Adult chest radiograph common exam pathology

Adult chest radiograph common exam pathology is essential to consider in the build up to radiology exams. The list of potential diagnoses is apparently endless, but there are some favorites that seem to appear with more frequency.

When dealing with the adult chest radiograph in the exam setting, it is key to determine where the pathology is and separate your lists out from there.

The lungs

If the pathology is parenchymal, consider which pattern it fits into.

Lobar collapse

An old favorite and often used as a starting film to get you settled. Don't muck it up! And don't try and make it more difficult than it is. While there are five classic lobar collapses to choose from, it would appear that three are commonly used:

• right upper lobe collapse

  • volume loss with raised horizontal fissure, rib-space narrowing and a raised hilum

  • a Golden S sign indicates the central mass causing obstruction and distal collapse

  • see right upper lobe collapse in the exam

• left upper lobe collapse

  • as the lobe collapses, it appears as a veil-like shadow over the left hemithorax

  • there may be associated hyper-expansion of the superior segment of the left lower lobe

  • see left upper lobe collapse in the exam

• left lower lobe collapse

  • look for retrocardiac density and loss of the medial hemidiaphragm

  • there may be a classic sail sign, but don't count on it

  • see left lower lobe collapse in the exam

Air-space opacification

Make sure that you use correct chest radiograph terminology when describing pathology and remember that there is more than one differential for air-space opacification - in real life, it will almost always be pneumonia, but in the exam... think again.

Remember also that air-space opacification starts as ground-glass change, progresses to airspace nodules that tend to confluence and finally result in confluent consolidation.

It is very unlikely that you will be given a simple lobar pneumonia so look more closely - is there associated pleural fluid, cavitation or associated pathology, e.g. rib destruction. Remember that consolidation is just air-space filled with solid material.

• pus, e.g. pulmonary infection

  • strange to get a simple lobar pneumonia, so look for accompanying signs

  • Pneumocystis pneumonia: peri-hilar patchy opacification

  • tuberculosis: can have any appearance

  • Klebsiella pneumoniae pneumonia: confluent consolidation with bulging fissures

  • Staphylococcus aureus pneumonia: cavitation

  • aspiration pneumonia: alcohol misuse, debilitating neurological disorder, recent fall or immobility

• fluid, e.g. pulmonary edema

  • look for associated features including pulmonary plethora, Kerley lines, effusions and cardiomegaly

• blood, e.g. pulmonary hemorrhage

  • Goodpasture syndrome: history of renal disease

  • granulomatosis with polyangiitis: history of nasal symptoms/sinus disease

  • other connective tissues diseases, infarction, AVM or underlying coagulopathy

• cells, e.g. adenocarcinoma

  • an exam favorite that can have any appearance

  • may be patchy or confluence, unilateral or bilateral

• other

  • protein in alveolar proteinosis

  • pulmonary sarcoidosis

  • eosinophilic pneumonia

Also remember the classic features of lobar consolidation and the silhouette sign to localize the pathology:

• right upper lobe consolidation

• right middle lobe consolidation

• right lower lobe consolidation

• left upper lobe consolidation

• left lower lobe consolidation

Cavitating lung lesion

The cavitating lung lesion is a common film to be shown in the exam, and you need to get your eye in to spot it. Cavitation can often be subtle, so double check any area of airspace opacification closely - it will change your differential completely.

• infective cavitation

  • most commonly Staphylococcus aureus infection

• neoplastic cavitation

  • think primary squamous cell bronchial carcinoma or squamous, colonic or sarcoma metastases

• granulomatous disease

  • granulomatosis with polyangiitis: history of nasal/sinus pathology

  • rheumatoid arthritis: look for the distal clavicular erosion

  • pulmonary sarcoidosis: associated nodule disease and hilar lymphadenopathy

  • progressive massive fibrosis: occupational history and background pulmonary nodules

• others

  • infarction

  • traumatic aortic injury

This is a bit of a mammoth project, which will be completed soon:

• septal lines

• lung cysts

• fibrosis (with and without lobar predilection)

• bronchiectasis

• differential transradience

See also

• radiology exams

  • viva technique

  • viva preparation