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Archana Laroia, M.D

Clinical Assistant Professor Section of Chest and cardiovascular Imaging

University of Iowa Hospitals and Clinics

Objectives:

� Emphasize a systematic approach for CXR

� Variants and hidden areas

� Recognition of common entities- case based approach

Why is CXR so important ?

•  “Internal physical examination"

•  Physical exam and chest x-ray are complimentary …… not mutually exclusive.

Systematic approach

Quality Control

Findings Localize

Differential diagnosis

Etiology

ABCDEF Approach

�  Airway & Abdomen �  Bones & soft tissue �  Cardiac (includes

pulmonary vasculature) �  Diaphragms �  Effusions �  Fields (lung)

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My Approach- Outside to Inside

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Epicardial fat pad

Pectus excavatum

Right middle lobe collapse

Normal lateral CXR Spine sign

Fever and chest pain

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Hampton’s Hump- Pulmonary infarct secondary to PE!!!

Hemoptysis, weight loss, hyponatremia on labs

Reverse S sign of Golden- Right upper lobe collapse consolidation with hilar mass

Check ET tube placement

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Check central line placement Check ET tube placement- s/p trauma

Deep sulcus sign

Tension Pneumothorax- Life threatening emergency!!!! POST CHEST TUBE PLACEMENT

Stat CXR - Presented with acute on Chronic SOB in ER CT scan obtained few hours later

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Interstitial pulmonary edema

ER patient with SOB Patient with massive intracranial bleed

What study should I order?

� Have a question about the Aorta, Pulmonary arteries, Heart- IV contrast will be necessary for proper evaluation

�  Lung parenchyma can be evaluated without IV contrast.

� Keep the low dose CT chest in mind for follow up of lung nodules!

ST is a 32 year old life long non-smoker with no significant medical history. She presented to the emergency department with a short history of unilateral chest pain with mild shortness of breath Examination findings Pulse - 98 beats per minute at rest Blood pressure - 120/80 Respiratory rate - 24 per minute But she is able to speak in full sentences

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Pre-op Chest x-ray in an asymptomatic 48 M

Obtain old CT images; 2-year stability usually requires no further follow-up. If no previous images are available- For small solid SPNs (≤8 mm), follow the Fleischner Society guidelines on intervals for repeat CT For large solid SPNs (>8 mm), assess the probability of malignancy according to clinical and imaging characteristics . Consider pulmonology consult. Pure GG nodules (≤5 mm) require no follow-up Algorithm for follow-up imaging is provided for larger GG SPNs.

Key points

•  Interpret chest X-rays in view of the clinical setting .

•  When requesting a chest X-ray always provide specific clinical information.

•  When ordering cross-sectional imaging may consult your friendly radiologist!