Review of Basic Chest X-Ray Diagnostic Radiographs Compiled and Presented by Marc Imhotep Cray, M.D. Basic Medical Sciences Professor Radiology 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 Imaging
Introduction Next 9 slides are created using data from: USUHS - Chest X-Ray ReviewREVIEW OF NORMAL CHESTADMINISTRATIVEINITIAL SURVEY
REVIEW OF NORMAL CHESTA systematic approach to film review and is therefore, designed suchthat the major areas of the chest should be viewed in the sequentialorder (see next slide for checklist)
REVIEW OF NORMAL CHEST (2) Sequenced Checklist1.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 chestwall.4.Review abdomen for bowel gas, organ size, abnormal calcifications, freeair, 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 (3) Sequenced Checklist8. Review hila:A.normal relationshipsB.size9. Review lungs and pleura:A.compare lung sizesB.evaluate pulmonary vascular pattern: compare upper to lower lobe, right to left,normal tapering to peripheryC.pulmonary parenchymaD.pleural surfaces a.fissures - major and minor - if seen b.compare hemidiaphragms c.follow pleura around rib cage
ADMINISTRATIVEGet in the habit of always checkingthe following items before anythingelse. It takes a few seconds and is animportant legal safe guard as well.1.Patients name.2.Date exam done (very important ifcomparing prior exams).3.Check for position markers - rightvs. left, upright.
ADMINISTRATIVE (2)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. Youcant find a subtle pneumothorax if there is patient motion or the film isoverexposed.
ADMINISTRATIVE (3)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 forestfor the trees comes true. For instance, an absent breast shadow on a film of apatient after a mastectomy.After completing your administrative housekeeping, get a general overview of thefilm before zooming in on tiny detail.Notice the following because it may change the baseline normals you use asreference 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.
The Chest X-RayThe following radiographic plates are scan ins from:Felson, B., et al.: Principles of Chest Roentgenology. Philadelphia, W.B. SaundersCo., 1973.Fraser, R., et al.: Diagnosis of Diseases of the Chest, 3rd edition. Philadelphia,W.B. Saunders Co., 1988.
DensitiesThe 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-made
Techniques - ProjectionP-A (relation of x-ray beam to patient)
CXR InterpretationThe following radiographic plates are scan ins from:Felson, B., et al.: Principles of Chest Roentgenology. Philadelphia, W.B. SaundersCo., 1973.Fraser, R., et al.: Diagnosis of Diseases of the Chest, 3rd edition. Philadelphia,W.B. Saunders Co., 1988.
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