Darkening in the lungs on x-ray. Focal shadows in the lung tissue On the left at the apex of the lung there is a single focal shadow

Rosenshtrauch L. S., Winner M. G.

To focal shadows, usually determined on x-rays and tomograms of the lungs, include shadows with a diameter of 3 mm to 1.5 cm. The small size of the formations and often a small number of them cause the appearance of an uncertain x-ray picture. Many radiologists use the term “focal-like opacities” when describing and interpreting many pathological processes in the lungs.

It is sometimes believed that focal changes are characteristic only of tuberculosis, and focal-like changes are characteristic of other processes that differ from tuberculosis in being more dynamic. However, it is known that a focal or focal-like shadow on a radiograph is a reflection of a completely specific morphological substrate, and it can be different (inflammatory, tumor, scar, etc.). In this regard, focal-like shadows are very diverse in size, localization, intensity, the nature of the contours of the lesions, changes in the pulmonary pattern and lung tissue. Focal changes in the lungs can be single, multiple, scattered or disseminated.

The following techniques allow us to clarify the nature of focal-like shadows:

1. Fluoroscopy and radiography.
2. Tomography, computed tomography.
3. Bronchography.
4. Probing of the bronchi.
5. Transthoracic puncture.

Normally, focal-like shadows may be caused by the nipples of the mammary glands. The localization, shape, and symmetrical arrangement of these shadows usually make it possible to distinguish them from changes in the lungs without much difficulty.

According to the Classification of Tuberculosis, depending on the extent and volume of lung damage with focal tuberculous changes, two forms are distinguished - focal and disseminated. Focal tuberculosis is characterized by a limited lesion, occupying no more than 1-2 segments on each side. A more common lesion is called disseminated tuberculosis.

For focal tuberculosis The disease is asymptomatic for a long time or with mild symptoms, which makes its early clinical detection difficult. Disseminated tuberculosis can develop acutely, subacutely or covertly. In acute and subacute forms, the disease is usually detected when the patient consults a doctor with complaints of increased fatigue, weakness, fever, and cough. In approximately 70-80% of cases, the process is diagnosed by fluorography, although some patients have mild clinical symptoms.

Mycobacterium tuberculosis is found in sputum and bronchial washings in disseminated tuberculosis in 70-80% of cases. Damage to other internal organs is rare (2.2%). Analysis of the diagnostic process at the stages of examining patients shows that difficulties in determining the nature of the disease arise quite often - in approximately 24% of newly ill patients. Often these patients are initially treated for pneumonia, sarcoidosis, influenza, sore throat, etc.

X-ray picture of focal pulmonary tuberculosis depends on the phase of the process: in the phase of decay and infiltration, tomograms reveal foci without clear contours, with small foci of destruction in them, as well as uneven infiltration of the surrounding lung tissue, a limited “inflammatory” increase in the pulmonary pattern (lymphangitis). With regression of the process, the number of focal shadows decreases, the contours of individual lesions become clearer. Taking into account the fairly typical localization of the process in segments I-II, as well as the polymorphism of the lesions, often the presence of small calcifications, it is possible to diagnose and differentiate focal tuberculosis without great difficulty. The difference between focal tuberculosis and focal bronchopneumonia is based on the rapid regression of the latter. Pneumonia, as is known, is a dynamic process, and after 10-12 days, focal shadows completely cease to be detected, and with tuberculosis, noticeable regression occurs after 1.5-2 months.

X-ray picture of disseminated tuberculosis is very diverse, but we can distinguish its most common and rare variants. Most often, polymorphic focal changes are localized in the apical-posterior segments of the upper lobes and the VI segment, and are characterized by an uneven distribution of foci in the affected area. At the same time, small foci of destruction are detected by tomography in approximately 60% of patients. The pulmonary pattern in the areas of greatest damage is poorly differentiated, as it is covered by an abundance of focal shadows. There are no symptoms of hyperplasia of the intrathoracic lymph nodes. On radiographs and tomograms, with a characteristic picture of disseminated tuberculosis, limited or subtotal dissemination with destructive changes and asymmetry of damage to the sides of the lungs is determined. The lesions undergo almost complete regression with the formation of moderate sclerotic changes by the 4-5th month of treatment.

Very rarely, disseminated tuberculosis is accompanied by bronchoadenitis or the lesions are localized mainly in the basal segments of the lungs. At the same time, the unevenness of damage to the right and left lungs also remains. Adenopathy is observed in young people with primary tuberculosis or in older people with reactivation of a previously suffered process in the calcified lymph nodes of the lung root. Thus, in most cases of disseminated tuberculosis, based on the clinical (detection of Mycobacterium tuberculosis) and radiological picture, characterized by the typical localization of foci, their polymorphism, destruction, it will be possible to reliably diagnose this disease.

Difficulties arise with adenopathy or the location of lesions in the basal segments. In the first case, bronchoscopy data become important, in which infiltrative bronchial tuberculosis or lymphobronchial fistulas are detected and bacilli are confirmed. In the second case, when there are no destructive changes, mycobacterium tuberculosis is not detected, and the foci are localized in the lower zones of both lungs, regardless of whether there are any clinical manifestations of the disease or not, it is not possible to reliably establish or reject the diagnosis of tuberculosis with a single study. Diagnostic tactics in such cases depend on the clinical manifestations of the disease. If a febrile state is observed and the duration of the illness is short, then test therapy should be carried out. If the body temperature is not elevated and the patient’s condition is satisfactory, then morphological verification of the diagnosis is necessary - a lung biopsy.

According to statistics, every hour in Russia one person dies from tuberculosis. A routine examination, especially if a person is at risk, can detect the disease in time, which means that prescribed therapy can prevent complications.

Today we will look at most common fluorography results deciphering which will allow us to find out what they mean, what we should pay special attention to when we receive information about a chest x-ray.

Doctors write very illegibly, some people believe that this is due to the fact that the patient does not understand what kind of disease he has. This may be so, but it is surprising that at the same time they parse and understand what their colleague wrote.

What is fluorography

Fluorography is an examination of the chest using X-ray irradiation, with the results of the examination recorded on film. The technique is already somewhat outdated, but is still the cheapest way to check your lungs for any pathologies.

Principle of obtaining results

The radiologist visually distinguishes changes in the density of lung tissue on photographic film. Those places where the density is higher than in healthy lungs indicate some problems in the tissues. The connective tissue, growing, replaces the lung tissue and appears as lighter areas on fluorography.

Much of the results depend on the qualifications and experience of the doctor.. There was even such a curious case when a young doctor saw a shadow in the left half of the lungs, began to sound the alarm, but it turned out that it was the heart! But, of course, this is from the category of medical legends.

What can you see in the photographs

There are adhesions, fibrosis, layers, shadows, sclerosis, heaviness, radiance, cicatricial changes. All these abnormalities, if present, are visible on films of the lungs.

If a person has asthma, then the image will show that the walls of his bronchi are thickened, this is due to the fact that they bear a higher load. The images can also identify cysts, abscesses and cavities, calcifications, emphysema, and cancer.

The most common conclusions after fluorography

Please note that if you really have any serious problems in your lungs, you will be told about this immediately when you come to collect your results. If you were not sent to a tuberculosis clinic or for an x-ray to clarify the disease, then everything is more or less fine. Now let's look at the most common lung problems.

The roots are expanded and compacted

The roots of the lungs are the main bronchus, bronchial arteries, pulmonary artery and pulmonary vein. This is one of the most common diagnoses, indicates some chronic processes occurring in the lungs. Chronic bronchitis, edema, pneumonia, pneumonia.

If in your conclusion it is written “roots are compacted, expanded”, then this indicates that you have a chronic inflammatory process in the lungs. Experienced smokers often have this exact fluorography result.

The roots are heavy

This is also a common result of fluorography. All the same problems are to blame for its manifestation - chronic or acute processes in the lungs. Most often, the heaviness of the pulmonary pattern or the heaviness of the roots of the lungs is detected in smokers, as well as with bronchitis. It may also indicate an occupational disease associated with stress on the lungs, for example, when working in hazardous industries.

If the results only say "heaviness of the roots of the lungs", don’t panic, everything is within acceptable limits, especially if you weren’t sent anywhere. But it is important to take into account the signal and monitor the condition of your lungs, avoiding exacerbation of chronic processes.

Increased vascular or pulmonary pattern

The pulmonary pattern is the shadows on the fluorogram, “cast” by the veins and arteries piercing the lungs. It is also called vascular pattern. If such an item is written in the results, it means that in some part of the lungs there is an area into which blood flows more intensely along the arteries.

It is recorded in some acute inflammatory processes, bronchitis, pneumonia, and may also indicate pneumonitis, and requires a repeat image to make sure there is no oncology.

Fibrous tissue, fibrosis

This is evidence of some previous pulmonary disease. This may be evidence of a previous operation, an old injury, or a past infection. Fibrous tissue belongs to the connective tissue and serves to replace damaged lung cells. Fibrosis in the lungs indicates that everything has healed and there is no threat.

Calcifications

These are isolated cells affected by tuberculosis or pneumonia. The body seems to stick a substance similar to bone tissue around the problem area. Round shadows are visible in the photo. If a person has a lot of calcifications, this indicates that the body has overcome the infection and the disease did not develop. Therefore, if you are found to have calcifications in your lungs, there should be no concern.

Another thing is aortic calcification

Calcification is the gradual accumulation of insoluble calcium salts on the walls of the aorta. As a rule, calcified plaques are visible on fluorography; this, in principle, is not a pulmonary problem, but it is diagnosed by fluorography. These plaques themselves are dangerous both because they can come off and clog the vessels, and also because the vessels themselves become brittle, as if they were made of crystal.

I advise you to take this diagnosis very seriously.. Any increase in pressure can become critical. It is necessary to consult a specialist and limit the intake of calcium into the body. If calcium is deposited on the walls of blood vessels, it means that there is an excess amount of it. calcium is deposited in tissues and blood vessels. This happens when there is an excess of calcium in the blood.

Focal shadow - lesions

Focal shadows, or foci, are darkening of the lung field, a fairly common symptom. The size of the shadows is usually up to 1 cm.

If you or your child have shadows in the middle or lower parts of the lungs, then this indicates the presence of focal pneumonia.

Signs of active inflammation may include uneven edges, increased pulmonary pattern, and merging of shadows. If the focal shadows have smooth and dense contours, it means that the inflammation is ending. But consultation with a therapist is necessary. Probably, pneumonia, which turned into pneumonia, “settled” deep in the lung tissue.

If focal shadows are found in the upper parts of the lungs, then this indicates possible tuberculosis and requires clarification.

Pleuroapical layers, adhesions

After inflammation, adhesions may occur; these are also connective structures that isolate the area of ​​inflammation from healthy tissue. If you see adhesions in the image, then there is no cause for concern..

Pleuroapical layers are compactions of the pleura of the pulmonary apices. The layers may indicate some kind of inflammatory process that occurred relatively recently. Most often about tuberculosis infection. However, if the doctor does not consider the picture serious, then there should be no reason to worry.

Pneumosclerosis

This increase in connective tissue in the lungs may be the result of disease. Such as bronchitis, pneumonia, tuberculosis, working in dusty industries, smoking.

Tissues lose elasticity and become denser. The structure of the bronchi may change, the lung tissue itself becomes similar to dried fruit - it decreases in size. Also is one of the diseases requiring observation. Staying in dry, thin mountain air is indicated. Resorts in the Caucasus are highly recommended. For example, in Teberda it is very good for pulmonary patients; I have been to these parts myself. If possible, then go and live there in both summer and winter.

Sinus sealed or free

Pleural sinuses are cavities formed by pleural folds. A healthy person has free sinuses. But if there are any problems, then liquid accumulates there. If you have "sinus is sealed", this means that there is the presence of adhesions, probably after pleurisy. There is no reason to worry.

Changes from the diaphragm

Diaphragm anomaly is quite common. Other similar names are high dome position, dome relaxation, diaphragm dome flattening. The reasons may be: disturbances in the gastrointestinal tract, liver problems, pleurisy, excess weight, oncology. This sign is interpreted based on other available data, analyzes and studies.

Examples of results and their interpretation

They regularly send me emails [email protected] photographs of radiologists' reports. I decided to add the illegible handwriting of the doctors and give a transcript. Maybe by looking at examples you can identify your diagnosis. I would be grateful to everyone who replenishes the database.

Conclusion of a radiologist - Pneumosclerosis. Aortic calcification.

On this conclusion it is written: The pulmonary pattern is strengthened and deformed in the lower part on the right side. The roots are heavy.

Conclusions

Annual fluorography will allow you to identify lung problems, if any, at an early stage. At many enterprises, employees are routinely sent for examinations, but those who neglect this procedure risk unexpectedly finding out that they have some difficulties, God forbid, of course.

In radiology, the spot is called a shadow. A spot-like shadow less than 1 centimeter in diameter is a focal shadow. A focal shadow is a lesion whose size ranges from 0.1 cm to 1.0 cm. These pathological lesions are characteristic of various nosological forms. By origin, these lesions can be of inflammatory and tumor origin, and are also caused by hemorrhage, edema, and atelectasis. X-ray experience proves that lesions in the lungs occur in inflammatory diseases that pathologically change the structure of the pulmonary parenchyma. In our country, foci are also characteristic of tuberculosis (focal tuberculosis). In practice, it often occurs when there are 2-3 lesions in one lung, then radiologists talk about a group of lesions in the lung. Inexperienced and young specialists mistake the cross-section of a vessel, the shadow of the nipples of the mammary gland, as well as calcium deposits in the cartilage of the ribs as focal shadows.

A focal shadow has the following characteristics:

1) Localization of focal shadow.
2) Prevalence of focal shadow.
3) Contours of focal shadow.
4) Intensity of focal shadow.

This patient has a lesion in the middle lobe of the right lung with a decay cavity in the center (indicated by an arrow). According to the clinic, the patient was diagnosed with tuberculosis.

White spot on x-ray of lungs/white spot on x-ray of lungs/white spots on lungs/two spots on lungs/lung disease spot on lung

For each disease there is a characteristic localization of the outbreak. Tuberculosis (focal tuberculosis and tuberculoma) is characterized by localization in the apices of the lungs and under the collarbone. With pneumonia, the localization can be any, but inflammatory lung diseases are characterized by a group of foci (2-3 foci). For peripheral lung cancer or tumor metastasis, a characteristic sign on the radiograph is a single lesion without signs of calcification.

The contours of the lesion can be sharp or blurred. Blurred contours more often indicate an inflammatory cause of the origin of the lesion. If on the radiograph we encounter a single lesion with sharp contours, which is not located in the apex and subclavian region, then the radiologist suspects peripheral cancer. A single focus with sharp contours located at the apex or under the collarbone suggests tuberculosis (focal tuberculosis or tuberculoma).

The following structure of the focus is distinguished: homogeneous or heterogeneous. If we consider the example of pulmonary tuberculosis, then, using these properties, we can tell the phase of the disease, which is taken into account when choosing chemotherapy. A homogeneous focal shadow is characteristic of tuberculosis in the consolidation phase, and a heterogeneous shadow is characteristic of tuberculoma.

This patient showed changes in the roots of the lung, which corresponds to tuberculosis of the intrathoracic lymph nodes in a patient with prolonged fever and cough.

Small spot on the lung/small spot on the lung/spots in the lungs on x-ray/

When talking about the intensity of a focal shadow, radiologists often compare the intensity with nearby anatomical structures, for example, with the blood vessels of the lungs.

The following intensity of the focus is distinguished:

1) low-intensity shadow - if the focus is visualized with intensity, like a longitudinal section of a vessel.
2) medium-intensity shadow - if the focus is visualized with intensity, like a vessel in an axial section.
3) dense focus (high-intensity shadow) - if the focus is visualized with an intensity higher than the intensity of the lung vessel in the axial section.

With a low-intensity shadow on the radiograph, depending on the clinic, it is possible to suspect focal pneumonia or tuberculosis in the infiltration phase (focal tuberculosis). A medium-intensity shadow indicates the attenuation of the tuberculosis process, which is most often observed with adequate treatment.

Also, radiologists separately identify a Ghon lesion or a decayed calcified lesion in the lung, which, together with a calcified lymph node, suggests a primary tuberculosis complex.

Each lesion (spot), if you look closely, is unique, and only an experienced radiologist is able to compare the clinical picture with the picture on the x-ray. To avoid unnecessary diagnostic errors, radiography is done in two projections, and is also performed after a certain time to assess the dynamics of the lesion. Let’s say that if a 70-year-old patient who has been smoking all his life has a single lesion in the lung, then it is more correct to regard this formation as lung cancer.

A 76-year-old patient was diagnosed with a shadow in the right lung. Initially, peripheral lung cancer was suspected, but the diagnosis for this patient was hamartoma of the right lung.

Round spot on the lung/pneumonia of the lungs on the right side spots on the lungs/spots on the lungs causes

The round spot on the radiograph corresponds to radiographic round shadow syndrome. Round shadow syndrome is said to occur when the following shadows are visualized on an x-ray:

1) Single shadows of a round shape.
2) Single shadows of a semicircular shape.
3) Single oval-shaped shadows.
4) Multiple round shadows.
5) Multiple semicircular shadows.
6) Multiple oval-shaped shadows.

Another important criterion for telling when a round shadow is visible on an x-ray is size. The size of a round shadow should be more than 1 centimeter since smaller shadows are focal points.

A round shadow, like a lesion, is caused by various pathological causes in the lung, for example:

1) Inflammatory process.
2) Tumor process.

Also, a round shadow is visualized when there are cavities in the lung with fluid. There are also reasons not related to lung pathology, but in which a round shadow is visualized - this is pleural pathology. These include pleurisy (inflammation of the pleura), pleural tumor, and cyst.

The patient has a cyst filled with fluid.

Spots on the right lung/spot on the left lung/spot on the lungs during fluorography

In order to guess what disease the round shadow belongs to, the radiologist initially answers the following questions:

1) What shape is the shadow?
2) Is there a relationship with surrounding organs?
3) What are the contours of the shadow?
4) What is the structure of the shadow?

The shape of the rounded shadow delineates the process into a pathological process that is inside and outside the lung. Intrapulmonary pathology is characterized by a round, but also an oval-shaped shadow. An oval-shaped shadow occurs with lung cysts that are filled with fluid. Also, an oval-shaped shadow is a characteristic picture when the cyst has increased in size to such a size that it comes into contact with the diaphragm, pleura, mediastinum, and chest wall.

The contours of a rounded shadow allow the radiologist to establish the cause of the pathology, and therefore are an important sign in the description.

The contours are:

1) Fuzzy or also called unsharp.
2) Clear or sharp.

Fuzzy contours for inflammatory diseases are mild. It is impossible to make a specific diagnosis in this case, but the identified symptom narrows the differential range. If the contours are clear, one should assume a lung tumor, tuberculoma, or a fluid cystic formation that does not contain air inside.

The patient has a darkening in the right lung, which is characteristic of lobar pneumonia.

Spot on the lung image/x-ray of the lungs white spot/x-ray of the lungs light spot

A rounded shadow in its structure is visualized as homogeneous or heterogeneous. The shadow is uniform in tuberculoma, but against the background of the shadow, calcium must be a prerequisite. If a round formation is encountered with a cavity inside, then the first thing radiologists think about is a tumor with decay or infiltrative tuberculosis in the decay phase. Cancer is more characterized by a rounded shadow with a cavity, in which uneven internal contours and uneven wall thickness. Tuberculoma is characterized by small, crescent-shaped cavities. A cavity with liquid contents is visualized when the cyst is opened (exit of liquid contents) into the bronchus, as well as in case of a lung abscess, which is accompanied by a serious condition of the patient.

When interpreting a radiograph with a round shadow, it happens that despite taking into account all the above signs, the radiologist did not come to a conclusion. Then a prerequisite for making a diagnosis is the correct assessment of the lung tissue that is adjacent to the pathological focus. If the lung tissue surrounding the lesion with blurred contours is intact, then this is a sign of fresh inflammation (acute and subacute phase). Fibrosis of the tissue surrounding the lesion indicates a chronic inflammatory process, which is more often characteristic of tuberculosis. Chronic inflammation of tuberculous origin is characterized by a path to the pulmonary root, which is visualized as a bronchus draining the cavity with thickened walls.

This patient has left lung cancer.

Sometimes, to take care of health, there is not enough time, responsibility, desire, and finally, awareness of the importance of this task. That is why in medical institutions, both public and private, there is a requirement to undergo a number of mandatory examinations, regardless of the reason for the visit. One of these procedures is annual fluorography. Doctors recommend undergoing a lung x-ray or x-ray to detect diseases such as lung cancer or tuberculosis. Early detection of these and other diseases improves the effectiveness of treatment and increases the likelihood of a positive outcome.

There are cases when darkening is recorded in the final picture of the lungs, which causes feelings close to panic in patients. Let's figure out what darkening on the lungs looks like on an X-ray, where it comes from, what it could be and what the reason for its formation is. There are quite a few factors contributing to the appearance of black and white spots in photographs. But before moving on to considering the causes of darkening and analyzing them, you must first find out what a standard x-ray looks like.

What does a classic x-ray look like?

The classic photograph is a reverse (negative) image. The difference between a negative and a positive radiograph is that there is an inverse shadow correspondence. That is, the light parts in the picture show organs with maximum density, which retain and absorb X-rays, and the darker areas, respectively, show less dense tissues and voids that allow radiation to pass through unhindered.

Healthy lungs in the picture look like this: the right one is short and wide, the left one is long and narrow, which corresponds to the norm. These areas should be transparent, as they contain a large volume of air and practically do not interfere with the passage of X-rays.

Reasons for the appearance of spots in the photo

There can be many reasons for the appearance of spots. Only a qualified radiologist can give a complete transcript. Nevertheless, we can identify the main reasons why darkening occurs in a fluorography image:

• foci of active tuberculosis and post-tuberculosis changes;
• the occurrence of a benign or malignant tumor;
• consequences of smoking;
• post-traumatic lesions;
• accumulation of intrapleural fluid;
• bronchitis types of diseases;
• the presence of abscesses.

The location of the spot plays a big role. Depending on its location - on the right or left lung, in the lower or upper part - the value of this darkening may also change. To find out the true cause of the shadow in the picture, you need to consult a specialized specialist.

Types of shading

The spots in the lungs in the fluorography image are noticeably different from each other in appearance. It may be a dark or white spot. There are such deviations as enlarged (with acute bronchitis, pneumonia) or stringy roots (which indicate chronic bronchitis, smoking), as well as bilateral linear shadows (with tuberculous infiltrate and cavity). It may not even be a spot, but just a white dot. In medicine, it is customary to classify darkening into several main types:

• focal;
• focal;
• segmental;
• indefinite shape;
• shared;
• with the presence of liquid.

Based on the type of darkening, the doctor will be able to make an accurate diagnosis and prescribe a course of treatment.

Focal darkening in the lungs

Shadows of this type arise due to inflammatory, tumor, scar processes that affect the respiratory organs, or due to vascular pathology. Despite the fact that the size of such darkening does not exceed one and a half centimeters, they can cause serious illnesses. They look like a small clear shadow on a fluorography image, the so-called nodule spot. The cause of their occurrence is often impossible to determine, as is the nature; in such cases, additional examinations are necessary. Focal, or focal-like, darkening varies in size, location, intensity, and can be single, multiple, scattered and disseminated. If focal darkening is found along with symptoms such as fever, headache, cough, or a feeling of heaviness in the chest, this may be the first sign of bronchopneumonia.

Ring shadow syndrome

A darkening in the form of a ring-shaped shadow on an x-ray is a sign of a decay cavity. It may indicate several pathologies. The main and most common means that there was contact with a person with tuberculosis, but the body was able to enclose the tuberculosis bacillus in a calcium shell and prevent it from developing, that is, calcification was formed. The reasons for such a shadow can also be:

• abscess;
• air cyst;
• disintegrating tumor.

To make an accurate diagnosis, you will need to undergo further examination.

Circular focal shades

Focal, or circular, eclipses often exceed the size of one centimeter and are also one of the signs of the onset of the disease. Focal shadows require careful investigation, as they can be signs of dangerous conditions such as:

The causes of the appearance of focal or spherical shadows can be cysts (congenital or acquired). They may even indicate the appearance of the following types of tumor processes:

• sarcoma and metastases are malignant;
• hamartochondroma, adenoma and fibroma are benign.

Segmental and lobar darkening

The darkening present in the fluorography image can be localized in the form of single segments with very different contours. Often segmental darkening has the shape of a triangle. There may be more than one area with similar shadows. In order to determine the exact cause of their occurrence, you will need to undergo a full examination. The presence of single segments may indicate:

• endobronchial tumors;
• presence of a foreign body or mechanical damage.

But the appearance of a group of segments is much more dangerous and may indicate:

• pneumonia;
• the presence of tuberculosis or other inflammations;
• central cancer;
• metastases of malignant tumors in other organs.

Lobar darkening, although similar to segmental darkening, still has differences. The contours of the shadow are clearly visible and easily defined. They can have different shapes. The presence of such spots means:

• chronic lung disease;
• the presence of bronchial obstruction.

If the lower or middle part of the lung is darkened, this indicates the presence of a malignant or benign tumor.

Shading of an indeterminate shape

If the image reveals a spot on the lungs of an indeterminate shape, in most cases this indicates the presence of staphylococcal pneumonia. This disease has several forms:

• primary - may occur due to an inflammatory process in the tissues of the lung or bronchi;
• secondary - may manifest itself due to the development of a purulent focus in the body.

Nowadays this disease is quite common. In addition to pneumonia, this type of darkening indicates tissue swelling, the presence of a tumor, hemorrhage and other pathologies. The exact source of the stain can be determined after the necessary laboratory tests.

If the appearance of this kind of spots is accompanied by the presence of metastases, fever, weakness and cough, this may mean a cancerous tumor, inflammation of the lung or the presence of pleurisy.

Darkening with liquid

If fluid is visible on fluorography, this indicates swelling of the organ. This condition occurs due to increased pulmonary capillary pressure or decreased protein levels in the body. Edema is divided into two types, it is divided according to the causes of its occurrence:

• hydrostatic edema. Its cause is increased intravascular pressure, as a result of which fluid enters the alveoli and fills the lung. The cause of such edema may be diseases of the cardiovascular system;
• membranous edema. It occurs due to the accumulation of toxins in the body, as a result of which fluid also enters the lung.

In order to determine the cause of the spot, an X-ray in additional projections, a computed tomography scan, and interpretation of the resulting sections by a professional are required.

Total blackout syndrome

By total darkening we mean darkening of the entire lung field on an x-ray. The darkening can be one-sided or two-sided.

Double-sided dimming most often indicates:

• toxic or cardiac pulmonary edema;
• staphylococcal pneumonia;
• pleural moorings.

One-sided darkening is also divided into several subtypes:

• homogeneous;
• total;
• intense.

Homogeneous darkening may indicate atelectasis of the lung or complete absence of the organ (for example, with a congenital disease). Total shadows are observed with inflammatory infiltration or pleural scarring. The presence of intense darkening indicates encysted pleurisy or an extensive pulmonary cyst.

In general, total darkening indicates serious health problems, so taking a second X-ray and consulting an independent doctor is the best decision.

What dark spots look like on an x-ray in various diseases

X-ray allows you to visually study the condition of the lung tissue, based on the presence or absence of shadows, the correspondence of their shape and concentration to the normal picture, which may mean the presence or exclusion of pathological processes. If the darkening is accompanied by characteristic symptoms, then additional blood tests may not be needed.

Tuberculosis

If a linear darkening of the lung in the upper part is detected on fluorography, the conclusion is disappointing - it is most likely tuberculosis. But if there is no cough, an accurate diagnosis can only be made with a complete examination of the patient. There is no point in delaying this, since detecting tuberculosis in the early stages is the key to a quick and successful recovery.

Pneumonia

If fluorography shows dark areas in the lower part of the lung, this is most likely pneumonia. You can see the symptoms of the disease more clearly in the photograph taken at the culmination point of its course. On film, such specific spots look fuzzy and have a very heterogeneous structure.

The presence of such shadows in a healthy person indicates that he has had pneumonia or bronchitis. With complete recovery, these spots will disappear completely.

Lung cancer

One of the most terrible diagnoses remains, of course, cancer. A characteristic spot in the lungs, visible on an x-ray, may indicate the development of this disease. It is worth noting that as long as the size of the formations is less than 2 mm, it is difficult to make a medical conclusion using fluorography, but when they reach 3 mm, it becomes possible to establish a diagnosis; for this, the image is taken in two different projections: frontal and lateral.

The presence of cancer is indicated by the presence of a shadow with a blurring outline. A large white spot stands out against its background, which indicates the disintegration of the tumor.

To make a final diagnosis, just an image will not be enough; you will need to undergo a full range of examinations prescribed by specialists.

Pleurisy

During their work, doctors have to deal with various common symptoms, such as cough, fever or, for example, weakness in the body. Patients, as a rule, do not attach much importance to them, but these ordinary signs may be indicators of fluid accumulation in the pleural cavity. In photographs this phenomenon is not expressed by any rigid geometric contours. Darkening of an unclear form represents pathological changes in the tissues of the lungs and may turn out to be nothing more than staphylococcal pneumonia.

According to medical statistics, staphylococcal pneumonia is becoming more common. The darkening itself in the image indicates tissue edema, internal hemorrhage, pulmonary infarction, tumor and the very appearance of pleural fluid, as well as other diseases that can be detected through laboratory tests.

Nicotine addiction

Many patients who seek help from doctors suffer from nicotine addiction, and today this is not uncommon. If the x-ray shows darkening, smoking may be the cause. This is due to the fact that cavities form in the bronchi, and the biggest difficulty is that at first glance it is difficult to determine the structural boundaries of the roots of the lungs. They are usually too blurry. This is explained by the fact that the pulmonary vessels begin to enlarge due to respiratory failure, which is why blurring is observed on the contours of the roots. But despite this, an X-ray of a smoker has a chance to reveal various diseases of the respiratory system, including tuberculosis and lung cancer.

With paragonimiasis

In the initial stages, paraganimosis occurs as an acute allergic disease. During this period, it is difficult to make a diagnosis, since there are practically no symptoms. Later, specific symptoms appear, such as cough and chest pain.

Fluorography shows characteristic foci with radial shadows.

For candidiasis

A spot on the picture may indicate the presence of candidiasis. In some cases, miliary opacities occur.

The symptoms of the disease are similar to bronchitis. A complication of the disease can be pleurisy.

For diffuse pneumosclerosis

If the image shows increased transparency of the lung tissue, this may indicate the presence of diffuse pneumosclerosis. It is often combined with focal eclipses.

Symptoms of the disease are cough with sputum, shortness of breath and general weakness.

For fever

If the darkening on fluorography has a large focus and uneven edges, these are symptoms of fever. Often it has pronounced symptoms, so a picture with such signs is already an additional confirmation of the disease.

Excessive sweating, chest pain and shortness of breath are the first signs of this condition.

Presence of a foreign body in the lungs

It happens that a spot on an x-ray in the lungs indicates the presence of a foreign body. Most often, this affects children, who tend to taste everything and, through negligence, can swallow an object. To the chagrin of doctors, such foreign bodies cannot always be detected using x-rays, so in such cases it is recommended to resort to endoscopic diagnostic methods. One of the main signs of foreign elements in the lungs is the presence of light spots. It is also important that it is not possible to make a diagnosis based on a fluorogram of the lungs alone; in such situations, this issue must be dealt with by a highly qualified radiologist.

What to do if spots are detected on an x-ray

The most correct decision in this situation would be not to panic. There is no need to treat spots detected during fluorography of the lungs until a full examination has been completed. As has already become clear, there can be many reasons for their appearance, so you cannot make a diagnosis yourself without consulting a specialized doctor.

If abnormalities in the pulmonary pattern are detected, you should contact a specialist: a pulmonologist or a phthisiatrician. To clarify the diagnosis, the doctor prescribes:

• General and biochemical analysis of blood and urine;
• X-ray in the necessary projections;
• Diaskintest or sputum culture to detect the presence of tuberculosis pathogens;
• computed tomography of the lungs;
• bronchoscopy of the lungs or tracheobronchoscopy, when the respiratory organs are examined using a probe that is inserted through the nose.

There is no point in postponing treatment, especially if darkening is detected on the child’s lungs. A timely, accurate diagnosis will help quickly defeat the disease.

Quite often, to provide the most informative and accurate state of the respiratory organs, doctors prescribe such a common study as an x-ray. This procedure is often indicated in order to clarify the result of previously performed fluorography or based on the general clinical picture of the patient’s condition. For example, with certain lung diseases, the density of some lung tissues becomes increased. In the resulting images, each of which shows the condition of the lungs, similar phenomena are noted in the form of spots and darkening in the lungs on the X-ray.

If the patient is informed about the discovery of spots, the first reaction of most is fear, many think that this is a malignant formation. Cancer gives some darkening, but is far from the only reason for the appearance of spots. In order to avoid wasting unnecessary nerves, and also to begin to act as quickly as possible when blackouts are detected, it is worth studying their types, as well as becoming familiar with the main reasons for their occurrence.

Causes of spots on the received images

The main reasons for the appearance of spots or darkening in an x-ray photo can be the following causes of darkening in the lungs:

If such darkening is detected, doctors usually prescribe additional forms of examination. This is based precisely on a large number of reasons that can lead to their formation. Competent treatment is prescribed only after the nature of the formations and the causes of darkening in the lungs have been fully established. Normal symptoms and health status are taken into account.

When diagnosed with pneumonia, an x-ray is the only option to identify a serious illness.

What spots might there be in the picture?

In the process of conducting an additional medical examination and carefully studying the resulting images, the specialist evaluates the darkening according to the following parameters:

• The location of the spot is the upper, lower or middle part of the lung. It can also be the outer, inner and middle lobe of this organ. This way you can get a clear picture of the disease;
• The size makes it possible to determine the total area of ​​pathology;
• Level of expression. Based on this feature, the degree of density of the lesion present can be determined. The severity can be moderate, weak and intense;
• General outline. Pay attention to whether the stain has smooth or uneven edges. Often on this basis it is possible to determine the nature of education.

In addition to the differences listed above, spots in the image can be classified according to other criteria. Doctors must take them into account in order to establish a more accurate diagnosis.

Spots and dark spots that occur in the lungs and trachea can be characterized by their location, but also by appearance and general shape. The distribution is as follows:

1. Share. The spot has a clear outline and can be particularly concave or significantly convex. Darkening can develop against the background of inflammation, cirrhosis or destruction. If a spot of this type is located in the middle or lower part of the lung, the doctor may suspect a malignant formation.
2. Focal. These are relatively small centimeter-sized formations that can prove the presence of inflammation, the development of pathology of veins and blood vessels, as well as the development of peripheral cancer, dangerous tuberculosis and sudden pulmonary infarction. If such lesions were found against the background of headache, cough and pain, bronchial pneumonia can be judged.
3. Indefinite in form. These are special spots that do not have a bright expression or outline. To give the patient the most accurate diagnosis, more modern types of examination, such as CT or MRI, are prescribed. Such white spots often indicate pathologies such as pleurisy, pneumonia, hemorrhage, as well as various types of tumors. The diagnosis is confirmed not only by CT scan, but also by laboratory tests.
4. Liquid. This is direct evidence of pulmonary edema. The fluid collected in the lungs may be due to increased pressure in numerous vessels and the degree of permeability of their alveolar wall. In this case, the liquid immediately enters the lung tissue, disrupting its functionality.
5. Segmental. We are talking about darkening in the form of a triangle. This is evidence of pathologies such as a cancerous tumor, various benign formations, pneumonia, the presence of metastases coming from other organs, tuberculosis and fluid accumulation. The doctor’s competence is very important here, since the earlier measures are taken, the greater the chance the patient will have if a fatal pathology is detected.
6. Focus. As a rule, these are single spots, the size of which is on average 1 cm. Such lesions arise against the background of pneumonia, with increased fluid content in the organs, breathing, tuberculosis, and they can also be cysts and purulent abscesses.

Making an accurate diagnosis based on the type and location of spots alone is impossible. It is for this reason that additional high-quality examination is required.

If darkening is visible in the picture, you should immediately consult a doctor who can identify or exclude the presence of a dangerous disease.

Decoding of received images

A few minutes after the fluorography examination, a person receives a picture and its detailed transcript. Comments on the image may contain the following information in the form of medical terms, each of which characterizes certain health problems:

• Enlargement of the roots of the right or left lung, which may indicate bronchitis or pneumonia; Heavy roots are special pathological changes that occur due to smoking or acute bronchitis;
• The presence of an in-depth pattern of the vessels of the right or left lung indicates a violation of blood circulation in the respiratory organs, various problems with blood vessels and the heart, bronchitis, as well as inflammation in the lungs, which may be the initial stage of the oncological process;
• Fibrosis and fibrous tissue are a consequence of previous surgical interventions and injuries;
• Focal shadows, which are specific shadows. If such shadows are accompanied by an increase in the general vascular pattern, the doctor can judge pneumonia;
• Calcifications of the right or left lung - means that the person had contact with a patient with tuberculosis. At the same time, the healthy body of an uninfected person encloses the rod in a calcium shell. It is the power of immunity that prevents the spread of infection;
• Changes in the diaphragm - all this can be the consequences of problems such as obesity, pleurisy, diseases of the gastrointestinal tract.

Spots and dark spots found in the image can be evidence of several dozen different diseases; it is for this reason that after the x-ray it is necessary to continue a high-quality medical examination of the right or left lung.

Follow-up examination

To conduct further examination, the doctor may send the patient to a pulmonologist or oncologist, where he will be shown to undergo certain specific procedures. Here are the most common ones:

1. This may be a diaskintest, which can determine the presence of tuberculosis. If we compare this procedure with Mantoux, which quite often gives a false and inaccurate result, such an examination does not respond to BCG, which often shows a complete absence of a problem in the child. This is an ideal opportunity to diagnose tuberculosis as accurately as possible.
2. The study of sputum of children and adults is another mandatory analysis that is carried out in the laboratory. Based on the results obtained, it is possible to detect tubercle bacilli, the presence of malignant cells, as well as various impurities that may be characteristic of certain pathological conditions.
3. Quite often, doctors prescribe a more modern examination method - computed tomography of the lungs. This is an additional, informative method for diagnosing diseases of the lung tissue, pleura and mediastinum. It turned out that this is the most reliable method.
4. Lung bronchoscopy or tracheobronchoscopy may also be used. This procedure is performed using medical endoscopes that are quite flexible in design and are inserted through the nose. Through this form of examination, you can see the lungs and also take material, completely painlessly. The collected material, as a rule, is subjected to subsequent diagnostics - bacterial, histological and cytological.

If a doctor suspects lung cancer based on an x-ray, a tumor marker test may be prescribed. The analysis makes it possible to detect specific proteins that are usually produced by emerging malignant tumors.

Summing up

If darkening or light spots are found in the picture, do not panic when you see the picture. The best solution in this case would be to strictly follow the doctor’s recommendations. The specialist will conduct a more detailed additional examination to clarify the diagnosis. This is the only way to develop the highest quality treatment, take timely measures and thereby prevent quite serious complications.

If an x-ray shows a shadow in the lungs, this may indicate a dangerous pathology or physiological condition. Remember that a radiograph is a summation of the thickness of anatomical structures.

X-ray darkening syndrome in the lungs appears on the image as a white spot of various sizes (focal, segmental, subtotal, total). Many anatomical structures and pathological changes are involved in its formation.

If an x-ray shows darkening in the lungs, what does this mean? Let's take a closer look in the article.

What causes “darkening” in the lungs in the picture?

Depending on the location, the white spot can be:

• pulmonary;
• extrapulmonary.

Darkness in the lungs occurs due to:

• tissue compaction during the inflammatory process;
• tumor growth;
• localized abscesses or cysts;
• collapse of lung tissue with atelectasis;
• tuberculosis.

Extrapulmonary causes of darkening on a chest x-ray:

• fluid in the pleural cavity;
• exudative and encysted inflammation of the pleura;
• pathological formations in the spine and ribs;
• mediastinal tumors;
• aortic aneurysm;
• swollen lymph nodes;
• diseases of the esophagus and intestines (hernias);
• pathology of the diaphragm;
• lipoma in the costophrenic sinus.

X-ray. Round formation in the projection of the right root (enlarged lymph node)

The main causes of dark spots in the lung on an x-ray

Describing the causes of spots in the pulmonary parenchyma, it is convenient to classify all formations into: limited and widespread.

Radiologists consider a limited darkening to be a shadow that does not exceed 1.5 cm in diameter. In shape, these formations can be round, oval, lumpy or irregular in structure. With encysted pleurisy, the white spot has a triangular shape. Similar shadows can be seen in atelectasis.

Causes of extensive darkening:

• exudative pleurisy;
• pneumonia;
• miliary tuberculosis;
• pulmonary edema.

White spots in the image are also caused by artifacts (foreign bodies).

To make a correct diagnosis when detecting opacification syndrome, a radiologist must have knowledge of nosological forms of diseases and have practical experience in interpreting chest x-rays. Young specialists are afraid to perform radiography in a lateral projection, since in these images the image is formed by summing up many anatomical formations, which significantly complicates the detection of diseases.

Sometimes darkening in the pulmonary parenchyma is a consequence of pneumonia and persists in a person for years. Such patients are classified as X-ray positive, which is indicated accordingly in the X-ray diagnostic passport.

X-ray of the lungs showed a dark spot - what is it?

If there is a dark spot on the x-ray, increased airiness of the lung tissue should be suspected. The syndrome can be limited or widespread. The shape is: round, oval, triangular.

Segmental darkening on a radiograph with a path to the root (peripheral cancer)

A round dark spot is observed on an image of the lungs with an hydatid cyst. True, around the formation there is a clear white outline formed by the wall of the cyst.

Emphysema (increased airiness of the alveoli) is manifested by total clearing on both sides. With a local emphysematous bulla, the dark spot is limited to several ribs or a segment.

X-ray diagnosis of this syndrome is not difficult for radiologists who have seen many images of the chest organs during their practical work.

How dangerous is darkening or clearing in the lungs?

Darkening and clearing in the pulmonary parenchyma - is it dangerous? To answer this question, the doctor should analyze a set of laboratory and instrumental methods and examine the person. Only after this can he say whether enlightenment or darkening is really dangerous.

X-ray diagnostics is an auxiliary diagnostic method. It is designed to supplement information about the condition of patients’ organs and tissues. If you pay attention to the protocol for describing the radiograph, the end point there is the “conclusion” of the radiologist, but not the “diagnosis”. This approach is adopted in medicine due to the fact that X-ray radiation “passes” through many anatomical structures, some of which are not displayed on film.

It is easy to differentiate total darkening after obtaining the results of other diagnostic methods. Because of this, the sanitary rules state that x-ray examinations are carried out only after all other types of diagnostic tests have been carried out. The approach allows not only to reliably verify the conclusion, but also to select the optimal projections to obtain maximum information from the images.

X-ray images of various types of dark spots in the lungs

The term “darkening in the lungs” is used when identifying any pulmonary pathology. Every adult knows what fluorography is. This screening study allows you to identify pathology in the lungs, mediastinum and chest wall. Regular preventive examinations, including this examination, allow you to identify diseases in the early stages. Currently, according to WHO recommendations, ordinary people need to undergo fluorography once every two years. It is recommended that kindergarten workers, teachers, doctors and food industry workers do this study once a year.

What does darkening mean and how is it detected?

The pathology of the chest organs detected during fluorography is formulated by doctors as “darkening in the lungs.” Moreover, this formulation hides any reason that is not necessarily of a malignant nature. A large number of diseases can manifest as a shadow in the lung, ranging from banal pulmonary fibrosis to cancer. To exclude false data when pathological changes are detected, it is recommended to perform an X-ray examination of the chest organs.

However, it is not fundamental when making a diagnosis. But it allows you to eliminate errors in the interpretation of fluorographic data, excluding the presence of various artifacts, defects in the film itself and the examination technique.

The most detailed examination of the chest organs is computed tomography. It allows you to make a diagnosis with a high degree of probability and decide on further treatment tactics.

It is worth knowing that any lung disease is manifested by a change in the lung tissue, characterized by its compaction and subsequently a violation of airiness. It is these areas that form the pathological focus. In some cases, these changes may mask more serious pathology and cause poor outcomes. Moreover, the radiological term “darkening” is actually manifested by the appearance of light areas on the radiograph.

– up to 10, multiple – not countable);

Shape (correct - if it corresponds to geometric shapes:

triangle, square, circle, etc., incorrect - does not correspond);

Intensity (weak – corresponds to the shadow of the vessel in the longitudinal

projections, medium – cross-section of the vessel, high – density

cortical rib);

Contour (clear, fuzzy, smooth, uneven);

Structure (homogeneous, inhomogeneous - due to foci or

enlightenment);

Condition of the surrounding lung tissue (changed or not changed).

At the same time, for ease of memorization, you can use the mnemonic device “PO-CHI-FO-RA – IN-RI-KO-S”, where PO is position; CHI - number of shadows; FO - shadow shape; RA – shadow dimensions; IN – shadow intensity; RI – shadow pattern (structure); KO – contours; C – condition of the surrounding lung tissue.

Let us consider in more detail the radiological Sd and characterize the clinical forms of tuberculosis in accordance with the leading Sd.

3.2. Focal shadow syndrome. X-ray characteristics

focal tuberculosis

Sdfocal shadow characterized by the presence in the lung tissue of lesions extending no more than 2 lung segments; if both lungs are affected, no more than one segment on each side. Hearth- this is a pathological round shadow formation with a diameter of up to 1.0-1.5 cm. In size, the lesions can be: small - up to 3 mm, medium - 4-6 mm, large - 6 or more mm, in number - single, few or multiple .

This Sd is most often found in focal pulmonary tuberculosis, pneumonia, and lung cancer.

For focal tuberculosis Characteristic is the upper lobe localization of the process with damage to the posterior parts of the lungs, no more than 2 segments (usually S1, S2, S6), group location of lesions, polymorphism of lesions (Appendix 4, Fig. 5).

With a soft-focal form focal tuberculosis, foci are often large and medium-sized, irregular in shape, with unclear, blurred contours, low and medium intensity, without old changes in the surrounding lung tissue, with a tendency to merge foci, with a ratio of specific and nonspecific components of inflammation of 1:2.

With fibrous-focal form lesions of small and medium size, with a more or less regular shape, with fairly clear contours, high and medium intensity, are located on an altered pulmonary background (limited fibrosis, linear shadows), there is no pronounced tendency to merge the lesions.

3.3. Dissemination syndrome. X-ray characteristics

miliary, subacute, chronic disseminated

pulmonary tuberculosis

Sddissemination characterized by the presence of multiple focal shadows in both lungs. Dissemination can be:

1) by prevalence:

Widespread (when a large area is affected, sometimes the whole

lung);

Limited (over 2 intercostal spaces).

2) by symmetry:

Symmetrical (with hematogenous genesis of the disease);

Asymmetrical (with lymphogenous and bronchogenic genesis).

Sd dissemination is determined in miliary, disseminated pulmonary tuberculosis, pulmonary sarcoidosis, pneumoconiosis, pneumonia, carcinomatosis, alveolitis and other diseases.

For miliary pulmonary tuberculosis the lesions are small (up to 3 mm), monomorphic, of low or medium intensity, with more or less clear contours, without disintegration, located symmetrically throughout all parts of both lungs, mainly in the apical-middle parts, do not have a tendency to merge, the root of the lungs is not involved in the process , the formation of a pulmonary heart is possible (Appendix 4, Fig. 7, 10).

For subacute disseminated tuberculosis the lesions are larger (3-5-7 mm), polymorphic, with unclear contours, of medium intensity, tend to merge into foci, form decay cavities, with localization in the apical-middle parts of the lungs, with a decrease in the density of the lesions from top to bottom, no symmetry lesions, there is a connection with the root in the form of a peribronchial or perivascular track; calcifications can sometimes be detected in the root, as a result of tuberculosis. In a number of patients, “stamped” (“spectacled”) cavities in the form of thin-walled cavities without a perifocal reaction may be detected in the apices of both lungs behind the clavicles. With the lymphogenous spread of infection, a “butterfly” symptom can be detected - dissemination mainly in the basal region, there is a connection with the root, the shape of the process resembles the wings of a butterfly (Appendix 4, Fig. 8).

For chronic disseminated tuberculosis there are foci of different sizes and different intensities - a symptom of a “starry sky”: denser, more intense shadows with clear contours - residual changes from a previous outbreak of tuberculosis, shadows of low, medium intensity, with fuzzy contours - manifestations of a real outbreak. In addition, you can identify the “weeping willow” symptom - the root is pulled upward and takes a more vertical position. Decay cavities, areas of emphysema, pneumosclerosis, pleural layers, and sometimes a shift of the mediastinum towards a larger lesion can be detected (Appendix 4, Fig. 9).

3.4. Round shadow syndrome. X-ray characteristics

tuberculoma, round and lobular infiltrate with

infiltrative pulmonary tuberculosis

Sdrounded shadow characterized by the presence in the lungs of a focal shadow with a diameter of more than 1-1.5 cm. Foci in size can be small (up to 2 cm), medium (2-4 cm), large (4-6 cm); by quantity - single or multiple.

Sd of a round shadow is given by tuberculomas, infiltrative tuberculosis (round, lobular infiltrate), peripheral cancer, eosinophilic pneumonia, benign tumors, encysted pleurisy, filled cyst.

Tuberculomas are characterized by the presence in the lungs of often a single focal shadow of medium size, medium intensity, inhomogeneous structure due to focality and decay cavities with their marginal location near the mouth of the draining bronchus, the contours are unclear in the active phase of the process, clear - in the inactive phase; along the periphery of the tuberculoma there are foci of elimination, there is a path to the root of the lungs, calcifications can be detected in the roots of the lungs, and as the process progresses, appositional growth of tuberculoma can be observed. Sometimes it is possible to identify a symptom of “flattening” when the largest transverse diameter of the tuberculoma is perpendicular to the draining bronchus (Appendix 4, Fig. 6).

Lobular infiltrate with infiltrative pulmonary tuberculosis, it manifests itself in the form of a round or polygonal racket-type shadow with a diameter of 1.5-2 cm, low and medium intensity, homogeneous or inhomogeneous due to focality and destruction, with unclear contours due to perifocal inflammation.

Round infiltrate characterized, as a rule, by a single focus of a round shape, with a diameter of more than 2 cm, low and medium intensity, a heterogeneous structure due to calcifications and compacted foci, the contours are unclear, in the regression phase they are clear, decay cavities are identified in up to 40% of cases, foci of lymphogenous and bronchogenic contamination, path to the root, pleural layers, the predominant localization of the process is often in the upper sections (segments 1,2,6), the roots are not changed (Appendix 4. Fig. 11).

3.5. Lung tissue compaction syndrome. X-ray

characteristics of infiltrative, fibrous-cavernous,

cirrhotic pulmonary tuberculosis, caseous pneumonia

Sdcompaction of lung tissue characterized by the presence of irregularly shaped darkening in the lungs. In length it can be:

Limited compaction of lung tissue (up to 2 segments);

Subtotal compaction of lung tissue (more than 2 segments, but less

whole lung);

Total compaction of lung tissue (damage to the whole lung or

both lungs).

Sd of pulmonary tissue compaction is determined in infiltrative pulmonary tuberculosis (cloud-like infiltrate, periscissuritis, lobitis), fibrous-cavernous, cirrhotic pulmonary tuberculosis, caseous pneumonia, lobar pneumonia, lung cancer, lung malformations, atelectasis of a segment or lobe, pneumosclerosis, pulmonary infarction, swelling of the lung tissue, after pneumonectomy and other lung diseases.

Cloud-like infiltrate in infiltrative pulmonary tuberculosis represented by darkening of irregular shape, within 1-2 segments, with unclear contours in the exudative phase of inflammation and clear in the productive nature of inflammation, inhomogeneous structure due to focality and decay cavities (70% of cases), with predominant localization in the upper parts of the lungs, less often in the lower and middle lobe in adenogenic forms of tuberculosis, a path to the root of the lung and foci of bronchogenic and lymphogenic genesis are also revealed (Appendix 4, Fig. 12).

For periscissuritis the darkening is located in the upper lobe on the border of the interlobar grooves, has a triangular shape with the base facing the chest, with the apex towards the root of the lung. The lower border of the shadow is smooth, clear, the interlobar pleura is retracted towards the infiltrate (due to atelectasis, sclerosis of the affected area). The upper border is vague, gradually passes into the surrounding tissue, decay is detected in 70% of cases.

Upper lobe lobitis characterized by the presence of darkening within an entire lobe, a homogeneous or heterogeneous structure with the boundary of the interlobar fissure concave into the infiltrate, with a decrease in the volume fraction and the detection of decay in up to 70% of cases.

With mid-lobe lobitis the affected lobe gives a triangular-shaped shadow with the apex facing outward and a wide base towards the mediastinum; the upper border along the horizontal interlobar fissure may be slightly convex, the lower border blurred.

Lower lobe lobitis presented as a large-focal formation, irregular in shape, with blurred contours in the lower parts of the pulmonary field.

Lobar form of caseous pneumonia characterized by the presence within one lobe or the entire lung of high intensity shadow formation, first of a homogeneous structure, due to apneumatosis, and then inhomogeneous, due to focality and multiple decay cavities (more than 5), medium and large in size (sometimes up to the size of an entire lobe - destroyed lung), the cavities have unclear internal and external contours, in some of them sequesters are detected, segmental bronchi are clearly visualized (“air bronchography”), and foci of bronchogenic screening to other parts of the lungs are also determined. Decay zones dominate over infiltration zones

(Appendix 4, Fig. 13).

Fibrous-cavernous tuberculosis is presented on the radiograph by darkening of a segment, lobe or the whole lung, of medium intensity, with a decrease in their volume and with a displacement of the mediastinal organs towards the most pronounced lesion, due to fibrosis of the lung tissue. The shadow has unclear contours and an inhomogeneous structure, due to cavities and foci of contamination sealed in fibrosis. Fibrous cavities are thick-walled, usually more than 4 cm in diameter, with sharp internal contours and blurred external ones against the background of compacted lung tissue, their shape is irregular, the cavity window is opaque with a compacted pleura and in the projection of fibrous-changed lung tissue. In one lung there can be several cavities of different sizes: the larger ones are old, sometimes with sequestration, the smaller ones are fresh, daughter ones. More often the process is localized in the apices of the lungs and can be unilateral or bilateral. The roots of the lungs are fibrous, pulled upward (“weeping willow symptom”). Emphysema, pneumosclerosis, bronchiectasis, foci of bronchogenic screenings of varying sizes and intensity into the lung and the opposite lung are also detected (Appendix 4, Fig. 15).

Cirrhotic tuberculosis characterized by the presence of darkening in the lungs, often in the upper or middle parts of the pulmonary field, predominantly of high intensity, with irregular slit-shaped clearings, with the presence of dense, partially calcified focal shadows in the lung tissue and roots of the lungs. The affected parts of the lungs are reduced in volume, the intercostal spaces are narrowed, the root is fibrotic, pulled upward, there is a displacement of the mediastinal organs towards the lesion, emphysema and bronchiectasis are observed. In the lungs, zones of cirrhosis and fibrosis prevail (Appendix 4, Fig. 16).

3.6. Cavity syndrome. X-ray characteristics

cavernous pulmonary tuberculosis

Sdcavities On an x-ray it appears as a ring-shaped closed shadow with clearing in the center. There are false and true cavities. The true cavity, in contrast to the false one observed due to a random combination of shadows, is well differentiated in two projections. The cavities can be small in size - up to 2 cm, medium - 2-4 cm, large - 4-6 cm, giant - more than 6 cm; by quantity - single, multiple; according to the degree of wall formation - formed (with a well-defined fibrous wall) and unformed (fresh, with an elastic wall, with a well-defined perifocal reaction). When assessing a cavity, the type of external and internal contour of the cavity wall, the presence of fluid level or sequestration in it, and the condition of the lung surrounding the cavity are necessarily analyzed.

Cavity Sd is determined in all forms of respiratory tuberculosis that occur with decay. It is leading in cavernous pulmonary tuberculosis. It is also found in disintegrating lung cancer, abscess pneumonia, cyst, abscess, bullous emphysema, bronchiectasis, echinococcosis.

For cavernous pulmonary tuberculosis the cavities are often single, isolated, medium-sized, round in shape, with thin walls up to 4 mm, with a well-defined internal contour and a less clear external one, as a rule, with a well-defined cavity window, with limited foci of screenings along the periphery, without infiltrative and fibrous changes in surrounding lung tissue, without displacement of the mediastinal organs, with localization within 1-2 segments (S1, S2, S6), often in the upper lobe, the process is predominantly unilateral (Appendix 4, Fig. 14).

3.7. Pulmonary root pathology syndrome. X-ray

characteristics of intrathoracic lymphatic tuberculosis

nodes

Sdroot pathology characterized by radiographic expansion of the root, its deformation, disruption of the structure, changes in their contours, damage to one or both roots.

This Sd occurs in tuberculosis of the intrathoracic lymph nodes, stage I sarcoidosis, lymphogranulomatosis, central cancer, and nonspecific lymphadenopathies.

For tuberculosis of intrathoracic lymph nodes the process is more often one-sided, the bronchopulmonary lymph nodes are predominantly affected, the structure of the root is disturbed, it is expanded and deformed. In the infiltrative form of tuberculosis of the intrathoracic lymph nodes, the contours of the root are unclear, blurred due to perinodular inflammation. In the tumorous form, they are clear, since the process does not go beyond the capsule of the lymph node. In the small form, there is an increase in no more than 1-2 groups of lymph nodes (usually the para-aortic group and lymph nodes of the ductus botalus), up to 1.5 cm in size in the infiltration phase, up to 6 mm in the calcification phase (Appendix 4, Fig. 17, 18, 19 ).

There are difficulties in identifying the main radiological syndrome with primary tuberculosis complex, since this form of tuberculosis is characterized by the presence of primary affect, lymphangitis and lymphadenitis in the lungs. Primary affect can be presented in the form of a shadow of different sizes, shapes, low or medium intensity. In this regard, with this form of tuberculosis, based on this radiological sign, we can assume either Sd compaction of the lung tissue, or a rounded shadow or focal shadow in the lungs, depending on the stage of the process (pneumonic, resorption, compaction, calcification). In addition, with the primary tuberculosis complex, the shadow in the lung is connected by a path of lymphangitis with the root of the lung. The root is enlarged, deformed, structureless, with unclear contours, i.e. there is Sd root pathology. In most cases in clinical practice, it is necessary to carry out a differential diagnosis of the primary tuberculosis complex with nonspecific pneumonia, within the framework of Sd compaction of the lung tissue (Appendix 4, Fig. 20).

3.8. Pleural pathology syndrome. X-ray characteristics

tuberculous pleurisy

Sdpleural pathologies manifested by the presence of homogeneous darkening in the lower part of the lungs, high intensity, merging with the contours of the diaphragm, mediastinum, with an oblique upper line (Ellis-Demoiseau-Sokolov line), running from top to bottom and from back to front; with a significant accumulation of fluid, a shift of the mediastinal shadow to the opposite side is noted .

With interlobar pleurisy, a homogeneous intense shadow of a lens-shaped, spindle-shaped shape is determined, with convex, clear contours along the interlobar fissure.

Sd pathology of the pleura occurs in para- and metapneumonic pleurisy, pleurisy of cancer etiology, pleural mesothelioma, can be fungal, post-traumatic etiology, can occur in diseases of the cardiovascular system (cardiac effusions), systemic lupus erythematosus, diseases of the gastrointestinal tract (with pancreatitis) and also for tuberculosis.

X-ray tuberculous pleurisy manifests itself with the same radiological symptoms as with other pleurisy, but can have a recurrent course, does not respond well to nonspecific antibacterial therapy, and with it residual changes in the form of adhesions are more pronounced (Appendix 4, Fig. 21, 22).

3.9. Pulmonary pattern pathology syndrome

Sd pathologies of the pulmonary pattern- This is the most common radiological syndrome in lung diseases. It can be based on a wide variety of processes - swelling of the interstitial tissue of the lung, changes in the blood supply of the pulmonary arteries and veins, inflammatory infiltration of the interstitial tissue, malformations of blood vessels, bronchi, diseases of the bronchial tree, sclerotic compaction of the lung stroma, etc.

With pathology, the pulmonary pattern can be:

Reinforced;

Lean;

Weakened;

Deformed;

Excessive (enriched);

Absent.

Pulmonary pattern is considered strengthened, if it can be traced throughout the pulmonary field (more than 4 cm from the apical pleura and 1.5-2 cm from the costal pleura), as well as if the number and width of vascular shadows in the costal rhombus per unit area increases. The transparency of the lung fields decreases. An increase in the pulmonary pattern can occur with congenital and acquired heart defects, pneumosclerosis of any origin, and with a compensatory increase in blood supply to the lungs.

Pulmonary pattern impoverished, if it is traced less than normal. At the same time, the distance from the terminal branches of the shadows of the vessels to the edge of the pulmonary field increases. Small-caliber vessels are not identified, medium-caliber ones lose clarity and sometimes become intermittent. In general, the number of shadows per unit area decreases. The transparency of the lung fields increases. A depleted pulmonary pattern is observed with compensatory hyperpneumatosis, underdevelopment of the arterial network of the lung.

Weakened The pulmonary pattern is characterized by the fact that its elements are poorly or not at all defined, since they are covered by pathological shadow formations.

When deformed pulmonary pattern, the dichotomy of the division of vascular shadows is disrupted, their disproportionate expansion, discontinuity, and fracture are possible. The contours of the vessels become unclear.

When in the pulmonary pattern, in addition to the vascular shadows, the shadows of the compacted walls of the bronchi are distinguished in the form of so-called “paired stripes” or lung stroma, perivascular interstitial spaces, such a pulmonary pattern is interpreted as excess. Excessive or enriched pulmonary pattern is always accompanied by deformation. Distinguish 3 main types of deformation of the pulmonary pattern:

1) heavy type;

2) reticular-loop type;

3) cellular type.

Each of these types of deformations is rare in its pure form. Determination of the type of deformation is carried out according to the leading variant of the violation of its shape in the x-ray picture.

Pulmonary pattern absent with spontaneous pneumothorax, when the lung collapses due to the presence of air in the pleural cavity.

Unusual linear shadows include Kerley lines in patients with pulmonary hypertension, observed in the lower outer parts of the lung fields in the form of narrow horizontal stripes.

Thus, In previous chapters, we examined in detail the first 3 stages of assessing chest x-rays in normal conditions and in pulmonary tuberculosis. After assessing all symptoms identified on radiographs and Sd for tuberculosis, they proceed to the next 4th stage – x-ray clinical analysis, i.e., studying clinical and laboratory data from medical history and outpatient records and comparing them with radiological information . This stage allows you to obtain additional information about the development of the disease and its course.

Important in the diagnosis of tuberculosis and assessment of the dynamics of the process - 5th stage of assessment of radiographs, consisting in comparing the results of an x-ray clinical study with previous data, both x-ray and clinical during observation and treatment. The nature of the evolution of the pathological process sometimes allows us to establish the pathogenesis and etiology of the disease, avoid missing pathology, and ensure timely detection of tuberculosis. It is important to note that when assessing the x-ray dynamics of the process, it is possible to identify changes in the main x-ray Sd ​​due to regression or progression of the tuberculosis process into other clinical forms. For example, focal pulmonary tuberculosis (Sd focal shadow) can progress to infiltrative pulmonary tuberculosis (Sd compaction of lung tissue).

The final 6th stage analysis of radiographs of the chest organs in frontal and lateral projections is drawing up an X-ray examination protocol indicating the changes identified during the examination and formulating a conclusion (diagnostic clinical radiological report).

Scheme of the X-ray examination protocol presented below.

It includes:

1. Passport part: last name, first name, patronymic of the patient; age.

2. Date of the X-ray examination.

3. Methodology of X-ray examination, its projections:

Survey radiography of the chest organs in a direct projection;

X-ray of the chest organs in lateral projection, etc.

4. Determining the technical characteristics of the image:

Hardness (shot hard, soft, standard hardness);

Contrast (contrast, non-contrast);

Determining the correct installation of the patient (correct,

incorrect);

Identification of artifacts (present, absent);

Determination of the breathing phase in which the picture was taken (usually the inhalation phase,

less often - exhalation).

5. Assessment of the soft tissues of the chest (not changed, changed:

subcutaneous emphysema, dense inclusions, etc.).

6. Assessment of the bone structures of the chest (unchanged, changed:

malformations, fractures and other pathological manifestations).

When assessing the soft tissues and bone structures of the chest

the correspondence of these anatomical formations is determined

normal appearance of a shadow image. They are analyzed

position, shape, size, shadow intensity, structure, contours,

relation to other parts of the chest, presence of nuclei

ossification, the state of physiological curves of the spine.

7. Assessment of the mediastinal shadow:

Position (displaced, not displaced);

Shape (round, trapezoidal, “pipe symptom”; regular,

incorrect);

Identification of the arcs of the heart (expressed, not expressed);

Determination of heart size (not enlarged, enlarged: right or

left side of the heart);

Determination of the type of constitution (normosthenic, hypersthenic, asthenic).

8. Assessment of the roots of the lungs:

Position (not changed, changed: the root is pulled up, lowered

Shape (root not changed, deformed);

Size, or width (not changed, increased);

Contours (clear, fuzzy, smooth, uneven);

Structure (structured, little structured, structureless);

Type of branching of the pulmonary vessels of the root (main, scattered);

Presence of calcifications.

9. Lung assessment: characterization of pulmonary fields, pulmonary

zones, projections of interlobar, intersegmental boundaries. Lung fields

can be transparent, opaque due to shading and

enlightenment.

If there are dark spots in the lungs, indicate:

a) localization or position (by lobes, segments, pulmonary zones,

fields or in accordance with the position of other anatomical

structures - ribs, vertebrae, etc.);

b) the nature of the shadow (focal, focal, darkened area or linear shadow);

c) the magnitude or size of the shadow (in millimeters, centimeters);

d) quantity (single, isolated, few,

multiple);

e) form (correct, incorrect);

f) intensity (weak, medium, high);

g) contour (clear, fuzzy, even, uneven);

h) structure (homogeneous, inhomogeneous);

i) the state of the surrounding lung tissue (changed or not changed).

When describing cavities in the lungs in the protocol, they should be indicated

localization, shape, size, quantity, closed contours of the cavity, wall thickness, condition of the outer and inner walls of the cavity (clear, fuzzy contours).

10. Assessment of the pulmonary pattern includes determining the length, shape, contours, nature of branches, and density of the pulmonary pattern. The pulmonary pattern may not be changed, strengthened, weakened, depleted, deformed (stringy, mesh-looped, cellular type), or may be absent.

11.Assessment of the pleura: attention is paid to the condition of the domes of the pleura, interlobar, mediastinal pleura; it is possible to identify the emphasis of the interlobar pleura, pleural layers, the level of fluid in the pleural cavity, changes in the pleura may be absent.

12. Assessment of the diaphragm: the position of the diaphragm is indicated (not changed, changed), shape (dome-shaped or flattened), contours (clear, fuzzy, jagged), sinuses (transparent, opaque, pointed in shape, blunt).

During the analysis of radiographs, pathological radiological Sds are identified and among them the main (leading) radiological Sd is established.

In most cases, complete analysis and description of radiographs is carried out speculatively. Mostly only identified pathological changes are recorded in the protocol. In this case, for greater clarity, diagrams of sketches of the lungs highlighting radiological changes can be used. For educational purposes, it is recommended in the protocol to include a full description of radiographs with the obligatory highlighting of the main radiological Sd.

The description protocol can be based on one of 3 principles: skialogical, morphological, morphoscyalogical, depending on the degree of information content of the x-ray picture. It is important to note that the radiological conclusion should be based only on the morphological principle. This is achieved by transforming the skialogical picture into its morphological substrate.

The conclusion can be presented when describing radiographs in the form of a final or syndromic diagnosis. If there are reliable, absolute data obtained by other research methods, and indirect radiological data for the active tuberculosis process, when formulating a conclusion, it is necessary to indicate:

Name of the clinical form of tuberculosis;

Localization of the process (lung, lobe, segment);

Phase of the tuberculosis process:

a) infiltration, decay, contamination;

b) resorption, compaction, scarring, calcification.

Presence of complications (pleurisy, atelectasis, spontaneous pneumothorax, etc.)

In the absence of reliable data in favor of tuberculosis, a differential diagnostic series of diseases within the main X-ray Sd ​​that have the greatest likelihood of detection should be identified and indicated in the conclusion.

It is important to note that the radiological report does not represent a clinical diagnosis, but is the basis for it. The final clinical diagnosis is determined by the attending physician.

If there is no pathology during an X-ray examination, the conclusion states “No radiologically visible pathology was found in the organs and tissues of the chest.”

TEST QUESTIONS

1. What are the main stages of assessing a chest x-ray?

cells (answer on page 8).

2. Draw the segmental structure of the lungs in the straight, right and left

lateral projection indicating the segments of the right and left lung

(answer on pp. 62-63).

3. As shown by an X-ray of the chest organs in the frontal and lateral directions

projections to determine the course of the main interlobar fissure (answer to

pp. 16, 20).

4. Identify the main radiological features of radiographs

chest organs in young children (answer on page 35).

5. List the main radiological Sd for tuberculosis

respiratory organs (answer on page 36).

6. What radiological Sd is typical for miliary

pulmonary tuberculosis (answer on page 38).

7. Determine the main radiographic Sd on the presented

chest x-rays on page 73 (response to

8. What diseases will you differentiate tuberculoma from?

within the framework of the basic radiology Sd (answer on page 39).

9. Specify the characteristic radiological signs of caseous

pneumonia (answer on page 41).

10. For what lung diseases can Sd be determined?

compaction of lung tissue (answer on page 40).

TEST TASKS

1. X-ray examination for respiratory diseases

should start:

a) with fluorography in frontal and lateral projections;

b) from fluoroscopy in various projections;

c) with survey radiography in frontal and lateral projections;

d) from tomography of the lungs in direct and lateral projections.

2. Name 4 main signs by which left and right are determined

lung on a radiograph in direct projection:

3. Name the anatomical structures that are displayed as 4

mediastinal arches on the left on a plain radiograph of the chest organs

4. In which segments of the lungs does tuberculosis most often occur in adults?

(underline the correct answer).

1, 2, 3, 4, 5, 6, 7, 8, 9, 10.

5. Specify the radiological Sd characteristic of

infiltrative pulmonary tuberculosis (underline the correct

a) Sd cavity;

b) Sd of focal shadow;

c) Sd root pathology;

d) Sd pathology of the pulmonary pattern;

e) Sd compaction of lung tissue;

e) Sd dissemination.

6. X-ray signs of the infiltrative form

tuberculosis of the intrathoracic lymph nodes is:

a) increase in root size;

b) the root is polycyclically modified and has a clear root;

c) change in root structure;

d) narrowing of the lumen of the stem bronchus;

e) strengthening of the pulmonary pattern in the hilar zone.

7. The sizes of foci in miliary tuberculosis are:

b) up to 6 mm;

c) up to 10 mm;

d) up to 15 mm;

e) up to 20 mm.

8. Ring-shaped shadow in the lungs with a path to the root and polymorphic

the foci around are characterized by:

a) for a cyst;

b) for a tumor with decay;

c) for tuberculous cavity;

d) for acute abscess;

e) for chronic abscess.

9. X-ray signs of pulmonary tuberculoma are:

a) darkening in the lung, associated with a path with an expanded root;

b) ring-shaped shadow;

c) rounded shadow more than 1 cm;

d) limited darkening with clear contours within one

segment.

10. Name 5 lung diseases in which

Cavity SD:

11. Differential diagnosis of intrathoracic tuberculosis

lymph nodes are most often performed:

a) with silicosis;

b) with central cancer;

c) with adenomatosis;

d) with hamartoma;

e) with periscissuritis.

12. The following are characteristic of focal pulmonary tuberculosis

X-ray signs:

a) lesions occupying more than 3 segments;

b) multiple foci located throughout all fields of the lungs;

c) lesions occupying up to 2 segments;

d) single foci with calcifications in the roots of the lungs;

e) single lesions in the middle lobe with areas of clearing.

13. A 30-year-old patient has a homogeneous darkening in the lower parts

lungs up to 3 ribs, merging with the dome of the diaphragm and shadow

mediastinum, with an oblique superior line, with slight displacement of organs

mediastinum to the healthy side. These changes may have

a) with caseous pneumonia;

b) with spontaneous pneumothorax;

c) with exudative pleurisy;

d) with a lung tumor.

14. In case of pathology, the pulmonary pattern can be:

15. Which clinical form of pulmonary tuberculosis is listed?

lower, accompanied by a shift of the mediastinal organs to the side

lesions:

a) infiltrative pulmonary tuberculosis;

b) focal pulmonary tuberculosis;

c) tuberculoma;

d) fibrous-cavernous pulmonary tuberculosis;

e) disseminated pulmonary tuberculosis.

STANDARD ANSWERS

2. a) shadow of the heart;

b) aortic arch;

c) right dome of the diaphragm;

d) gas bubble of the stomach on the left.

3. a) the descending part of the aortic arch;

b) conus pulmonary artery;

c) left atrial appendage;

d) left ventricle.

6. a), c), d), e).

10. a) abscess pneumonia;

b) abscess;

c) destructive forms of tuberculosis;

d) decaying cancer;

14. a) reinforced;

b) depleted;

c) weakened;

d) deformed;

d) absent.

SITUATIONAL TASKS

Task No. 1

A 35-year-old man, unemployed, was admitted to the clinic with complaints of weakness, fever up to 37.5 °C, cough with mucous sputum, shortness of breath on exercise.

Life history: had contact with a patient with tuberculosis in prison. The last fluorographic examination took place 1 year ago - without pathology. Past diseases: duodenal ulcer, 2 years without exacerbations.

History of illness: I noticed a deterioration in health 3 weeks ago, when weakness, dry cough appeared, and the temperature increased to 38.5°C. He was treated as an outpatient for ARVI without improvement.

Objectively: general condition is satisfactory, low nutrition. The skin is clean and pale. Peripheral lymph nodes are palpated on the left in the axillary region up to 0.7 cm in diameter (dense, mobile, painless). During auscultation in the lungs, vesicular breathing and collateral respiratory sounds are not heard. Heart sounds are clear, rhythmic, blood pressure is 120/70 mm. rt. art., pulse 98 per minute. The tongue is covered with a white coating. The abdomen is slightly painful on palpation in the epigastric region. The liver is not enlarged, along the edge of the costal arch. Stool and diuresis without any peculiarities.