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Clinical skill3 cxr-final
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Clinical skill3 cxr-final

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  • 1. Diagnosis of Congestive Heart Failure :Presented by Dr. Mahmood Yaseen Hachim
  • 2. CHEST X-RAY
  • 3. X-Ray
  • 4. R Mahmood Yaseen 22/9/1076 PA Male Standing Routine Check UpStep Action Findings Notes1 Identifications data a. Patients Name a. Date of Birth (Age) a. Sex a. Indication for CXR Clinical suspicion and provisional diagnosis
  • 5. R Mahmood Yaseen 22/9/1076 PA Male Standing Routine Check Up2 Side Marker (Orientation) Right Side and Left Side of the CXR One side is labels usually either • Look to the CXR as you R=right or L=Left are looking at the patient = the patients right side is on your left side and vice versa
  • 6. R Mahmood Yaseen 22/9/1076 PA Male Standing Routine Check Up3 Technical Considerations of CXR quality a. Position of the Patient: Standard • Check if any mark • Sitting: means severe illness, unable to stand position is standing stating the patients was o Raised diaphragm not standing during the o Reduced inflation of lungs CXR o Folded soft tissue of the patients front like skin • Supine: means very severe illness, unable to sit o The fluid level will be lost
  • 7. R Mahmood Yaseen 22/9/1076 PA Male Standing Routine Check Upa. Projection: • If the cassette is in the back and the beam pass • Objects near the cassette will appear direction of X-Ray from front to back =(AP)=Anterior -Posterior in their size but the organs far from beam passage • If the cassette is in the front and the beam pass the cassette will look falsely enlarges through the patient from back to front =(PA)=Posterior-Anterior as a shadow, it is so importnat in case of heart size assessment • Either right or left side of the chest = Lateral • So AP is not used to check heart size, it should be PA
  • 8. AP PA
  • 9. R Mahmood Yaseen 22/9/1076 PA Male Standing Routine Check UpRotation • Spinous processes of thoracic vertebra should • Rotation can cause abnormal appear at the center of each appearance of the mediastinum • The spinous process of T4 should be between and other structures the heads of the clavicle • if it isnt the body is rotated
  • 10. R Mahmood Yaseen 22/9/1076 PA Male Standing Routine Check UpQuality and Exposure of X-Rays • Is the film penetrated • Too little exposure will make lungs appear too properly? white • In a properly penetrated film • Too much exposure will make structures more the vertebral interspaces dark and mask the signs should be visible behind the central (cardiac) shadow
  • 11. R Mahmood Yaseen 22/9/1076 PA Male Standing Routine Check Upa. Inflation : Proper CXR should be • There must be more than 9 ribs visible posterior to • If poor inflation then the taken with full inflation of lungs say the inspiration was perfect lung will appear more (deep inspiration and hold breath) • So count the ribs starting from the 1st rib dense • Trachea will be drawn to the right side • Heart will look abnormally enlarged
  • 12. Poor Inspiration Good Inspiration
  • 13. R Mahmood Yaseen 22/9/1076 PA Male Standing Routine Check Upa. Inclusions: the CXR felid should • Check if the lung include all the chest structures apices are shown • Check if both costophrenic angles are seen
  • 14. R Mahmood Yaseen 22/9/1076 PA Male Standing Routine Check Up4 Look for different intensities • Black=gas • Dark Grey=fat • Light Grey=soft tissue or fluids • White=bone and calcifications • Intense white=metal
  • 15. R Mahmood Yaseen 22/9/1076 PA Male Standing Routine Check Up5 Clinical Interpretation a. Mediastinum • Examine the Mediastinal Border for abnormality
  • 16. R Mahmood Yaseen 22/9/1076 PA Male Standing Routine Check Up5 Clinical Interpretation a. Mediastinum • Look to the trachea and the bronchi
  • 17. RMahmood Yaseen22/9/1076 PAMale StandingRoutine Check UpHeart • Any visible valves (in case of metal valves) • The heart size is enlarged in • Cardiac Size should be less than 50% of the Congestive heart failure thoracic width in PA file measured by RULER
  • 18. R Mahmood Yaseen 22/9/1076 PA Male Standing Routine Check Upa. Mediastinal masses, calcification or free air
  • 19. R Mahmood Yaseen 22/9/1076 PA Male Standing Routine Check UpExamine the hila: regions of lung • Hila should be rounded • Look for difference connection to central circulation, looks and symmetrical in densities opaque on the right and left side of • The right hila is 1 cm • Asymmetry mediastinum, they are made mainly by lower than the left hila • Loss of normal pulmonary arteries and veins concavity
  • 20. PulmonaryHypertension
  • 21. RMahmood Yaseen22/9/1076 PAMale StandingRoutine Check UpLungs: • Lung feilds of equal densities • In heart failure there will be pulmonary edema • Right hemidiaphragm slightly higher than the left • Bilateral , lung shadowing classically in the middle • Sharp costophrenic angles and cardiophrenic angel and upper zones causing bat wings appearance • The horizontal fissure in the right lung passes horizontally from • Pulmonary vessels engorgement (blood vessles the midpoint of the right hilum to about the 6th rib in the axillary more than 5 mm in diameter in upper zone line • Kerley B lines: short horizontal white lines close to • The pleura should be thin and symmetrical the lung periphery cuased by edema of interlobular septa
  • 22. RMahmood Yaseen PA22/9/1076Male StandingRoutine Check UpLook for the remaining structuresa. Bones : examine their densities • Examine the shoulder girdle • Lytic lesions and trabecular pattern • Ribs • Sclerosis • Clavicles • Erosions • Thoracic vertebrae • Fractures • Dislocationsa. Soft Tissue • Check Surgical Emphysema • Air pockets in soft tissuea. Breasts • In females • Missing breast by disease or surgery • Nipples are rounded opacities that may be misdiagnosed as lesionsa. Abdomen • See air in the stomach below left • Gastic bubbles seen as rounded top hemidiaphragm and horizontal base shape • Free air under diaphragm • Free air appear between liver and right hemidiaphragm or above gastric bubbles
  • 23. Step Action Findings A B F1 Identifications data 1 0.5 0 a. Patients Name a. Date of Birth (Age) a. Sex a. Indication for CXR2 Side Marker (Orientation) 0.3 0.15 Right Side and Left Side of the CXR3 Technical Considerations of CXR quality 1.2 0.5 0 a. Position of the Patient: • Standing 0.2 • Sitting • Supine a. Projection: • (AP or PA or Lateral) 0.2 a. Rotation • Rotated or not 0.2 a. Quality and Exposure of X-Rays • Too little exposure 0.2 • Too much exposure a. Inflation : • Proper inhalation or not 0.2 a. Inclusions: • lung apices are shown 0.2 • both costophrenic angles are seen4 Clinical Interpretation 1.5 0.75 a. Mediastinum • Mediastinal Border for abnormality 0.25 • Trachea and the bronchi a. Heart • Any visible valves 0.25 • Cardiac Size a. Mediastinal masses, calcification or free air 0.25 a. Examine the hila: • Density 0.25 • Symmetry a. Lungs: • Lung fields densities 0.25 • costophrenic angles • cardiophrenic angel • The horizontal fissure • The pleura5 Look for the remaining structures 1 0.5 a. Bones • Examine the shoulder girdle 0.25 • Ribs • Clavicles • Thoracic vertebrae a. Soft Tissue • Check Surgical Emphysema 0.25 a. Breasts • Shape 0.25 • Nipples are rounded opacities that may be misdiagnosed as lesions a. Abdomen • Gastic bubbles 0.25 • Free air under diaphragm
  • 24. CXR in Congestive Heart Failure
  • 25. Kerley B Lines Oedema of the interlobar septa Horizontal, non branching, whiteSeen at periphery above costphrenic angle

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