ivms-review of basic chest x-ray and diagnostic radiographs
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Review of Basic Chest X Ray
Diagnostic Radiographs
1
Prepared and presented by:Marc Imhotep Cray, M.D.
Basic Medical Sciences Teacher
http://www.imhotepvirtualmedsch.com/
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REVIEW OF NORMAL CHEST
ADMINISTRATIVE
INITIAL SURVEY
Introduction
The first 9 slides are extracted and modified from
USUHS - Chest X-Ray Review
2
This presentation is a part of the
IVMS Mini-Medical School Course Sequence
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REVIEW OF NORMAL CHEST A systematic approach to film review and is therefore, designed such
that the major areas of the chest should be viewed in the sequential
order (see next slide for checklist)
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1.Check patient name, position, technical quality.2.Soft tissue including breast, chest wall, companion shadow.
3.Review soft tissues and skeletal structures of shoulder girdles and chest wall.
4.Review abdomen for bowel gas, organ size, abnormal calcifications, free air,
etc.
5.Review soft tissues and spine of neck.
6.Review spine and rib cage: check alignment, disc space narrowing, lytic orblastic regions, etc.
7.Review mediastinum:
A. overall size and shape
B. trachea: position
C. margins: SVC, ascending aorta, right atrium, left subclavian artery,
aortic arch, main pulmonary artery, left ventricle
D. lines and stripes: paratracheal, paraspinal, paraesophageal
(azygoesophageal), paraaortic
E. retrosternal clear space
REVIEW OF NORMAL CHEST (2) Sequenced Checklist
4
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REVIEW OF NORMAL CHEST (3) Sequenced Checklist
8. Review hila:A.normal relationships
B.size
9. Review lungs and pleura:
A.compare lung sizesB.evaluate pulmonary vascular pattern: compare upper to
lower lobe, right to left, normal tapering to periphery
C.pulmonary parenchyma
D.pleural surfaces
a.fissures - major and minor - if seen
b.compare hemidiaphragms
c.follow pleura around rib cage
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ADMINISTRATIVE
Get in the habit of always
checking the following items
before anything else. It takes a
few seconds and is an important
legal safe guard as well.1.Patient's name.
2.Date exam done (very
important if comparing prior
exams).
3.Check for position markers -
right vs. left, upright.
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Other items to check before commencing with clinical review of the film include:
1.Type of film (although this is a chest program, practice noticing if it is a plain film,
CT, angio, MRI, etc.)2.Patients position - supine, upright, lateral, decubitus.
3.Technical quality of exam - learn what are the acceptable limits for the exam. You
can't find a subtle pneumothorax if there is patient motion or the film is
overexposed.
ADMINISTRATIVE (2)
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A basic principle to adopt is going from general observations to specific
details. Sometimes a change may be so major that the old saying about
missing the forest for the trees comes true. For instance, an absent
breast shadow on a film of a patient after a mastectomy.
After completing your administrative housekeeping, get a general
overview of the film before zooming in on tiny detail.
Notice the following because it may change the baseline normals you
use as reference points, and you may be sensitized to look for specific
findings.
1.General Body Size, Shape, and Symmetry2.Male vs. Female
3.Is this an infant, child, young adult, elderly person?
4.Survey for foreign objects - tubes, IV lines, EKG leads, surgical drains,
prosthesis, etc., as well as non-medical objects, bullets, shrapnel, glass,
etc.
ADMINISTRATIVE (3)
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The Chest X-Ray
The following radiographic plates are scan ins from my personal copies of:
Felson, B., et al.: Principles of Chest Roentgenology. Philadelphia, W.B. Saunders Co., 1973.
Fraser, R., et al.: Diagnosis of Diseases of the Chest, 3rd edition. Philadelphia, W.B. Saunders
Co., 1988.Non-commercial , educational purposes only
See: U.S. Copyright Office Fair Use at http://www.copyright.gov/fls/fl102.html 9
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Lecture Outline
•Densities
•Techniques
•
Anatomy•CXR Interpretation
•Common Pathologies
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Densities
The big two densities are:
(1) WHITE - Bone
(2) BLACK - Air
The others are:
(3) DARK GREY- Fat
(4) GREY- Soft tissue/water
And if anything Man-made is on the film,it is:
(5) BRIGHT WHITE - Man-made
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Techniques - Projection
P-A (relation of x-ray beam to patient)
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Techniques - Projection (continued)
Lateral
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Techniques - Projection (continued)
Lateral Decubitus
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Rotation
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Rotation (continued)
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Penetration
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Inspiration/Expiration
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Anatomy
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Anatomy
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Anatomy
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Lobes
Right upper lobe:
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Lobes (continued)
Right middle lobe:
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Lobes (continued)
Right lower lobe:
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Lobes (continued)
Left lower lobe:
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Lobes (continued)
Left upper lobe with Lingula:
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Lobes (continued)
Lingula:
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Lobes (continued)
Left upper lobe - upper division:
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Heart (continued)
Right border: Edge of (r) Atrium
2. Left border: (l) Ventricle + Atrium
3. Posterior border: Left Ventricle
4. Anterior border: Right Ventricle
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Heart (continued)
Valves
31
di i
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Mediastinum
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Hilum
Made of:
1. Pulmonary Art.+Veins
2. The Bronchi
Left Hilus higher (max 1-2,5 cm)
Identical: size, shape, density
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Ribs
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Lateral CXR
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Lateral CXR (continued)
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Lateral CXR (continued)
Tracheoesophageal Stripe
37
Lateral CXR (continued)
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Lateral CXR (continued)
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CXR Interpretation
The following radiographic plates are scan ins from my personal copies of:
Felson, B., et al.: Principles of Chest Roentgenology. Philadelphia, W.B.
Saunders Co., 1973.
Fraser, R., et al.: Diagnosis of Diseases of the Chest, 3rd edition. Philadelphia,
W.B. Saunders Co., 1988.
Non-commercial , educational purposes only
See: U.S. Copyright Office Fair Use at http://www.copyright.gov/fls/fl102.html
39
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Technical Details
• Type
• Orientation
• Rotation• Inspiration/expiration
• Penetration
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Lungs:
•
Lungs• Density
• Symmetry
• Lesions
41
Heart
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Heart
Size:
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Heart• Size of heart
• Size of individual
chambers of heart
• Size of pulmonary vessels• Evidence of stents, clips,
wires and valves
•
Outline of aorta and IVCand SVC
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Mediastinum:
• Width
• Contour
• AP window
• Size
• Location 44
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Review areas:
• Apices
• Behind the heart
• CP angles
• Below the diaphragm
• Soft tissues ( breast, surgical emphysema)
• Ribs & clavicle
• Vertebrae
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Identify the lesion → localise the lesion →
describe the lesion → give DDx
Never stop looking, carry on with your
systematic approach!!
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Pathology
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RML pneumonia49
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RLL pneumonia50
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LUL pneumonia51
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LLL pneumonia52
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• Consolidation on CT53
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Hilar mass54
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The Enlarged Hila
• Causes:
1. Adenopathies (neoplasia, infection)
2. Primary Tumor
3. Vascular
4. Sarcoidosis
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• Multiple Masses56
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Hilar Lymphadenopathy - BL57
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Pleural Effusion59
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Pulmonary Fibrosis60
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Heart failure61
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Pneumothorax62
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RUL collapse63
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LLL collapse64
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Air under the diaphragm65
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Emphysema66
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Cavitating lesion67
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Hiatus hernia68
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Miliary shadowing69
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Chest Tube, NG Tube, Pulm. artery cath
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THE END THANK YOU FOR YOUR ATTENTION
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Further study:
Radiology Online Study Resources:
Albert Einstein Medical Center - LearningRadiology | eMedicine -
Radiology | GE - Medcyclopaedia | McGill University - Basic
Radiology Primer: An Introduction to Problem-Oriented Imaging
Algorithms | Medical College of Wisconsin - Chorus |
RadiologyEducation.com | SearchingRadiology.com | StudentBMJ -
Introduction to Imaging | USUHS - Chest X-Ray Review
THE END, THANK YOU FOR YOUR ATTENTION