Review of Basic Chest X-Ray Diagnostic Radiographs Compiled and Presented by Marc Imhotep Cray, M.D.Basic Medical Sciences ProfessorRadiology 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| Yale University -Cardiothoracic ImagingREVIEW OF NORMAL CHESTADMINISTRATIVEINITIAL SURVEYIntroductionNext 9 slides are created using data from:USUHS -Chest X-Ray ReviewREVIEW OF NORMAL CHESTA 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)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, lyticor blasticregions, etc.7.Review mediastinum:A.overall size and shapeB.trachea: positionC.margins: SVC, ascending aorta, right atrium, left subclavianartery, aortic arch, main pulmonary artery, left ventricleD.lines and stripes: paratracheal, paraspinal, paraesophageal(azygoesophageal), paraaorticE.retrosternalclear spaceREVIEW OF NORMAL CHEST (2)Sequenced ChecklistREVIEW OF NORMAL CHEST (3)Sequenced Checklist8. Review hila: A.normal relationships B.size 9. Review lungs and pleura: A.compare lung sizes B.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 ADMINISTRATIVEGet 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.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 pneumothoraxif there is patient motion or the film is overexposed. ADMINISTRATIVE (2)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 normalsyou use as reference points, and you may be sensitized to look for specific findings. 1.General Body Size, Shape, and Symmetry2.Male vs. Female3.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)The Chest X-RayThe following radiographic plates are scan ins from: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. Lecture Outline•Densities•Techniques•Anatomy•CXR Interpretation•Common PathologiesDensitiesThe big two densities are:(1) WHITE -Bone(2) BLACK -AirThe others are:(3) DARK GREY-Fat (4) GREY-Soft tissue/waterAnd if anything Man-made is on the film, it is:(5) BRIGHT WHITE -Man-madeTechniques -ProjectionP-A (relation of x-ray beam to patient)Techniques -Projection (continued)LateralTechniques -Projection (continued)Lateral DecubitusRotationRotation (continued)PenetrationInspiration/ExpirationAnatomyAnatomyAnatomyLobesRight upper lobe:Lobes(continued)Right middle lobe:Lobes(continued)Right lower lobe:Lobes(continued)Left lower lobe:Lobes(continued)Left upper lobe with Lingula:Lobes(continued)Lingula:Lobes(continued)Left upper lobe -upper division:Heart(continued)Right border: Edge of (r) Atrium3. Left border: (l) Ventricle + Atrium4. Posterior border: ReftVentricle5. Anterior border: Right VentricleHeart(continued)Heart(continued)ValvesMediastinumHilumMade of:1. Pulmonary Art.+Veins2. The BronchiLeft Hilushigher (max 1-2,5 cm)Identical: size, shape, densityRibsLateral CXRLateral CXR(continued)Lateral CXR(continued)Tracheoesophageal StripeLateral CXR(continued)CXR InterpretationThe following radiographic plates are scan ins from: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. Technical Details•Type•Orientation•Rotation •Inspiration/expiration•PenetrationLungs:•Lungs•Density•Symmetry•LesionsHeartSize: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 IVC and SVC Mediastinum:•Width •Contour•AP window•Size•LocationReview areas:•Apices•Behind the heart•CP angles•Below the diaphragm•Soft tissues ( breast, surgical emphysema) •Ribs & clavicle •Vertebrae Identify the lesion → localise the lesion → describe the lesion → give DDxNever stop looking, carry on with your systematic approach!!PathologyRUL pneumoniaRML pneumoniaRLL pneumoniaLUL pneumoniaLLL pneumonia•Consolidation on CTHilarmassThe Enlarged Hila•Causes:1. Adenopathies(neoplasia, infection)2. Primary Tumor3. Vascular4. Sarcoidosis•Multiple MassesHilarLymphadenopathy-BLPleural EffusionPulmonary FibrosisHeart failurePneumothoraxRUL collapseLLL collapseAir under the diaphragmEmphysemaCavitating lesionHiatus herniaMiliary shadowingChest Tube, NG Tube, Pulm. artery cathIVMSis the ultimate medical student Web 2.0 companion. This SDL-Face to Face hybrid courseware is a digitally tagged and content enhanced replication of the United States Medical Licensing Examination's Cognitive Learning Objectives (Steps 1, 2 or 3). Including authoritative reusable learning object (RLO) integration and scholarly Web Interactive PowerPoint-driven multimedia shows/PDFs. Comprehensive hypermedia BMS learning outcomes and detailed, content enriched learning objectives.IVMS Coueseware Hot-Linked Overview /PPt Presentation/PDF Version THE END, THANK YOU FOR YOUR ATTENTIONPLEASE VISIT AND TELL US WHAT YOU THINKhttp://ivms.blogspot.com/