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

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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

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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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58

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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