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IVMS-Review of Basic Chest X-Ray and Diagnostic Radiography

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IVMS-Review of Basic Chest X-Ray and Diagnostic Radiography

IVMS-Review of Basic Chest X-Ray and Diagnostic Radiography


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  • 1. 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
  • 2. Introduction Next 9 slides are created using data from: USUHS - Chest X-Ray ReviewREVIEW OF NORMAL CHESTADMINISTRATIVEINITIAL SURVEY
  • 3. 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)
  • 4. 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
  • 5. 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
  • 6. 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.
  • 7. 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.
  • 8. 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.
  • 9. 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.
  • 10. Lecture Outline•Densities•Techniques•Anatomy•CXR Interpretation•Common Pathologies
  • 11. 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
  • 12. Techniques - ProjectionP-A (relation of x-ray beam to patient)
  • 13. Techniques - Projection (continued) Lateral
  • 14. Techniques - Projection (continued) Lateral Decubitus
  • 15. Rotation
  • 16. Rotation (continued)
  • 17. Penetration
  • 18. Inspiration/Expiration
  • 19. Anatomy
  • 20. Anatomy
  • 21. Anatomy
  • 22. LobesRight upper lobe:
  • 23. Lobes (continued)Right middle lobe:
  • 24. Lobes (continued)Right lower lobe:
  • 25. Lobes (continued)Left lower lobe:
  • 26. Lobes (continued)Left upper lobe with Lingula:
  • 27. Lobes (continued) Lingula:
  • 28. Lobes (continued)Left upper lobe - upper division:
  • 29. Heart (continued)Right border: Edge of (r) Atrium3. Left border: (l) Ventricle + Atrium4. Posterior border: Reft Ventricle5. Anterior border: Right Ventricle
  • 30. Heart (continued)
  • 31. Heart (continued)Valves
  • 32. Mediastinum
  • 33. HilumMade of:1. Pulmonary Art.+Veins2. The BronchiLeft Hilus higher (max 1-2,5 cm)Identical: size, shape, density
  • 34. Ribs
  • 35. Lateral CXR
  • 36. Lateral CXR (continued)
  • 37. Lateral CXR (continued) Tracheoesophageal Stripe
  • 38. Lateral CXR (continued)
  • 39. 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.
  • 40. Technical Details• Type• Orientation• Rotation• Inspiration/expiration• Penetration
  • 41. Lungs:•Lungs• Density• Symmetry• Lesions
  • 42. HeartSize:
  • 43. 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
  • 44. Mediastinum:• Width• Contour• AP window • Size • Location
  • 45. Review areas:• Apices• Behind the heart• CP angles• Below the diaphragm• Soft tissues ( breast, surgical emphysema)• Ribs & clavicle• Vertebrae
  • 46. Identify the lesion → localise the lesion → describe the lesion → give DDx Never stop looking, carry on with your systematic approach!!
  • 47. Pathology
  • 48. RUL pneumonia
  • 49. RML pneumonia
  • 50. RLL pneumonia
  • 51. LUL pneumonia
  • 52. LLL pneumonia
  • 53. • Consolidation on CT
  • 54. Hilar mass
  • 55. The Enlarged Hila• Causes: 1. Adenopathies (neoplasia, infection) 2. Primary Tumor 3. Vascular 4. Sarcoidosis
  • 56. • Multiple Masses
  • 57. Hilar Lymphadenopathy - BL
  • 58. Pleural Effusion
  • 59. Pulmonary Fibrosis
  • 60. Heart failure
  • 61. Pneumothorax
  • 62. RUL collapse
  • 63. LLL collapse
  • 64. Air under the diaphragm
  • 65. Emphysema
  • 66. Cavitating lesion
  • 67. Hiatus hernia
  • 68. Miliary shadowing
  • 69. Chest Tube, NG Tube, Pulm. artery cath
  • 70. THE END, THANK YOU FOR YOUR ATTENTION PLEASE VISIT AND TELL US WHAT YOU THINK http://ivms.blogspot.com/IVMS is the ultimate medical student Web 2.0 companion. This SDL-Face to Face hybridcourseware is a digitally tagged and content enhanced replication of the United StatesMedical Licensing Examinations Cognitive Learning Objectives (Steps 1, 2 or 3). Includingauthoritative reusable learning object (RLO) integration and scholarly Web InteractivePowerPoint-driven multimedia shows/PDFs. Comprehensive hypermedia BMS learningoutcomes and detailed, content enriched learning objectives. IVMS Coueseware Hot-Linked Overview / PPt Presentation/ PDF Version