Chest PA Chest Lat

Chest PA

Patients PA CXRNormal PA CXR(-) blunting of thecostophrenic angle(-) pulmonary congestion(-) pulmonary infiltrates(-) bone deformities(-) flattening of the R&L hemidiaphragm(-) tracheal deviation

Patients PA CXRNormal PA CXR(+) heart enlargementSlight straightening of the L cardiac border

Normal location of the apex: 5th ICS, MCLNormal PA CXR

The patients apex is located on the 7th ICS MCL DOWNWARD DISPLACEMENT OF THE APEXPatients PA CXR

Cardio-thoracic RatioPatients PA CXRNormal PA CXR

Which chamber/s is/are enlarged?Squires Fundamentals of Radiology, 6th ed.1 R brachiocephalic vessels2 Ascending aorta and superimposed SVC3 R atrium 5 L brachiocephalic vessels6 Aortic arch7 Pulmonary trunk8 L atrial appendage9 L ventricleNormalLVELAELAE & LVE (in long-standing MS)

Patients PA CXRNormal PA CXRProminent L atrial appendageLeft Atrial Enlargement

Patients PA CXRNormal PA CXRCarina not appreciated (cannot be measured for widening)

Patients PA CXRNormal PA CXRNo double density along the R cardiac border

Possible L Ventricular EnlargementDownward dipping of the left heartPatients PA CXR

LV outflow tractPatients PA CXRPossible L Ventricular Enlargement

Possible R Ventricular EnlargementRounding of the cardiac apexPatients PA CXR

Lateral Chest Xray

Normal Lateral CXRPatients Lateral CXRTracheaEsophagusTracheaEsophagusHeartHeart

Left atrial enlargementEsophagusRetrocardiac free spaceEsophagusRetrocardiac free space

LV outflow tractLeft cardiac borderLeft cardiac borderLV outflow tractLeft venticular enlargement

Convex posterior heart borderPosterior margin of the IVCObliterated posterior margin of the IVCLeft venticular enlargement

Left venticular enlargementHoffman Rigler sign

Right ventricular enlargementRetrosternal space2/31/3Retrosternal space

On PA view, starting midline, we can observe the trachea, which does not show any deviation. Going laterally, you can see the pulmonary vascularities, which do not indicate any pathology, thus there is no pulmonary congestion. Looking at the lungs fields, there is no pulmonary infiltrates. Going downwards, the R and L hemidiaphragms are not flattened, and there is no blunting of the costophrenic angle on the Right. Now looking at the bones, no deformities are observed.

http://info.med.yale.edu/intmed/cardio/imaging/cases/normal_female_1/index.html Most striking in this PA chest film is the left heart enlargement, most evident just by looking at it. We confirm this by counting for the location of the apex, which is normally at the 5th ICS, MCL.

As we know, we count the intercostal spaces in the anterior chest below the rib to which they refer to. This is the 1st rib and the 2nd rib, and between is the 1st ICS. As we follow the 2nd, 3rd, 4th, and 5th ICS, we find that the normal apex lies here, along the midclavicular line. Another means to determine enlargement is by computing for the cardio-thoracic ratio. However, we cannot measure the cardio-thoracic ratio in the film of our patient because the right inner side of the rib cage was not included in the cropping of the her chest filmNormal lateral CXR:Trachea anterior to esophagus

Laterally, the patients esophagus was displaced by the enlarged LA posteriorly.Also, there is obliteration of the retrocardiac free space (by the LA) in the patients CXRNormally, there is a convex posterior heart borderIn the patient, there is already rounding of the left cardiac borderAlso, there is already elongation of the LV outflow tractNormally, the convex posterior heart border does not extend beyond the posterior margin of the IVCIn the patient, the posterior margin of the IVC is already obliterated by the posterior cardiac borderHoffman Rigler sign (not done here because not the ACTUAL radiograph was given)

It is done by drawing a 2.0-cm vertical line upward along the inferior vena cava from the point where the posterior wall of the left ventricle and inferior vena cava cross in the lateral projection. From this point, a second line is drawn parallel to the vertebral bodies. If the distance between the left ventricular border and the vertical line exceeds 1.8 cm, left ventricular enlargement is suggested.

Normally, the heart occupies only 1/3 of the retrosternal spaceIn the patient, the heart occupies almost 2/3 of the retrosternal space