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BULGING FISSURE SIGN – KLEBSIELLA :

 Due to excessive secretions in infected , the expands producing a mass effect exerting pressure on adjacent fissures.  In this case the horizontal fissure appears bulged due to upper lobe pathology – klebsiella pneumonia

LUNG ABSCESS – AIR FLUID LEVEL WITHIN THE LUNG.

 In the patients presents with signs of infection- high grade fever, elevated counts .  On CXR, a thick walled cavity with air-fluid level within the lung parenchyma

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ASPERGILLOMA/ FUNGAL BALL – AIR / MONOD SIGN

 In a pre-existsing cavity of lung gets infected with aspergillous fungus to form a fungal ball that occupies the dependent portion of the cavity  There is air surrounding the fungal ball giving a crescentic lucency – MONOD SIGN  Air cresentic sign is associated with invasive aspergillosis

CENTRAL – ABPA

 Multiple thick walled cystic lesions presnt in the lung parenchyma towards the hilar region – CENTRAL BRONCHECTASIS  They maybe associated with fixed or transient infiltrates within the lung , then it s acase of allergic bronchopulmonary aspergillosis

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MILIARY TB

 Patient being evaluated for low grade fever,  CXR shows multiple tiny discrete nodules in scattered throughout inn both lung fields  “ RANDOM DISTRIBUTION OF NODULES IN HRCT”

ANIGIOINVASIVE ASPERGILLOSIS:

Central area of opacity & surrounding area of haziness

REVERSE HALO SIGN / ATOLL SIGN – COP

 area of haziness surrounded by opacity.  Seen in CRYPTOGENIC ORGANISING PNEUMONIA

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ADENOID HYPERTROPHY WITH NASOPHARYNGEAL AIRWAY COMPRESSION

 Child presents with recurrent upper infections , snoring  Lateral nasopharyngeal radiograph shows : marked enlargement of adenoid soft tissue resulting in severe narrowing of the nasopharyngeal airway

THUMB SIGN –

The shadow of becomes thick & enlarged causing a narrowing of airway on lateral X ray . The swollen epiglottis shadow looks like a thumb & hence called thumb sign

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STEEPLE SIGN – ACUTE LARYNGO TRACHEO

The subglottic airway narrows to give the appearance of that of a steeple of the church , hence called .

PLEURAL EFFUSION

 Best radiograph – lateral decubitus view (10-25 ml)

 Best investigation/ IOC : USG (5-10ml)

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BLUNTING OF CP ANGLE : earliest finding on erect PA view (200 ml)

 Fluid is in the posterior CP angle, & small amount spilled into the lateral CP angle which is visible as blunting of the angle.

NORMAL

PLEURAL MENISCUS SIGN: 500 ml : with further collection of fluid from above , the fluid will settle down into the dependent part with gravity creating an ill defined concave upper margin - Meniscus

OPAQUE HEMITHORAX : differential diagnosis

WHITE OUT LUNG

Can be any of the following : & are differentiated based on

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 Massive : shift to opposite side  Collapse : mediastinal shift to same side due to volume loss  Consolidation : no mediastinal shift

Mediastinal shift to opposite side

OPAQUE HEMITHORAX

Effusion on supine film : When the patient is lying supine, the fluid will settle in the posterior chest wall (dependent part) & on X ray ( with beams passing anterior to posterior,) there will be increased density over the entire lung field but since the lung parenchyma is normal ,the vascular markings within the lungs will be visible

LAMELLAR PLEURAL EFFUSION

Sometimes instead of settling along the posterior chest wall, the fluid will rise up along the lateral wall like a lamella / band

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LOCULATED / FISSURAL PLEURAL EFFUSION: Usually the pleural effusion is collection of free fluid within the two layers of pleura & hence settle to the dependent part , but at times the fluid gets traped within the fissures – called fissural plural effusion

It will appear as an oval shaped opacity on chest X ray with the long axis of the opacity being parallel to the fissure.

HISTORY CLINGER : PHANTOM/ VANISHING LUNG TUMOUR in an elderly person with chronic failure , with CXR showing a mass like opacity which disappeared completely when the heart failure if treated/ resolved .

Pleural effusion on CT : collection of fluid on the dependent part & it appears at the same density as that of water with no enhancement.

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EMPYEMA –SPLIT PLEURAL SIGN

Along with the homogenous collection of fluid along the lateral chest wall, there is a thin rim of enhancement of the parietal & visceral pleura on either side of the collection , suggesting inflammation

PNEUMOTHORAX

Best radiograph : Expiratory CXR

Best investigation/IOC: CT

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Rx: NEEDLE Things to looks for in CXR of : THORACOTOMY  Visceral pleural line (differential radiographic density theory) INTERCOSTAL DRAIN  Hyperlucency with absent vascular markings INSERTION  Mediastinal shift to opposite side  TENSION PNEUMOTHORAX  Expanded rib cage

On M Mode USG in pneumothorax : BARCODE/STRATOSPHERE SIGN

SEASHORE SIGN : normal USG thorax

Other signs on USG in pneumothorax :

 A LINES: horizontally oriented lines , like reverberation artifacts.

 Absence of pleural sliding  Lung point identification sign

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HYDROPNEUMOTHORAX

Air fluid level in

MEDIASTINAL TUMOURS

 First Ix : CXR  Best Ix /IOC: CECT; EXCEPTION : Posterior Mediastinal Tumours – MRI (because most of these tumours are neurogenic & MRI is helpful in evaluating the extent, involvement of neighboring structure etc)

 Overall MC Mediastinal Mass Lesion: THYMOMA  MC Anterior Mediastinal Mass Lesion : THYMOMA  MC Middle Mediastinal Mass Lesion : LYMPH NODE MASS  MC Middle Mediastinal Mass Lesion In Children: DUPLICATION CYCTS  MC Posterior Mediastinal Mass Lesion: NEUROGENIC TUMOUR

ANTERIOR MEDIASTINAL TUMOURS

HILUM OVERLAY SIGN:

 Cardiac vs mediastinal mass

 When there is a mass lesion overlapping hilum on CXR & the hilar vessels are visible (HILAR OVERLAY), it is most likely a mediastinal lesion whereas a cardiac lesion will NOT produce HILAR OVERLAY but instead the hilar vessels/ markings will get pushed to the lateral margin of the mass