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Chapter 15. Interpreting Chest X-Rays, CT Scans, and MRIs

A 64-year-old man presents with persistent cough and a 9 kg (20 lb) weight loss over 6 months. He is a current smoker with a 50-pack-year history of tobacco use. Physical exam reveals stable vital signs with f = 14 breaths/min. There is no abnormality to percussion on chest exam; bronchovesicular breath sounds are auscultated without wheezes. His chest radiograph (shown below) is reported as being abnormal. Given the patient's history, what is the most accurate description of this radiological abnormality?

a. Consolidation of the left upper lobe

b. Left upper lobe atelectasis

c. Mediastinal mass

d. Left upper lobe mass

e. Aneurysmal dilatation of left pulmonary artery

image

The most correct answer is d, a left upper lobe mass.

The chest radiograph shows a round opacity projecting just laterally and cephalad to the left hilum. Because the medial margin of the opacity is seen, a mediastinal mass is excluded (answer c). The left pulmonary artery can be seen easily in its normal location (answer e). The opacity is smaller than the left upper lobe, and no air bronchograms are present, excluding consolidation (answer a). The inferior margin of the opacity is not a long straight or gently curving line, as is the major fissure, and therefore left upper lobe atelectasis is also not evident (answer b). The chest CT scan for this patient is shown below as confirmation.

CASE 15.1.

CT scan of chest confirming presence of a left upper lobe mass. Students should remember to visualize such CT slices as if they were standing at the foot of the patient's bed as the man lies supine. Thus, like x-rays, the patient's left is on the right.

A 49-year-old man (current smoker) presents with progressive dyspnea, associated with right-sided chest discomfort, 12 kg (26 lb) weight loss, and whitish productive phlegm of two weeks' duration. Over the past 48 hours, he has coughed up dark red blood in small amounts. Physical exam reveals stable vital signs but with increased f = 22 breaths/min. An oral cavity exam reveals poor dentition with multiple caries of his teeth. There are decreased breath sounds on the right side by auscultation. His chest x-rays (shown at right) are reported as being abnormal. Given this patient's history and chest x-ray findings, what is the most appropriate next step in his diagnosis and/or treatment?

a. Diagnostic bronchoscopy

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