clinical skill3 cxr-final
TRANSCRIPT
Diagnosis of Congestive Heart Failure
Presented by:Dr. Mahmood Yaseen Hachim
CHEST X-RAY
X-Ray
StepActionFindingsNotes
1Identifications dataa. Patients Namea. Date of Birth (Age)a. Sex
a. Indication for CXRClinical suspicion and provisional diagnosis
Mahmood Yaseen22/9/1076MaleRoutine Check Up
R
PAStanding
2Side Marker (Orientation)
Right Side and Left Side of the CXROne side is labels usually either R=right or L=Left
Look to the CXR as you are looking at the patient = the patient's right side is on your left side and vice versa
Mahmood Yaseen22/9/1076MaleRoutine Check Up
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PAStanding
3Technical Considerations of CXR qualitya. Position of the Patient: Standard
position is standing
Check if any mark stating the patients was not standing during the CXR
Sitting: means severe illness, unable to stando Raised diaphragmo Reduced inflation of lungso Folded soft tissue of the patients front like skin
Supine: means very severe illness, unable to sito The fluid level will be lost
Mahmood Yaseen22/9/1076MaleRoutine Check Up
R
PAStanding
Mahmood Yaseen22/9/1076MaleRoutine Check Up
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PAStanding
a. Projection: direction of X-Ray beam passage through the patient
If the cassette is in the back and the beam pass from front to back =(AP)=Anterior -Posterior
If the cassette is in the front and the beam pass from back to front =(PA)=Posterior-Anterior
Either right or left side of the chest = Lateral
Objects near the cassette will appear in their size but the organs far from the cassette will look falsely enlarges as a shadow, it is so importnat in case of heart size assessment
So AP is not used to check heart size, it should be PA
AP PA
Mahmood Yaseen22/9/1076MaleRoutine Check Up
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PAStanding
Rotation Spinous processes of thoracic vertebra should appear at the center of each
The spinous process of T4 should be between the heads of the clavicle
if it isn't the body is rotated
Rotation can cause abnormal appearance of the mediastinum and other structures
Mahmood Yaseen22/9/1076MaleRoutine Check Up
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Quality and Exposure of X-Rays Is the film penetrated properly?
In a properly penetrated film the vertebral interspaces should be visible behind the central (cardiac) shadow
Too little exposure will make lungs appear too white
Too much exposure will make structures more dark and mask the signs
Mahmood Yaseen22/9/1076MaleRoutine Check Up
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a. Inflation : Proper CXR should be taken with full inflation of lungs (deep inspiration and hold breath)
There must be more than 9 ribs visible posterior to say the inspiration was perfect
So count the ribs starting from the 1st rib
If poor inflation then the lung will appear more dense
Trachea will be drawn to the right side
Heart will look abnormally enlarged
Poor Inspiration Good Inspiration
Mahmood Yaseen22/9/1076MaleRoutine Check Up
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a. Inclusions: the CXR felid should include all the chest structures
Check if the lung apices are shown
Check if both costophrenic angles are seen
Mahmood Yaseen22/9/1076MaleRoutine Check Up
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4Look for different intensities Black=gas Dark Grey=fat Light Grey=soft tissue or
fluids White=bone and calcifications Intense white=metal
Mahmood Yaseen22/9/1076MaleRoutine Check Up
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5Clinical Interpretation
a. Mediastinum Examine the Mediastinal Border for abnormality
Mahmood Yaseen22/9/1076MaleRoutine Check Up
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5Clinical Interpretation
a. Mediastinum Look to the trachea and the bronchi
Mahmood Yaseen22/9/1076MaleRoutine Check Up
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Heart Any visible valves (in case of metal valves) Cardiac Size should be less than 50% of the
thoracic width in PA file measured by RULER
The heart size is enlarged in Congestive heart failure
Mahmood Yaseen22/9/1076MaleRoutine Check Up
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a. Mediastinal masses, calcification or free air
Mahmood Yaseen22/9/1076MaleRoutine Check Up
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Examine the hila: regions of lung connection to central circulation, looks opaque on the right and left side of mediastinum, they are made mainly by pulmonary arteries and veins
Hila should be rounded and symmetrical
The right hila is 1 cm lower than the left hila
Look for difference in densities
Asymmetry Loss of normal
concavity
Pulmonary Hypertension
Mahmood Yaseen22/9/1076MaleRoutine Check Up
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PAStanding
Lungs: Lung feilds of equal densities Right hemidiaphragm slightly higher than the left Sharp costophrenic angles and cardiophrenic angel The horizontal fissure in the right lung passes horizontally from
the midpoint of the right hilum to about the 6th rib in the axillary line
The pleura should be thin and symmetrical
In heart failure there will be pulmonary edema Bilateral , lung shadowing classically in the middle
and upper zones causing bat wings appearance Pulmonary vessels engorgement (blood vessles
more than 5 mm in diameter in upper zone Kerley B lines: short horizontal white lines close
to the lung periphery cuased by edema of interlobular septa
Mahmood Yaseen22/9/1076MaleRoutine Check Up
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Look for the remaining structures
a. Bones : examine their densities and trabecular pattern
Examine the shoulder girdle Ribs Clavicles Thoracic vertebrae
Lytic lesions Sclerosis Erosions Fractures Dislocations
a. Soft Tissue Check Surgical Emphysema Air pockets in soft tissue
a. Breasts In females Nipples are rounded opacities that may be
misdiagnosed as lesions
Missing breast by disease or surgery
a. Abdomen See air in the stomach below left hemidiaphragm
Free air under diaphragm
Gastic bubbles seen as rounded top and horizontal base shape
Free air appear between liver and right hemidiaphragm or above gastric bubbles
StepActionFindingsABF
1Identifications data10.50
a. Patients Name
a. Date of Birth (Age)
a. Sex
a. Indication for CXR
2Side Marker (Orientation)0.30.15
Right Side and Left Side of the CXR
3Technical Considerations of CXR quality1.20.50
a. Position of the Patient: Standing Sitting Supine
0.2
a. Projection: (AP or PA or Lateral)0.2
a. Rotation Rotated or not0.2
a. Quality and Exposure of X-Rays Too little exposure Too much exposure
0.2
a. Inflation : Proper inhalation or not0.2
a. Inclusions: lung apices are shown both costophrenic angles are seen
0.2
4Clinical Interpretation1.50.75a. Mediastinum Mediastinal Border for abnormality
Trachea and the bronchi0.25
a. Heart Any visible valves Cardiac Size
0.25
a. Mediastinal masses, calcification or free air0.25
a. Examine the hila: Density Symmetry
0.25
a. Lungs: Lung fields densities costophrenic angles cardiophrenic angel The horizontal fissure The pleura
0.25
5Look for the remaining structures10.5a. Bones Examine the shoulder girdle
Ribs Clavicles Thoracic vertebrae
0.25
a. Soft Tissue Check Surgical Emphysema0.25
a. Breasts Shape Nipples are rounded opacities that may be misdiagnosed as lesions
0.25
a. Abdomen Gastic bubbles Free air under diaphragm
0.25
CXR in Congestive Heart Failure
Kerley B LinesOedema of the interlobar septa
Horizontal, non branching, whiteSeen at periphery above costphrenic angle