during the rst several days to one week following surgery. While it is not a normal nding, it is quite common and will usually resolve in a few days on its own.
163
Case 4
history: 69 year-old with long pulmonary history.
164
8 Black Belt Cases
Case 4
Correct You would verify that it is the correct patient and lm. Life Support No devices. Anatomy: Airways The carina and central airways are superiorly
retracted. The minor ssure is displaced superiorly.
Bones All appear normal. Contours The hila are obscured by large masses. The
aorta and main pulmonary artery are also obscured. The right hemidiaphragm has an abnormal shape. There are also multiple round, calcied densities seen near the hila.
Vascular The heart size is normal.
The vascular pedicle and pulmonary vasculature cannot be judged, but there is no pulmonary edema.
Interfaces There are silhouette signs along the right hemidiaphragm and the right heart border, as well as along the superior mediastinum bilaterally.
Categorize There are large bilateral mass lesions. In addition,

there are innumerable small nodules seen throughout the lungs. There is also evidence of scarring, with superior retraction of the hila and minor ssure. There is a right-sided pleural eusion (or thickening of the pleura).
Limitations None, excellent quality lm. Extra Look Trachea and hidden areas appear relatively normal. The hila are completely obscured by the masses.
165 This patient has long-standing silicosis which has gone on become progressive massive brosis. The changes of silicosis take many years to manifest on the chest lm, and then many more years to progress to this extent. Silicosis begins as multiple nodules, predominantly in the upper lungs which coalesce over time to form these large perihilar masses known as progressive massive brosis. There is also a lot of scarring and distortion of the normal pulmonary architecture which occurs, as can be seen from the superior retraction of the hilar and the shrinking of the upper lobes. The lymph nodes with peripheral (egg-shell) calcications are a common nding.
166
8 Black Belt Cases
Case 5
history: 63 year-old with a long pulmonary history.
167
Case 5
Correct You would verify that it is the correct patient and lm. Life Support No devices. Anatomy: Airways Airways normal, minor ssure not well seen. Bones All appear normal. Contours There are very bright lines seen along the
diaphragm bilaterally.
Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces All interfaces are well-preserved. Categorize There are poorly-dened densities seen over the lungs
bilaterally, but best seen just over the middle of the right lung. These do not have characteristics matching any of our parenchymal patterns.
There are calcied and non calcied plaques seen along the pleura, a consequence of prior occupational exposure to asbestos bers. The bright white lines along the diaphragm represent calcied pleural plaques seen from the side. The ill-dened opacities over the lungs represent both calcied and non-calcied pleural plaques seen en face. In almost all cases, plaques such as these are the result of repeated exposure to asbestos bers, but their presence does not indicate asbestosis. That term is used to describe the interstitial lung disease caused by asbestos exposure, and usually manifests itself as pulmonary brosis with other related clinical ndings.
168
8 Black Belt Cases
Case 6
history: 48 year-old with moderate shortness of breath.
169
Case 6
Correct You would verify that it is the correct patient and lm. Life Support No devices. Anatomy: Airways Airways normal, minor ssure displaced inferior slightly.
Bones All appear normal. Contours All appear normal. Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces All interfaces are well-preserved. Categorize There is an interstitial pattern seen in the right lung.
It is somewhat denser and slightly more nodular than other interstitial patterns we have encountered thus far.
This patient has lung cancer which has developed lymphangitic spread. Lymphangitic spread (spread of a malignancy through the pulmonary interstitium) can occur with primary lung tumors but also with malignancies from other sites (especially breast cancer). The tumors grow through the interstitial spaces without causing much, if any, architectural distortion.
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8 Black Belt Cases
Case 7
history: 24 year-old with a long pulmonary history.
171
Case 7
Correct You would verify that it is the correct patient and lm. Life Support No devices. Anatomy: Airways Airways normal, minor ssure not well seen. Bones All appear normal. Contours All appear normal. Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces All interfaces are well-preserved. Categorize There is an interstitial pattern seen throughout both
lungs. The reticular markings are somewhat thicker than other interstitial patterns encountered so far. Some of these lines look like tubes seen either from the side (tram-tracking) or end-on (ring shadows). There are also nodules seen, especially in the lung bases.
This is the pattern of fairly severe bronchiectasis in patient with cystic brosis. The interstitial pattern results from dilated bronchi (and bronchioles) with markedly thickened walls. What appear to be nodules are actually mucus-lled bronchi. These patients are at a very high risk of pneumonia, and so it is not uncommon to nd superimposed alveolar opacities as well.
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8 Black Belt Cases
Case 8
history: 54 year-old with hemoptysis.
173
Case 8
Correct You would verify that it is the correct patient and lm. Life Support No devices. Anatomy: Airways Airways normal, minor ssure normal. Bones All appear normal. Contours All appear normal. Vascular Heart, vascular pedicle and vasculature appear normal. Interfaces All interfaces are well-preserved. Categorize There are patchy, bilateral, uy (alveolar) opacities. Limitations None, excellent quality lm. Extra Look Trachea, hila and hidden areas all appear normal.
Without the clinical history, these opacities could easily be interpreted as representing bilateral pneumonia. In fact, this patient has Wegeners Granulomatosis and these opacities represent ooding of the alveolar spaces with hemorrhage, a common occurrence in Wegeners.

Case Book For The Medical Students Guide To The Plain Chest Film

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Case Book For The Medical Students Guide To The Plain Chest Film

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Handout for VMS II Course: Disease, Diagnosis and Therapeutics

Case Book for

The Medical Student's Guide to the Plain Chest Film

Edwin F. Donnelly, M.D., Ph.D.

i iii 1 23 43 63 87 107 129 153

How not To Use These Cases

How To Learn To Read Chest Films

White Belt Cases

White Belt Cases

1 White Belt Cases

history: 24 year-old presents to the emergency department with a cough.

1 White Belt Cases

history: 54 year-old presents to the emergency department with chest pain.

1 White Belt Cases

history: 44 year-old presents to the emergency department with a fever.

1 White Belt Cases

1 White Belt Cases

Bones All appear normal. Contours See below.

1 White Belt Cases

Interfaces The central hilar vessels show a silhouette sign. The

Categorize There is a uy, bilateral, symmetrical and central

history: 58 year-old smoker with hemoptysis.

1 White Belt Cases

Categorize There is a large, solid white opacity which falls into

1 White Belt Cases

Vascular Heart and vascular pedicle are normal in size.

1 White Belt Cases

history: 85 year-old with long-standing pulmonary symptoms.

1 White Belt Cases

Categorize The is a homogeneous white pattern seen laterally

1 White Belt Cases

Yellow Belt Cases

Yellow Belt Cases

2 Yellow Belt Cases

2 Yellow Belt Cases

Limitations The patient is rotated towards the right quite a

2 Yellow Belt Cases

Extra Look Trachea appears normal. The atelectasis described

2 Yellow Belt Cases

Contours The left mediastinal contour is abnormal,

Vascular The heart is mildly prominent, but the vascular pedicle

2 Yellow Belt Cases

Anatomy: Airways The trachea deviates slightly to the right. The

Vascular The heart and vascular pedicle are normal in size,

Interfaces The aortic knob and main pulmonary artery show a

Categorize There is a moderate-sized pneumothorax on the left.

2 Yellow Belt Cases

2 Yellow Belt Cases

2 Yellow Belt Cases

2 Yellow Belt Cases

2 Yellow Belt Cases

Orange Belt Cases

Orange Belt Cases

3 Orange Belt Cases

history: Patient in the emergency department with shortness of breath.

3 Orange Belt Cases

history: Patient in the emergency department with shortness of breath.

3 Orange Belt Cases

history: Increasingly-ill patient in the icu

3 Orange Belt Cases

3 Orange Belt Cases

history: 54 year-old internal medicine clinic patient with chronic dyspnea.