Tim Milligan – Page 21 – Toronto Notes

Pneumothorax – Pleural Disease

Tim Milligan November 12, 2015April 25, 2022 Pleural Disease

The patient’s left pneumothorax is more difficulty to diagnose on this supine film. This study demonstrates the “deep sulcus” sign, with the left costophrenic sulcus descending below the edge of the film. Other clues include a hyperlucent left hemithorax and slight sharpening of the left mediastinal border. This patient also has a tracheostomy, evidence of a prior sternotomy (not the multiple circular sternal wires), and a central venous catheter with its tip in the right ventricular outflow tract. The circular structures projecting over the chest, some with wires extending from them are ECG leads.

Pneumothorax - Pleural Disease

Pleural Effusion – RLD

Tim Milligan November 12, 2015April 25, 2022 Pleural Disease

This patient has a moderate-sized right pleural effusion. The lateral decubitus film places the effusion in the dependent position and will show layering unless the effusion is loculated. This is noted in the same patient’s left lateral decubitus film.

Pleural Effusion - RLD

PA Film

Tim Milligan November 12, 2015April 25, 2022 Pleural Disease

Normal PA film of a male. Note the right and left clavicles (cl), posterior (p1-4) and anterior (a1-2) ribs, right and left costophrenic angles(cpa), right cardiophrenic angles (cdpa), right and left hemidiaphragms (hd), gastric air bubble (gab), trachea (tr), right and left mainstem bronchi (br), mediastinal shadow (med), carina (ca), and right and left hila (hi). The normal position of the minor fissure (mi) is also indicated.

PA Film

Tim Milligan November 12, 2015April 25, 2022 Normal

PA Film

Normal – AP

Tim Milligan November 12, 2015April 25, 2022 Normal

Because the AP projection positions the heart and mediastinum further from the x-ray film than the PA projection, these structures appear magnified with the AP view. Other clues that you are looking at an AP projection include clavicles that project above the lung apices and scapulae that project over the lung fields.

Normal - AP

Nipple Shadows

Tim Milligan November 12, 2015April 25, 2022 Normal

Nipple shadows can often mimic pulmonary nodules. Clues to nipples being the source of the apparent nodules on the lateral radiograph, bilaterally and “lesions” whose inferior and lateral borders appear sharper than their superior and medial margins. Confirmation can be obtained by repeating the study with nipple markers or obtaining a different projection.

Nipple Shadows

Mediastinum

Tim Milligan November 12, 2015April 25, 2022 Normal

Components of the PA mediastianl shadow (A) include SVC (1), ascending aorta (2), RA (3), IVC (4), aortic arch (5), pulmonary trunk (6), LA appendage (7), and LV (8).
Mediastinal compartments on the lateral film (B) include: superior (S), anterior (A), middle (M) and posterior (P) compartments.

Mediastinum

Lateral Film

Tim Milligan November 12, 2015April 25, 2022 Normal

This is a normal lateral film of a female patient. Note the spine (sp), anterior costophrenic angle (acpa), gastric air bubble (gab), trachea (tr), left mainstem bronchus (lbr), right mainstem bronchus (rbr), aortic arch (ao), anterior/retrosternal (acs) and posterior/retrocardiac (pcs) clear spaces, and breast shadow (m)

Lateral Film

Inspiration and Expiration Films

Tim Milligan November 12, 2015April 25, 2022 Normal

On a film taken in full inspiration, the right hemidiaphragm should project over the 6th anterior interspace or 10th rib posteriorly. Films taken without a full inspiration are described as having a “poor inspiratory result”. This may result from a poor inspiratory effort or any other condition that prevents full inspiration.

This patient’s chest x-ray is normal in full inspiration. In relative expiration, the cardiac silhouette appears enlarged and the pulmonary vasculature appears crowded and indistinct. This appearance is easily mistaken for pulmonary edema

Inspiration and Expiration Films

Musculoskeletal

Tim Milligan November 12, 2015April 25, 2022 Musculoskeletal

Hypertrophic First Rib

Rib hypertrophy, often at the costochondral junction and particularly involving the first rib, commonly mimics a lung nodule on the PA projection. It has been called “the medical student’s tumor.” Clues that the “nodule” is in fact due to rib hypertrophy include its absence on the lateral view, bilaterality, and the presence of rib hypertrophy at other levels. If there is any doubt, a lordotic projection can be obtained.

Musculoskeletal

Author: Tim Milligan