Chest Practice Cases
Despite increasing breadth of modalities in the viva exam Chest radiographs still form an important part of the assessment process. The examiner might start with a CXR and then move onto a CT scan in the same case. From my experience of teaching local trainees and international people, overall chest is handled reasonably well by all but UK trainees are always a bit more organised in their presentation and thought process and this is likely due to the larger exposure they receive during their training. It is important to have a solid knowledge base and a sound approach. From talking to people who have done the exam over the years, they can throw curve balls and adjust the situation by asking challenging questions. As with the other sections I have uploaded a number of cases and suggested a style of presenting that I used. If you need a bit of help please use this to structure your revision. I cover chest in good depth on my course and offer more advice on common mistakes and pitfalls so if you needed a bit more support please let me know. Otherwise I hope this helps you in your prep!
Case 1: Model Answer and Analysis
Description CXR of an adult patient demonstrates reticular change in both lungs. This is more confluent in the right lung. No pleural effusions. No focal mass or consolidation. No hilar adenopathy. Normal mediastinum. No bony abnormalities. Differential diagnosis include inflammatory conditions such as pneumocystis jirovici, diffuse TB or viral pneumonitis. Extrinsic allergic alveolitis is also a differential diagnosis.
What can be done to help with diagnosis?
- Assess CD4 levels, if below 200 the patient is likely immunocompromised and at risk of fungal infections such as PCP.
- Check for risk factors such as occupational exposure for extrinsic allergic alveolitis.
What can be done next to help diagnose the condition? CT scan or bronchoalveolar lavage
What are the typical features of PCP on CT ?
- Pneumatocoeles subpleurally
- Ground glass change in the perihilar distribution.
- Depending on the status of the patient i.e. CD4 level and degree of treatment additional image features are possible such as cavities, nodules, effusions and lymphadenopathy. These are considered atypical features.
Commentary This is an actual case of PCP in a HIV patient
Tips Be aware of the typical features of PCP on CT and plain film imaging. The history is key as usual i.e. are there occupational risk factors. If no information is forthcoming then offer the infective modality in addition to a second differential diagnosis.
Case 2: 45 year old lady with long history of shortness of breath
Description CXR of an adult patient demonstrates two areas of focal consolidation in the left lower lobe. No air bronchograms. No cavitation. Multiple cysts are present within both lungs. The lungs are hyperinflated. No pleural effusions. Normal mediastinum. The appearance on imaging is suggestive of a underlying cystic lung disease with superadded infection. Differentials include langerhan cell histiocytosis and lymphangioleiomyomatosis. The patient would require a chest consult to guide their care and a CT chest for further characterisation
How would you distinguish between LAM and LCH on imaging?
LCH: contains cysts and nodules. Centrilobular distribution. Emphyesma and mosaic attenuation are also noted.
LAM: Multiple cysts of various size, chylous pleural effusion, recurrent pneumothorax, bilateral reticular nodular changes.
Commentary This is an example of LAM
Tips The examiner may show the plain film first and then move onto the CT. The CT may allow you to distinsguish between LAM and LCH on imaging.
Description AP Chest ray in a skeletally mature patient. This demonstrates air within the subcutaneous tissues-visualised as vertical streaky lucencies. There is also air within the mediastinum. A continuous diaphragm sign is also noted. The image features are in keeping with pneumomediastinum. The lungs are hyperinflated with scarring in the apices. No pneumothorax or consolidation. No acute bony injury. The differential diagnosis are ruptured oesophagus due to possible borhaaves syndrome, alveolar rupture, or traumatic rupture of the trachea or bronchus. I would be guided by the clinical history.
What would you do next Inform the clinician urgently.
What are the options to evaluate the case further
- If there was concern for oesophageal rupture a contrast swallow can be performed provided the patient was stable.
- If there was concern for other differential diagnosis or additional injury to say the mediastinum . A trauma protocol CT scan can be performed.
Commentary This is a case of soft tissue surgical emphysema and pneumomediastinum on CXR.
Tips The pneumomediastinum is gross-i.e this is not a subtle finding. The examiner may start with this and based on the discussion show a CT scan or a barium study if you accurately identify the signs and make sensible suggestions. If the mechanism of aetiology is trauma, then this may show additional features of trauma. Alternatively, the CT may show other differentials of a ruptured oesophagus such as liver disease. Sometimes it is difficult to describe features. In this case if you are confident that there is pneumomediastinum and soft tissue emphysema you can start by stating these facts. Then comment on significant negatives. Always good to state that you will inform the Clinician yourself without prompting. Do not automatically volunteer to offer a CT. Instead suggest you will have a discussion with the clinician to determine the next best course of action. Listen to the cues the examiners give you.
Case 4 39 year old presented with shortness breath and cough
Description There is opacification within the right upper lobe. This contains air bronchograms. No volume loss. No cavitation or bony destruction. Nodular opacification is present within the left lung and right lower lobe. No pleural effusions. No hilar adenopathy. My most likely diagnosis is an inflammatory process. I would recommend a repeat CXR in 6 weeks following treatment.
What other differential diagnosis is possible Neoplasia.
Why is cancer not top of your differential diagnosis On imaging no evidence of lobar collapse i.e. no volume loss, no cavitation. However, it is difficult to exclude a branchoalveolar cancer and requires clinical correlation. This will depend on the clinical presentation. If there is clinical concern for neoplasia the patient should be referred urgently to a chest physician for assessment.
How would the patient be managed Antibiotic therapy if clinically stable. If the patient is compromised in anyways suggest hospital referral for assessment.
Commentary This is an example of a right upper lobe consolidation, nodular change is present in the left lung. This is most likely to be infective in nature.
Tips Listen to the information provided by the examiner i.e. if they say smoker, history of weight loss and cough then neoplasia should be top of your differential diagnosis. If the history is of a young person with short history of cough and elevated inflammatory markers then infection is more sensible.
Case 5 Model Answer and Analysis
Description Chest X ray of an adult patient demonstrates a left apical cap, left upper lobe cavity with no evidence of local bone destruction, interstitial markings in the left upper lobe and right sided small pleural effusion. No hilar adenopathy. Normal heart size. Differentials include neoplasm or inflammatory process such as an aspergilloma. It would be helpful to assess if there is a previous X ray to determine if there was an existing cavity or structural abnormality such as a bronchogenic cyst.
What is an aspergilloma A mass like fungal ball that develops in a existing cavity. The cavity can be secondary to TB, bronchogenic cyst or in pulmonary sequestration.
How can you potentially distinguish between aspergilloma and a neoplasm Aspergilloma is a fungal ball which changes position. The X ray can be repeated with the patient supine or decubitus and the aspergilloma will move.
What can you do to help diagnose this condition Ideally analyse sputum for aspergillus filaments. Tissue and blood tests are also a possibility. The most invasive method is to perform a biopsy.
Commentary This is an actual case of aspergilloma.
Tips Be aware of the Monod sign (round mass surrounded by air crescent). Do not jump immediately to doing a CT scan, remember it is a discussion with the examiner. They may very well show you a CT scan. Ask for a previous film and explain your rationale for requesting this.
Description Chest Radiograph AP projection of an adult patient demonstrates a central line. This is projected over the SVC and is appropriately positioned. There is abnormal appearance of the left shoulder joint with ill defined lucency of the coracoid process. There is thinning of the bone cortex and soft tissue swelling. There is also abnormal appearance of the humeral head on the left side. No additional bony lesions noted. No focal active lung lesions. Normal mediastinum. Appearances are concerning for a bony neoplastic process. Either a primary cancer or metastasis. The central line is likely related to chemotherapy.
What would you do next Ideally compare to previous films. If the patient has a central line there must be previous x ray to compare to. If the bony lesion is present on previous films I would do nothing else. However, if it is new or there is evidence of progression I would recommend further assessment with a CT scan for staging.
What potential primary lesions can cause this Bony sarcoma or plasmacytoma.
Commentary This is an example of a bony metastasis in a patient already being treated for a renal neoplasm.
Tips Be aware of the normal position of the central line. Abnormal position is in the right atrium were the patient may develop arrhythmias. In case of bone metastasis examine the breasts to look for clips etc.
Case 7: Model Answer and Analysis
Description Chest radiograph of an adult patient demonstrates a focal well defined opacity in the right upper lobe. This is thick walled but has a central cavity with an air fluid level. There is minor volume loss in the right upper lobe. No additional lung lesions. No bony abnormalities appreciated. This could either be an aspergilloma in an existing cavity or a primary lesion such as a neoplasm. The patient will require referral to a chest physician for assessment and a CT chest.
What factors would make aspergilloma more likely The existence of a cavity would make this more likely.
How would this be treated The complications of this condition are empyema, pneumothorax and haemoptysis. If this is asymptomatic then this would not be treated. The options for treatment are resection or with drugs such as itriconazole.
Commentary This is an example of an aspergilloma
Tips The diagnosis of aspergilloma cannot be made on the basis of this plain film alone. CT is helpful as well as knowing the serology. Do not completely discount the possibility of a malignancy, include this in the periphery. As with everything the history will be helpful
Case 8 Model Answer and Analysis
Description Chest X ray of a skeletally mature patient demonstrates a widened mediastinum. I can see hila vessels, heart shadow and aortic arch through this lesion. The location is therefore in the anterior mediastinum. The heart is mildly enlarged but no focal lung lesions are visualised. No hila adenopathy. No pleural effusions. No bony abnormalities. Differential diagnosis include thymoma, teratoma, lymphoma. I would recommend an urgent CT chest, abdomen and pelvis as well as a thoracic consult.
Could this be a retrosternal goitre No, because there is no soft tissue extension above the level of the clavicles. The superior mediastinum is unremarkable.
Why have you localised to the anterior mediastinum The middle and posterior mediastinal silhuettes are preserved. The lesion is therefore considered anterior mediastinal.
Commentary This is an example of an anterior mediastinal mass on a chest x ray.
Tips The key to this case is identifying that this is an anterior mediastinal lesion. The description focuses on a systematic method of presenting the case with first covering the lesion, localising it and then looking at the chest and hila for significant positives and negatives. The examiner may then proceed to show you a CT scan to help formulate the diagnosis in the exam.
Case 9: Model Answer and Analysis
Description CXR of an adult patient demonstrates bilateral hilar adenopathy with widened right paratracheal stripe. Normal heart size. No pulmonary mass, consolidation or pleural effusion. No evidence of lung volume loss. No bony abnormalities. Differential diagnosis include sarcoid, lymphoma and TB. Suggest chest consult to guide the patients care.
What would you do next for assessment Further imaging with a CT chest if sarcoid was suspected. If there was clinical concern for lymphoma then I would recommend a CT scan of the chest, abdomen and pelvis with intravenous contrast.
Image features of sarcoid on a chest CT Initially the chest x ray maybe normal but sarcoid can cause lymphadenopathy, lung parenchymal changes such nodular opacities. End stage disease typically causes fibrosis.
Commentary This is a CXR demonstrating a Garland Triad of hilar and right paratracheal adenopathy.
Tips This CXR is an actual case of sarcoid but the presence of hilar adenopathy is not 100% classic for sarcoid!. In the description I have advocated describing the significant positives and significant negatives. It is important to listen to the clinical information i.e. the patient has night sweats, severe weight loss etc. in this case you should be swayed towards thinking about lymphoma. Either way my suggestion is instead of jumping to the CT scan after describing the CXR findings, suggest clinical referral. The examiner may say what would the clinician do-the answer is often CT imaging. I have not included TB in my differential diagnosis but again consider this based on the history.
Case 10: Model Answer and Analysis
Description Chest Radiograph in an adult patient demonstrates a large cystic lesion in the left hila with a soft tissue density within (monod sign). No adjacent bone destruction. No consolidation. No hilar adenopathy. No pleural effusions. Differentials include aspergilloma, infection in an existing cavity. The well defined margin makes neoplasm less likely. This requires clinical correlation and further assessment with a CT scan. Clinical history would also help to formulate diagnosis
If hydatid was suspected what can be done Serology confirmation, is one non invasive method of assessment.
Would you biopsy this lesion No because there is a risk of fluid entering circulation. This can cause anaphylactic reaction.
Commentary This is an example of hydatid of the chest although the diagnosis cannot be made on the image appearances solely.
Tips The examiner may provide history such as ingestion of undigested meat. Alternatively there maybe a history of infection or neoplasm. Look for supportive signs to help with this diagnosis.
Case 11 Model Answer and Analysis
Description Chest radiograph of an adult patient demonstrates bilateral lower lobe reticular shadowing. There is volume loss in the lower lobes as demonstrated by the position of the hila bilaterally. No focal pulmonary mass, consolidation or effusions. No bony abnormalities. Normal mediastinum and hila. The appearance is suggestive of a lower lobe fibrotic process. Differentials include idiopathic pulmonary fibrosis, scleroderma, asbestos, drugs. I would recommend a chest consult for further assessment to identify the cause.
What would you do next Recommend HRCT for further assessment.
Commentary Case of idiopathic pulmonary fibrosis
Tips This is an example of lower lobe fibrosis on CXR. Patients with lung disease are at higher risk of getting neoplasia. Look for evidence of this. Also try and look for ancillary findings to support the underlying cause. You can mention significant negatives i.e. no evidence of bone erosions to suggest rheumatoid arthritis, no distension of the oesophagus to suggest scleroderma, no features to suggest asbestos. Try and see examples of rheumatoid lung disease.
Case 12: Model Answer and Analysis
Description CXR of an adult patient. AP projection with suboptimal inspiration. There is an abnormal area of opacification in the left apex. The first and second left sided anterior ribs are not clearly seen separate from this lesion. This might represent rib destruction. The right apex is clear. No consolidation or pleural effusion. In summary left apical mass with concern for rib destruction. I would recommend urgent referral to a chest physician and in my centre it is normal practice to organise a CT chest and abdomen for further assessment.
Commentary This is a CXR of a left apical mass with suspicion of left sided rib destruction.
Tips This is a fairly classic case of a Pancoast tumour. It is important to look at the rest of the film to ensure there are no metastasis or additional lesions. I personally feel it is reasonable to suggest performing a CT scan straight of rather than recommend referring to a physician for further assessment.
Case 13: Model Answer and Analysis
Description CXR of an adult patient demonstrating a focal opacity within the right upper lobe. This has well defined borders. No spiculation The mediastinum is located adjacent to this but there is no obscuration of the mediastinal border-the mediastinal silhouette is preserved. No associated bone destruction. No cavitation. No additional pulmonary lesion but there is left hila adenopathy. No pleural effusions. The appearance on imaging is concerning for a neoplastic process. I would recommend an urgent chest consult and organise a CT scan of the chest, abdomen and pelvis to complete staging.
What can be done to complete staging PET CT scan and either CT guided biopsy or bronchoscopy.
What is the most likely differential diagnosis Bronchoalveolar cell cancer
Commentary Right super mediastinal lesion. Left hila node.
Tips Always look for additional signs to help diagnose the condition on the chest x ray. The next examination maybe a CT scan or a CT guided biopsy. The examiner may ask about the equipment used to perform a biopsy.
Case 14: Model Answer and Analysis
Description Chest X ray of an adult patient which demonstrates an opacity in the right lung arising out of the sixth right posterior rib. The inferior wall of the lesion is well defined. Superiorly this arises out of the rib. There is thinning of the rib but no bone destruction. Lung markings are seen through this. Rib notching is also demonstrated in several of the additional ribs inferiorly. No acute bony injury. No destructive bony changes. Normal mediastinum. No hila adenopathy. No evidence of anomaly of the aorta to suggest coarctation. Most likely differential diagnosis is neurofibromatosis. A second differential diagnosis is co-arcation of the aorta but this is less likely.
What would you do next Neurofibromatosis is a multisystem disorder. If the patient has other manifestations then these need to be assessed with imaging.
Commentary This is an example of a neurofibroma of the rib with rib notching.
Tips This is an example of a neurofibroma of the rib. It is important you do not get confused with a lung neoplasm. The lung markings are clearly seen separate to this area and it form an angle with the adjacent rib. Rib notching is also demonstrated.
Case 15: Model Answer and Analysis
Description Chest Radiograph of an adult patient demonstrates perihilar shadowing with interstitial thickening. No pleural effusions or hilar adenopathy. No cardiomegaly. No bony abnormalities. Differentials include PCP or alternate opportunistic infections such as TB, viral pneumonitis or invasive aspergillosis.
How would this case be managed Confirmation of diagnosis from serology or sputum. Treatment of infection and steroids.
Commentary Radiograph of Pneumocystis Pneumonia in a HIV patient
Tips The key is the underlying diagnosis of HIV. A similar CXR and CT appearance maybe noted in hypesensitivity pneumonitis.
Case 16: Model Answer and Analysis
Description This is a CXR of an adult patient, the cardiac apex is pointed in the right side of the chest. The heart is normal size. No evidence of bronchiectasis, No pulmonary mass, consolidation or pleural effusions. The stomach bubble is on the right side of the abdomen and the liver is on the left side of the abdomen. The appearances are in keeping with dextracardia and situs inversus. The patient may have underlying kartegeners syndrome. However, I would double check that the film has not been incorrectly labelled.
How can you check the film has not been labelled incorrectly?
- Look at old films
- Ask the clinician to assess the patient to determine where the heart is?
What would you do next?
There are no acute findings on this film that require drawing immediate attention to the physician referring for this test but the patient needs to be assessed for kartegeners syndrome.
What are the complications of this?
- Increased risk of infection, leading to bronchiectasis
- Sinus infections
- No specific GI problems with the invertion of the solid organs
Commentary This is an example of Kartagener’s syndrome.
Tips You maybe shown Kartegeners syndrome with bronchiectasis or even focal consolidation. Remember to check that the film has been labelled properly. You can ask to see previous films as well.
Case 17: Model Answer and Analysis
Description CXR of an adult patient demonstrates an ill defined mass within the right superior mediastinum. The right hila is poorly soon separate to this. There is elevation of the right hemi-diaphragm. No additional pulmonary lesions. There is an expansile lucent area within the fifth left posterior rib, with fracture of the 6th left posterior rib. Bony lesion is also demonstrated in the sixth right posterior rib. Appearances are suggestive of metastatic neoplasia with the likely primary in the right upper lobe. I would normally urgently contact the referrer and also organise a CT chest, abdomen and pelvis to complete the staging.
What type of primary lesion could it be Likely adenocarcinoma of the lung.
What tests can be done to confirm the diagnosis
- EBUS for diagnosis
- CT guided biopsy
But this depends on the location of the lesion and following MDT review
Commentary Lung neoplasia with rib fractures
Tips This is an example of a case where a few image findings are placed together to create a diagnosis, in this case metastatic cancer. Again describe the positive findings and mention significant negatives and positives. You can either mention positives and negatives i.e. right upper lobe lesion, bone metastasis, rib fracture and right upper lobe volume loss. No metastasis. No pleural effusions etc. It is reasonable to suggest organising a staging CT scan as this will speed up management.
Case 18: Model Answer and Analysis
Description Chest radiograph of an adult patient demonstrates widening of the right superior mediastinum. No pulmonary mass lesions, consolidation or pleural effusions. No destructive bony changes. The mediastinal lesion may represent a neoplasm. Differentials include lymphoma. The patient will require a CT scan of the chest, abdomen and pelvis for further assessment.
Could this be a retrosternal goitre No, because it does not extend above the level of the clavicle. No mass effect on the trachea.
Commentary This is a subtle finding of an abnormality within the mediastinum
Tips To score highly in this film, the key is to identify the subtle abnormality without a huge amount of prompting and then look for additional features i.e metastasis, or bone destruction. The case may move onto a CT scan next.
Case 19: Model Answer and Analysis
Description Chest radiograph of an adult patient demonstrates a left sided pleural opacity. This is lobular in nature involving the mediastinal and parietal pleura. There is associated volume loss in the left lung. No calcified pleural lesions. The right lung appears clear. Normal mediastinum. No rib abnormality demonstrated. Differential diagnosis for the appearance includes mesothelioma or a loculated pleural effusion. This can either be further assessed with a CT scan of the chest with intravenous contrast.
How do you distinguish between mesothelioma and loculated effusion
· Mesothelioma would appear as a nodular soft tissue mass in the pleural space crossing fissures.
· Calcified plaques will be present.
· Invasion of adjacent structures
· Bone destruction.
Commentary This is a plain film of a patient whom has had mesothelioma. The patient had been followed up with plain films. When the effusion did not resolve we performed a CT scan for assessment
Tips You maybe shown a case of supportive features of mesothelioma i.e. rib destruction. When presenting significant negatives as well as positives. Look for abnormalities that support what you have said.
Case 20: Model Answer and Analysis
Description There is a small left sided pneumothorax. Minor mediastinal shift to the right with flattening of the hemidiaphragm. The appearance is suggestive of tension pneumothorax. There is also an oesophageal stent. This appears appropriately positioned. No evidence of pneumomediastinum. No rib fractures. No pulmonary mass, consolidation or effusion. I would urgently convey the findings of this test to the referring clinician for management of the tension pneumothorax. Although there is no evidence of a pneumomediastinum we should perform a CT scan to assess for this.
If there was concern for oesophageal perforation, what can be done A barium swallow study with a water soluble contrast agent such as omnipaque or gastrograffin
What other tests can be done Endoscopy.
Commentary This is a case of a tension pneumothorax in someone who recently had an oesophageal stent placed.
Tips Pneumothorax without explanation i.e. chest trauma in a patient with an oesophageal stent is worrying. Look for a rib fracture to explain the cause. CT is more sensitive for a pneumomediastinum then a plain film. If this identified the patient will require assessment and treatment.
Case 21: Model Answer and Analysis
Description Chest radiograph of an adult patient demonstrates a right upper lobe collapse. No additional lung lesions. No pleural effusions. Normal mediastinum. No bony abnormalities. No evidence of a foreign body in the bronchus i.e. a teeth. The appearances are therefore concerning for a lung neoplasm. This will require a staging investigation for assessment and referral to a chest physician urgently.
What can the clinician do Perform bronchoscopy for tissue sample.
Commentary This is an example of a right upper lobe collapse
Tips Two ways to describe this case 1. Either you look at the case and say ‘there is a right upper lobe collapse’ or the abnormality can be described ‘chest radiograph shows right upper lobe opacification with volume loss. The appearance is in keeping with collapse’. Look for additional signs i.e. lung nodules, bone destruction or evidence of a tooth or foreign body to explain. This might lead to a CT scan or maybe the opening film. Be wary of the banana skin of a foreign body causing obstruction.