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i

Radiology Essence

Basics of Chest X-ray Interpretation


ii

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Radiology Essence

Basics of Chest X-ray Interpretation

Samyajyoti Das,

Subhajit Datta

(2015-16 batch MBBS students

Agartala Government Medical College)

EDUCREATION PUBLISHING (Since 2011)

www.educreation.in


iv

INTRODUCTION

This book is mainly intended for the students appearing in the

post-graduate medical admission tests around India along with all

the undergraduate students who wish to learn Radiology in a better

way. This book will give them a basic idea regarding the chest x-

ray interpretation and its use in different subjects of MBBS course.

Radiology is one of the subjects, which is not taught to a great

detail in under graduation but forms a significant part in a doctor‘s

life. More over with the changes in the patterns of questions

towards the clinical side in different competitive exams,

knowledge of radiological signs has become critical. More

importantly with proper radiological knowledge, early diagnosis of

the disease can save a patient‘s life.

This book is a humble attempt to provide you with one high yield,

comprehensive textbook to help you improve your diagnosis skills

in the field of Radiology.

The book is structured into normal chest x-ray, Quality and Tubes

in chest x-ray, Abnormalities along with Golden facts, Special

signs and Multiple choice questions. This book is written in a way

that once you go through this book, you have a comprehensive idea

about the subject and are able to answer majority of the questions

in Radiology. In today‘s competitive world every subject and every

question makes a difference with limited time available to the

students.

Although, we have given our best effort to make this book a

complete yet concise account of the subject. We request all our

readers and critics to kindly inform us about any deficiency


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regarding the book. Any suggestion to improve the book quality

will be most welcome.

Samyajyoti Das

([email protected])

SubhajitDatta

([email protected])


mailto:[email protected]

vi

ACKNOWLEDGEMENTS

We are grateful to our mentor Dr. Kishan Rao B, MBBS Third

year PGT in General Surgery at Agartala Government Medical

College for his constant support, advice and constructive criticism.

To all our teachers who always showed us the right way in our life

and taught us whatever we know.

To all our colleagues and seniors for their support, cooperation and

suggestions for betterment of the book and lastly to all our friends

who are in ‗Radiology Essence‘ group.

To Dr. Graham Lloyd-Jones FRCR, consultant radiologist at

Salisbury District Hospital UK, and editor of the website

www.radiologymasterclass.co.uk for his support in giving

permission for use of materials from the site.


http://www.radiologymasterclass.co.uk/

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THIS BOOK IS DEDICATED TO

Our Beloved Late Grandparents for their blessings.

To our parents Mr.Asim Das and Mrs.Dipa Das

Mr.Bivash Chandra Datta and Mrs.Sikha Datta

For being a constant source of encouragement and inspiration

throughout.


viii

FOREWORD

Radiography is often regarded as the ―third eye of a doctor‖. Thus

it is imperative on the part of a medical student to know at least the

basics of radiography and its interpretation.

Armored with its knowledge we can diagnose many clinical

conditions. Although important, it is rarely taught in medical

colleges as a routine in its curriculum.

Elation reigns over all emotions as we inform you about our

brother Samyajyoti Das and Subhajit Datta who have authored a

book on Basic Interpretation of Chest x-ray Radiograph. Being

very talented and intelligent students, they have dedicated this

humble effort to help others. Samyajyoti has already written

another book named "Language of Healthcare" to help students

communicate with the patients and is also a core member of the 28

"The White Army" Whatsapp groups which helps thousands of

medical students all over India to study better. Subhajit is creating

awareness about disease prevention among common people

through his Facebook page ―MEDTALK‖.

Understanding the concepts and then writing a book on it requires

enormous courage and confidence. Hope this book caters to the

needs of all medical students to learn radiology in an easier and

better way. Also I wish Samyajyoti and Subhajit all the success in

life and expecting more contributions from them in the field of

medicine.

-Dr. Kishan Rao B.

Third year M.S, General Surgery

Agartala Government Medical college


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TIPS FROM THE AUTHORS

Know the normal things thoroughly. May it be pulse, breath

sounds, heart sounds, bowel sounds or in this case Radiographs.

Read as many Normal radiographs as possible to know what is

Normal and, therefore what is Abnormal.

In Under Graduate level, if we can diagnose the condition it is

excellent. But we should be able to tell whether it is normal or

abnormal. We can‘t learn all abnormal because they are thousands

but normal is one. So let us learn that easy yet effective way.

Always follow a particular systemic approach.

We should know the proper anatomy because ―Eye doesn't see

what mind doesn't know.‖


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ABBREVIATIONS AND COMMON

TERMS USED IN RADIOLOGY

AAS - Acute Abdominal Series

ABC - Automatic Brightness Control

ABD - Abdomen

ADC - Analog-to-Digital Converter

AEC - Automatic Exposure Control

ALARA - As Low As Reasonably Achievable.

AP - Antero-Posterior

APR - Anatomical Programmed Radiography

BAS - Barium Swallow

BE - Barium Enema

CAT - Computed Axial Tomography

CCD - Charge Coupled Device

CHD - Coronary Heart Disease

CINE - Cinematographic

CPR - Cardio-Pulmonary Resuscitation

CR - Computed Radiography

CT - Computed Tomography

CTDI - Computed Tomography Dose Index

CXR - Chest x-ray

DDR - Direct Digital Radiography

DECUB - Decubitus

DICOM - Digital Imaging and Communication in Medicine

DSA - Digital Subtraction Angiography

EBCT - Electron Beam Computed Tomography

ECG - Electro Cardiogram

EPI - Echo Planar Imaging

ESR - Electron Spin Resonance

FPR - Fluoroscopy Programmed Radiography

GI - Gastrointestinal

IV - Intravenous

IVP - Intravenous Pyleogram

IVU - Intravenous Urogram

LAO - Left Anterior Oblique

LCD - Low Contrast Detail, Liquid Crystal Display


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LCR - Low Contrast Resolution

LPO - Left Posterior Oblique

LSF - Line Spread Function

MAMMO - Mammography, Mammogram

MDCT - Multi-Detector Computed Tomography

MRA - Magnetic Resonance Angiography

MRI - Magnetic Resonance Imaging

MRS - Magnetic Resonance Spectroscopy

MSCT - Multi-Slice Computed Tomography

PA - Postero-Anterior

PTCA - Percutaneous Transluminal Coronary Angioplasty

QA - Quality Assurance

QC - Quality Control

R&F - Radiography and Fluoroscopy

RAD - Radiation Absorbed Dose

RAO - Right Anterior Oblique

RPO - Right Posterior Oblique

SONO - Sonogram, Sonography

SPR - Scan Projection Radiograph

TCDD - Threshold Contrast Detail Detectability

TOMO - Tomography, Tomogram

UGI - Upper Gastrointestinal Series

US - Ultrasound, Ultrasonography

Abdo:-abdomen

AbdoE&S:-abdomen erect and supine (lying face upwards)

Angio:-angiogram (shows blood vessels)

Arthrogram:-this is a contrast study to view the joint cavity.

AP:-antero-posterior view

AXR:-abdominal X-ray

Barium:-a substance opaque to X-rays

BaE:-barium enema

BaSw:-barium swallow

BaM:-barium meal

BaFT:- barium follow through

Ca:- cancer

CB (WNCB):- core biopsy (wide needle core biopsy).

Small samples of tissue area unit taken employing a special needle

Contrastmedia:- the substance injected into spaces to outline them

as it is radio-opaque.Often called 'dye' but it is colourless


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CC:- cranio-caudal view.

#Often employed in diagnostic technique for the read taken

from on top of to below

CXR:- chest x-ray

Dopplerinultrasound:- the Doppler principle is used to detect and

measure flow in vessels

ERCP:-endoscopic retrograde cholangio-pancreatogram.

#Using a side-viewing endoscopic examination, the common

bile and pancreatic ducts are cannulated and contrast medium

is injected to outline the ducts

FFD:-focus film distance

FNA (c):- fine-needle aspiration cytology. Cells are taken by a fine

needle

HSG:- hystero-salpingogram.

An investigation to examine the uterine cavity and therefore the

fallopian tubes

IAM:- internal auditory meatus.

The point within the skull wherever the nerves enter the internal

ear

IVP:- intravenous pyelogram (same as IVU).

Contrast media is injected into a vein and is excreted by the

excretory organ, outlining the urinary system

IVU:- intravenous urogram (same as IVP)

KUB:- kidneys, ureters and bladder

LAT:- lateral view

LO:-lateral oblique view (often called oblique/obl view)

Mammo:- mammogram

MCU (G):- micturating cysto-urethrogram.

#It is an investigation in which the urinary tract is examined by

direct needle puncture before insertion of drainage catheter.

NOF:- neck of femur

ObstreticAFI:- amniotic fluid index

CRL:-crown rump length (measurement of fetus)

ET:- endometrial thickness (of the uterine cavity)

FH:-fetal heart

MSD:-mean sac diameter (measurement of fetal sac)

PA:- postero-anterior view


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PCN:-Percutaneous nephrostomy. Investigation of the urinary tract

by direct needle puncture, often before insertion of a drainage

catheter

PNS:-postnasal space

PT (H)C:- Percutaneous transhepatic cholangiogram.

Investigation of the biliary system within the liver via direct needle

puncture

Protogram:-Investigation of the rectum. Defaecating proctogram is

conducted during defaecation

RLat:-right lateral (or L Lat - left lateral) view

SIJs:-Sacro-iliac joints

Csp:-cervical spine

Lsp:-lumbar spine

LSsp:-lumbo-sacral spine

Tsp:-thoracic spine

SXR:-Skull X-ray

Tib&Fib:-tibia and fibula

TMJ:-temperomandibular joint

TVscan:- transvaginal ultrasound scan

Urodynamics :-The study of bladder function

US:- ultrasound


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Contents A FORTUNATE ACCIDENT……………………………………….…….…….1 FEW IMPORTANT DISCOVERIES IN RADIOLOGY………….….…....3 HOW X-RAY IS CHANGING THE WORLD?..................................4 BASICS OF CHEST X-RAY IN A NUTSHELL…………….…………….…..7 NORMAL ANATOMY OF CHEST X-RAY……………….….…………….22

1. Trachea and major bronchi……………………….……………..23 2. Hilar structures……………………………………………….……….24 3. Lung zones…………………………………………………….….……..27 4. Pleura and its spaces …………………………………...……..29 5. Lung lobes and fissures…………………………………………….31 6. Costophrenic recesses and angles…………………………….35 7. Diaphragm………………………………………………………………..38 8. Heart size and contours…………………………………………….40 9. Mediastinal contours……………………..………………………...42 10. Soft tissues………………………………………………………..……..45 11. Bones……………………………………………………………….………48

APPROACH TO QUALITY OF CHEST X-RAY………………………….….54 1. Inclusion……………………………………………………………………54 2. Projection……………………………………………..…………………..55 3. Rotation…………………………………………………………………….59 4. Inspiration and lung volume………………………………………62 5. Penetration……………………………………………………………….66

CHEST X-RAY: TUBES……………………………………………………………….70 1. ET Tubes – Position………………………………………………………72 2. NG Tubes – Position……………………………………………………..80 3. Position of CV catheters………………………………………………..87 4. Chest Drains – Position………………………………………………….97

APPROACH TO ABNORMALITIES ASSOCIATED WITH CHEST X-RAY………………………………………………………………….……………….103 1. Displacement of trachea………………………………………………103 2. Abnormalities associated with hila……………………………….105 3. Abnormalities associated with lungs……………………………..108 4. Abnormalities associated with pleura and its spaces……..113 5. Abnormalities associated with lobes, fissures and 6. Contours………………………………………………………………………..119 7. Abnormalities associated with diaphragm……………………..126 8. Cardiac contour and pulmonary oedema………………………..131


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9. Abnormalities associated with mediastinum……………………….137 10. Abnormalities associated with soft tissues………………………...141 11. Abnormalities associated with bone………………………..…………144 GOLDEN FACTS OF RADIOLOGY………………………………………………..148 Radiological Appearance of Heart in Various

Diseases…………………………………………………………………………………..150 SIGNS OF CHEST X-RAY RADIOLOGY…………………………………........153 MULTIPLE CHOICE QUESTIONS REGARDING CHEST X-RAY

RADIOLOGY……………………………………………………………………………..161 ANSWER TO THE QUESTIONS……………………………………………………184 REFERENCE………………………………………………………………………………189


1

A FORTUNATE ACCIDENT

German physicist Wilhelm Conrad Röentgen was studying the

process of electric current passing through a gas at an extreme low

pressure (in the year 1895).

Figure: Wilhelm Conrad Röentgen

He noticed that when he passed high voltage electricity through a

fluorescent tube, it started to glow; he then covered the tube with a

black paper and repeated the experiment.

To his great surprise, he observed that a plate coated with ‗barium

platinocyanide‘ in his lab was emitting fluorescence


Radiology Essence

2

So he came to a conclusion that an unknown ray was emitted by

the tube which could penetrate the black paper and caused glowing

of the plate.

As the source of the ray was unknown, he proposed the name ‗X

ray‘ for his new discovery.

Later, he took an X ray image of his wife‘s hand.

In the year 1901, he got the first ever Nobel Prize as a physicist for

his discovery.

It was indeed very sad that later he died of an epithelial cell

carcinoma.

X RAYS are invisible ELECTROMAGNETIC

RADIATION having wavelength of 10 Å to 0.01 Å

travelling at the speed of light.

X rays are a pure form of energy emitted due to collision of

electrons with tungsten atoms.

Modern X ray plates are made up of an emulsion-gelatin,

containing radiation sensitive silver halide crystals in a

flexible transparent blue tinted base.


3

FEW IMPORTANT DISCOVERIES IN

RADIOLOGY

Antoine Henri Bacquerel:-Radioactivity

Charles Dotter:-Image guided medical procedures; Father of

Interventional Radiology

David E. Kuhl:-Positron Emission Tomography (PET)

Ernest Rutherford:-Alpha/beta particles, neutrons; Father of

Nuclear Physics

Godfrey Hounsfield:-Computed Tomography (CT) scan

Ian Donald:-Ultrasonography (USG); Father of Obstetric

Ultrasound.

John Caffey:-Father of Pediatric Radiology

*****

DID YOU KNOW?

Roentgen Didn‘t Patent X-Ray.

Roentgen Was Colour Blind.

X-Rays Were Used Within Weeks By European

Surgeons After Its Discovery To Find Bullets And

Other Objects. From A Year After That X-Ray Was

Used To Detect Fractured Bones In United States.


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