SET T0036 -
GP Referrals -
Chest radiographs

A tough case. Subtle abnormalities.

These are the observations:

• Left hilum is slightly dense.
• A faint shadow - small and faint - is projected lateral to the left hilum.
• Otherwise normal appearances.

Comment: Given the history and these subtle findings - CT evaluation is necessary in order to assess the left lung and the left hilum.

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Follow up: see the CT section below. A density is situated anteriorly in the left upper lobe. Nodal enlargement at the left hilum.

[Proven bronchial carcinoma].

Right paratracheal increase in density - very suggestive of enlarged lymph nodes.

[Proven tuberculosis].

Uncertain about defining the normal, and detecting the abnormal, paratracheal appearances? Suggest . . .

See : The Chest X-Ray : A Survival Guide : Page 232

Observations:

• Discrete density projected over the right upper zone (RUZ).
• Possible - but not certain - interstitial shadows in the mid and lower zone  of the right lung.

Comment: CT evaluation needed - particularly to evaluate the RUZ density.

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See the CT slice below. This reveals that the RUZ density is a skin tag on the posterior wall of the thorax. (Incidentally, the CT showed that the lungs were entirely normal).

ADDITIONAL COMMENTS:

1. Remember that a lesion of sufficient density on the skin, when overlying the lung, will appear as a "lung lesion" on the frontal view.
2. In some countries, where a lateral CXR accompanies a frontal CXR as a routine, the skin density might well have been noted on the lateral CXR . . . and thus made a CT examination unneccessary.
3. In the UK it is common for most CXR examinations to be limited - by local protocol - to a frontal CXR only. Some overseas physicians - arguably correctly - find this particular UK practice bizarre: a three dimensional thorax is evaluated solely with a two dimensional image . . . when a simple at-the-same-time lateral radiograph would provide the third dimension.

REMINDER: Be very careful - whenever a frontal CXR is technically poor.

A small inspiration or some degree of rotation can make a normal CXR look abnormal. Being aware as to what constitutes good and bad technique will always influence your assessment of the chest radiograph.

COMMENTS:

• This CXR appears abnormal. There appears to be enlargement of the azygos node to the right of the trachea; also, there is a suspicion of some interstitial shadowing in the right lung.
• When this CXR was shown to the Radiologist - he noted that the CXR was essentially obtained in less than a full inspiration . . . and requested that the CXR be repeated with the patient encouraged to take a very deep breath.
• The repeat CXR was obtained 10 minutes after the initial CXR and it is shown below.
• This repeat CXR is entirely normal.
• Unsure as to what constitutes an adquate inspiration when assessing a frontal CXR? Suggest . . .
• See : The Chest X-Ray : A Survival Guide : Pages 6 & 237