Clinical skill tutorial part 3 (MSU tutorial class)

1. Essential
Clinical skill
“ จากพี่...สู่น้อง สู่มวลชน ”
The last pre-clinic course
อ.นพ.ปฏิญญา ยุทธชาวิทย์
ตรวจทาน : อ.พญ.ศุภวดีวงศ์นิจศีล
ขอขอบคุณเพื่อนๆพี่ๆแพทย์ขอนแก่น รุ่นที่ 37 และ 38 ที่รักทุกคน
คณะแพทยศาสตร์ มหาวิทยาลัยมหาสารคาม

3. CXR
interpretation
บรรยาย : อ.นพ.ปฏิญญา ยุทธชาวิทย์

4. Table of content
Part I : CXR
• Step by step interpretation
• Lung disease
• Heart disease
Part II : Abdominal film
• Step by step interpretation

5. Technique and Quality
1. ชื่อ : “ฟิล์ม ของ นาย/นาง.........”
2. ฟิล์ม ส่วนไหน : Chest x-ray, Plain abdomen, Plain KUB, etc.
3. ท่าอะไร : PA/AP + Supine/Upright/(Lt/Rt)Lateral decubitus
4. Inspiration : Full vs not -full (Post. 8-9 rib/Ant. 7-8 rib)
5. Exposure : Good vs Over vs Under
6. Position : Good vs Poor
วัดจาก Sternoclavicular jt ถึง spinous process
ว่าใกล้เคียงกันสองข้างหรือไม่ ? Rotation?
7. Finding
Film X-ray interpretation step-by-step

7. PA View
2.Scapula
อยู่นอก lung
field
1.Spinous
process ชี้ขึ้น
3.Air fluid
level in
stomach
PA จะ uprightเสมอ

8. Supine vs Upright vs Decubitus
Gastric air bubbles ใน
antrum เป็น supine
Gastric air bubbles ใน
fundus เป็น upright
สังเกตุ Air-Fluid level ตาม Gravity
ใน Lateral decubitus

9. Full Inspiration?
Full
6 anterior ribs or 10 posterior ribs

10. Well positioned vs Rotated ?

11. Under vs Good vs Over
exposure

12. Normal Film
เทคนิคการอ่าน
1. อ่าน Technic and Quality ก่อน
2. อ่านนอกเข ้าในหรือในออกนอกก็ได ้
3. Positive finding ควรอ่านก่อน
4. อ่าน Organ และ finding ที่ normal ด ้วย
5. ถ ้าเวลาเหลือให ้อ่าน artifact ต่างๆร่วมด ้วย

13. Chest PA
1. trachea
2. clavicle
3. aortic arch
4. spine of
scapula
5. first rib
6. posteriorrib
7. anterior rib
8. right pul.a
9. left pul.a

14. Abnormal finding description
• Where? (Which lung?, which lobe of lung?)
• Size
• Shape (focal or diffuse, rounded or spiculated, well or
poorly demarcated)
• Density (increased/decreased opacification)
• Texture (Homo/heterogenous)
• Other e.g. air bronchogram, fluid level, volume
change, artifact

15. Artifact ที่พบบ่อย
NG tube
EKG Lead
ICD
ET tube

16. Systemic approach
ABCDD
• Airway
• Breathing
• Cardiac and mediastinum
• Di- aphragm
• Deli-cates

17. Airway
• Is the trachea central?
• If not, is it deviated due to patient rotation
or pathology?
• If the cause is pathological, is the trachea
being…
• Pulled to one side : volume loss e.g. atelectasis
• Pushed away : increased volume e.g. mass, large plural
effusion
A

18. Breathing
• ประเมินไล่ลงมาจาก Apex >> Costophrenic angles
• Lt hilar ปกติต้องอยู่ต่ากว่า Rt hilar
• Both hilar should be in same density
• Look around edge of lung : pneumothorax ?
B

19. Cardiac and mediastinum
• Heart size (Cardiothoracic ratio; CT ratio)
• Clear cardiac and mediastinum boarder
• Shifted mediastinum?
• Widening mediastinum?
• Gas in mediastinum?
• Cardiac shadow and chamber enlargement
C

20. Diaphragm
• Both hemidiaphragms should be visible and
upwardly convex.
• The right hemidiaphragm is normally slightly higher
than the left due to the mass effect of the adjacent
liver.
• Look for free air under the diaphragm.
• Sharp costophrenic angle ?
D

21. Delicate
• Bone >> Rib fracture ?
• Soft tissue >> ? Swelling , Emphysema ? , surgical clip
• Line
• Commonly missed area :
•Apices •Hila •Behind the heart •Costophrenic
angles •Under the diaphragm
D

22. Delicate
D

24. LUNG Disease
• Silhouette sign
• Approach to increased opacity
• Cavitary lesion
• Interstitial pattern
Must-know films and conditions
• Pneumonia
• Pleural effusion
• Pulmonary edema
• Pneumothorax
• Atelectasis

25. Silhouette sign
Rt.upper Rt.Middle Rt.Lower
x x
Lt.upper Lt.Lingular&Lower
x
x

26. Air bronchogram
“air density (สีดำ) รูปร่ำงเหมือน
แขนงของ bronchus อยู่ภำยใน soft
tissue density (สีขำว)”
Consolidation
Pulmonary edema
Atelectasis (patent airway)
ARDS
Severe interstitial disease
Certain neoplasm
Scarring

27. Airspace opacities
“Fluid , Pus , Blood in Alveoli”
• Pneumonia : inflammatory exudate
• Pulmonary edema : edema fluid
• Pulmonary hemorhage : blood
• Aspiration : gastric juices
Solitary airspace opacities
• Pneumonia
• Infarction associated with PE
• Pulmonary contusion
• Connective tissue disease
• Drug reactions
• Hemorrhage
• Neoplasm
• Radiation pneumonitis/fibrosis
Multifocal airspace
opacities
•Pneumonia
• Pulmonary
edema/ARDS
• Bronchioloalveolar
cell CA
• Metastases
Bat’s wing pattern
• Pulmonary edema /
ARDS
• PCP
• Viral pneumonia

28. Bat’s wing pattern

29. Cotton ball appearance
Air opacities
•Pneumonia
• Pulmonary edema/ARDS
• Bronchioloalveolar cell CA
• Metastases

30. Atelectasis
Direct signs
 Displaced fissures
(Golden S sign-Mass)
 Increased radioopacity
 Vascular or bronchial
crowding
RUL Atelectasis

31. Indirect signs
 Hilar displacement
 Elevation of
hemidiaphragm
 Mediastinal shift
 Narrowing of the rib cage
 Compensatory
overinflation of
contralateral lung
LUL Atelectasis

32. RML Atelectasis

33. RLL Atelectasis

34. Lower lobe atelectasis

35. Whole lung atelectasis

36. Nodule <3cm vs Mass >3cm
• Malignant neoplasm
• Infectious granulomas
(TB, fungal)
• Benign tumors (harmatoma)
Single/Solitary pulmonary nodule

37. • Fungal ball
{Cresent shape}
•
Aspergillosis

38. Fungal ball
{Cresent shape}

39. Fungal ball
{Cresent shape}

40. Aspergilloma

41. Multiple pulmonary nodule
• 95% are metastases or
postinfectious granulomas

42. Cystic (Cavitary) lesion
1. ขนาดมากกว่า 1 cm.
2. คาว่า cyst ใช้กรณี thin wall (< 4 mm.)
3. บางครั้งอาจมี air-fluid level อยู่ภายใน
4. Pneumatocele → cyst develop after infection
• Multiple cysts and
reticulonodular
infiltration at
both upper lungs
Dx.Pulmonary TB

43. • Single thick wall cavity with
air fluid level at left lower lung
(silhouette with Lt. diaphragm)
Dx. Bacterial lung abscess
Single Cavitary
lesion DDx:
• Thick wall:
abscess, CA,
Wegners, fungus
• Thin wall:
pneumatocoele,
cyst, bulla,
metastatic CA,
Tbc,
Coccidiomycosis

44. Interstitial pattern
Nodular pattern
• round or irregular
opacities
• Diameter 1-9 mm.
Reticular or linear patter
• Fine linear or
netlike opacities
Reticulonodular pattern
• ผสมกันสองแบบ
• เจอบ่อยกว่าแบบเดี่ยวๆ

45. Nodular infiltration
DDx :
1. Miliary TB
2.fungal infection
3.Pneumoconiosis
4.sarcoidosis
Nodular infiltration
Both upper lung predominate
Dx. Miliary TB

46. Reticulonodular infiltration

47. Honeycombing appearance
• small cystic airspaces คล้ำยรังผึ้ง
• ถ้ำขนำดมำกกว่ำ 1 cm. และกระจำยตัวทั้งสองข้ำง พบในโรค cystic bronchiectasis

48. Pneumonia film
• Dense or patchy consolidation, usually unilateral
• Air bronchograms
• Lower lobe pneumonia is difficult to distinguish from
pleural effusion
• Specify lobe affected by ‘Silhouette sign’
Diaphragms: left and right lower lobes
Right heart border: right middle lobe
Left heart border: lingula (part of the left upper lobe)

50. Pneumonia Film
Lobar pneumonia
RUL
RML

51. Spherical/Round pneumonia
•Hemophilus influenzae
•Streptococcus
•Pneumococcus

52. Interstitial pneumonia
Viral pneumonia

53. Pneumothorax
Finding:
• Visible visceral
pleura line
• Absent distal
lung marking
• Tracheal shift
(tension)
• Collapse Rt/Lt
lung
บอกด้านด้วยเสมอ!!!
ออกบ่อย ถ้าดุแล้วเหมือนไม่มีอะไร
ให้ระลึกไว้เสมอ

55. Tension Pneumothorax

56. COPD
Finding:
1. Hyperinflated lungs/hyperairation
2. Tubular (tear drop,Hanging)
heart shape
3. Widened intercostal spaces
4. Flattened diaphragm

57. Pleural effusion
Finding:
• Blunt costophrenic angle
• If upright, homogenous
lower zone opacity with
curvilinear upper border
• If Fluid < 200 ml, it will be
not found in Frontal view.
Should do the lateral view

59. Congestive heart failure (CHF)
Signs of interstitial pulmonary edema (ระยะไม่รุนแรง)
1. พบ Septal lines ได้แก่ Kerly B line
2. Bronchial wall thickening
3. Pleural effusion
4. Fluid in fissure
Signs of alveolar pulmonary edema (ระยะรุนแรง)
1. Air spaces filling with or without air
bronchogram
2. Poorly defined margin
Four early reliable signs
Not Cardiomegaly,
Pulmonary vascular congest,
cephalization

60. Pulmonary edema finding
(ABCDEF)
•A: Alveolar and interstitial shadowing
•B: Kerley B lines (little white horizontal lines usually in the
lateral lower edges)
•C: Cardiomegaly (Cardiothoracic ratio of greater
than 50% on a PA X-ray)
•D: Upper lobe venous blood Diversion (prominent upper
lobe vasculature relative to the lower zones) ; cephalization
•E: Effusions
•F: Fluid in the horizontal fissure

62. Kerley B Lines.
interstitial pulmonary edema

63. interstitial pulmonary edema
Pleural effusion Fluid in the fissures

64. Peribronchial cuffing
- fluid in the walls of the bronchi produce numerous
“doughnut” densities

67. HEART disease

68. Normal anatomy

70. CARDIOMEGALY
CT ratio > 0.5 : Cardiomegaly
(or > 0.6 in newborn)
Cardiothoracic ratio = (R + L)/td
ระวัง!!
ต้องวัดออกมาจาก Spinous process จนถึง
Heart border ทั้งสองด้าน

71. Heart Anatomy in Film

72. Heart Border in Film

73. ถ้า LV โต Left heart border จะปักลงด้านล่างซ้าย

74. Pericardial effusion
• Flask-shape heart
• Hugh cardiomegaly
• Electricalalternans(EKG)

75. Mitral stenosis
Left atrium enlargement
• Double contour sign
• Widening of subcarinal angle >75
• Enlargement of LA appendage
Widening of
subcarinal angle
Enlargement of
LA appendage

76. Double contour sign

77. Mitral stenosis

78. Key Chest X-ray ที่ควรรู้
 Lobar pneumonia
 Atelectasis
 Pleural effusion
 Pulmonary TB
 Lung abscess
 Bronchiectasis
 Congestive heart failure
• Pneumothorax
• Pericardial
effusion
• Valvular heart
disease
ปล. การ Dx นั้น ต้องขึ้นกับ Setting+Clinical+PE ที่อยู่ในโจทย์เป็ นสาคัญ Film เป็ นตัว confirm เท่านั้น!!

80. Plain abdomen
film interpretation
บรรยาย : อ.นพ.ปฏิญญา ยุทธชาวิทย์

81. Technic and Quality
1. ชื่อ : “ฟิล์ม ของ นาย/นาง.........” (ตอนสอบจะโดนปิดเทปไว้)
2. ฟิล์ม ส่วนไหน : X-ray Plain abdomen
3. ท่าอะไร :Supine/Upright/(Lt/Rt)Lateral decubitus
4. Exposure : Good vs Over vs Under
5. Bowel-Gas pattern
(bowel gas, Extraluminal gas, Gas accumulate)
6. Soft tissue +- Mass
7. Abnormal Fluid & Calcification
8. Bone
9. Diagnosis
สิ่งที่ควรจะมีในการอ่าน Plain Film abdomen

82. Film-Density relate
Black : Air
Dark gray : Liquid
Light gray : Fat
White : Bone, Calcified
Bright-white : Metal

83. Abdominal structure and bowel gas
pattern
S
t

84. Abdominal structure and bowel gas
pattern

85. Bowel-Gas pattern
Bowel distension
1. Mechanical
- Small bowel
- Large bowel
2. Non-mechanical
3. Gas less

86. Mechanical small bowel obstruction
 Proximal dilatation
 Distal collapse
 Upright position shows air fluid levels with
different height in the same loop
 Step ladder pattern
 A bag of sausage
 String of bead sign

87. The small bowel is
disproportionately
dilated compared to the
large bowel
which is collapsed

88. Duodenal obstruction

89. Different height in the same loop Vs. Step ladder pattern

90. Different height in the same loop

91. Step ladder pattern

92. A bag of sausage

93. String - of - bead sign

94. Mechanical large bowel
obstruction
 Dilated colon to point of obstruction
 Little or no gas in rectum / sigmoid
 Little or no gas in small bowel if small if IC valve
remains competent
 Coffee bean sign – Sigmoid vulvulus

95. Left colonic obstruction from CA of splenic flexure

96. Coffee bean sign – Sigmoid vulvulus

97. Non-mechanical Bowel
distension
Adynamic/Generalize bowel ileus
• A bag of popcorn
• a less orderly arrangement
• Cause : Post-op, peritonitis, hypokalemia, sepsis
Localize ileus
• Appendictis : RLL bowel dilate +/- fecalith
• Pancretitis : Colon-Cut-Off sign

98. Appendicitis with Fecalith

99. A bag of popcorn

100. Colon-Cut-Off sign
จะพบว่ามีแต่ Transvere colon ที่ dilate กว่าปกติ

101. GasLess pattern
Bowel wall thickening
• Blood , Fluid , inflammatory cell infiltrate
• Thumb printing sign : Bowel ischemia

102. Bowel wall thickening

103. Thumb printing sign

104. Extraluminal Gas
1.Free air under dome
diaphragm
2.Falciform ligament sign
3.Hyperlucency sign of Liver
4.Double bowel wall
5.Foot ball sign
6.Triangular sign
7.Morison pouch sign
8.Invert V-sign
9.Urachus sign
Cause
1.Diverticulum perforate
2.Gut perforate
3.Post - operative

105. Pneumoperitoneum
• Free air under dome diaphragm

106. Falciform ligament sign

107. Hyperlucency sign of Liver

108. Rigler's/Double bowel wall
inner wall
outer
wall

109. Foot ball sign
A large volume of free gas has risen to the front of the
peritoneal cavity resulting in a large round black area -
'football sign

110. Triangle sign on supine and
lateral cross-table view.

111. Morison pouch sign

112. Urachus sign
the outlining of the middle
umbilicalligament

113. Intraperitoneal Fluid
• Centralized bowel loop : Mark ascites

114. Soft tissue / Mass
Splenomegaly

115. 1 hr ต่อมา
Bladder outlet obstruction – Pre and post cath

116. Mass in cologastric space
Pancretic pseudocyst

117. Right renal cyst

118. Calcification
Stone in Ureterocoele Staghorn calculi

119. Rim-like calcification
Renal cyst wall Gallbladder wall

120. Nephrocalcinosis
Jackstone calculus
associated with urinary stasis
or infection and are usually
calcium oxalate dihydrate
stones.

121. Calcific panceatitis
Chronic pancretitis
L1-L2 spine

122. Porcelain Gall bladder

123. Quiz time?!
Let’s see what remains…

124. 1
A 65 year old gentleman
presents with absolute
constipation (i.e. no
bowel motions or flatus
passed), nausea and
faeculent vomiting. There is
a preceding history of
increasing constipation over
the last month with blood
mixed in with the stool.
There has been 3 kg
unintentional weight loss
over the preceding 2
months. An abdominal X-
ray has been performed.

125. A 65 year old gentleman
presents with absolute
constipation (i.e. no
bowel motions or flatus
passed), nausea and
faeculent vomiting. There is
a preceding history of
increasing constipation over
the last month with blood
mixed in with the stool.
There has been 3 kg
unintentional weight loss
over the preceding 2
months. An abdominal X-
ray has been performed.
1 ต่อ

126. 2
An 85 year old woman
presents with abdominal
pain, distension and absolute
constipation. She has had a
previous stroke and is a
nursing home resident.
There has been a preceding
history of constipation. An
abdominal X-ray is
performed.

127. 3
A 52 year old man presents
with central abdominal pain,
nausea and vomiting. He
has not opened his bowels
for several days. He has had
similar episodes in the past.
As part of your assessment,
you request an abdominal X-
ray.

128. 4
A 40 year old man with
known ulcerative colitis
presents with severe
abdominal pain worse with
movement. There has been a
preceding history of
increasing frequency of
bloody diarrhoea and
pyrexia. An abdominal X-ray
has been performed.

129. 4 ต่อ
A 40 year old man with
known ulcerative colitis
presents with severe
abdominal pain worse with
movement. There has been a
preceding history of
increasing frequency of
bloody diarrhoea and
pyrexia. An abdominal X-ray
has been performed.

130. 5
A 35 year old man, who is
currently an in-patient on a
psychiatric ward, presents
with no bowel motions for
the past 5 days. He has a
background medical history
of depression and is
currently taking a tricyclic
antidepressant. An
abdominal X-ray is
performed as part of his
assessment.

131. 6
An 18 year old presents with
sudden onset right sided chest
pain and shortness of breath.
As part of his work up he
undergoes a chest X-ray.

132. 7
An 83 year old man presents
with shortness of breath and
weight loss. Clinical
examination reveals reduced
air entry in the right upper
zone. As part of his
assessment, he has a chest X-
ray performed.

133. 8
A 60 year old male patient
presents with with cough,
weight loss, and haematuria.
As part of his investigation, a
chest X-ray is performed.

134. 9
A 77 year old presents with
purulent cough, fever, and
shortness of breath. A chest
X-ray is performed.

135. 10
A 70 year old man presents
with chest pain, shortness of
breath, and cough productive
of pink, frothy sputum. He has
a past medical history
significant for hypertension
and diabetes, and he is a
lifelong smoker. You request a
chest X-ray as part of his
assessment.

136. 11
An unkempt 40 year old
woman presents to A&E with a
worsening cough and foul-
smelling, blood stained
sputum. She is feverish and
breathless. She has a
background of type 2 diabetes
and was recently diagnosed
with pneumonia. She says she
did not take her antibiotics as
they “didn’t agree with her”
and she failed to attend her
GP follow up appointments.
Below is her chest X-ray.

137. 12
A 45 year old woman presents
with right-sided pleuritic chest
pain and shortness of breath
to the medical assessment
unit. As part of her
assessment, you request a
chest X-ray.