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Basic CXR Interpretation_Diagnostic Radiography

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Basic CXR Interpretation_Diagnostic Radiography

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Basic CXR Interpretation_Diagnostic Radiography

  1. 1. Diagnostic Radiographs Basic CXR Interpretation Marc Imhotep Cray, M.D.
  2. 2.  Review of normal chest x-ray  Administrative  Initial survey Introduction 2
  3. 3. Review of normal chest x-ray A systematic approach to film review is most important skill to develop major areas of should be viewed in a sequential order 3
  4. 4. 1. 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 chest wall 4. Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc. 5. Review soft tissues and spine of neck Review of Normal CXR (2) Sequenced Checklist: 4
  5. 5. 5 6. Review spine and rib cage: check alignment, disc space narrowing, lytic or blastic 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 CXR (3) Sequenced Checklist:
  6. 6. 8. Review hila: a. normal relationships b. size 9. Review lungs and pleura: a. compare lung sizes b. evaluate pulmonary vascular pattern: compare upper to lower lobe, right to left, normal tapering to periphery c. pulmonary parenchyma d. pleural surfaces • fissures - major and minor - if seen • compare hemidiaphragms • follow pleura around rib cage 6 Review of Normal CXR (4) Sequenced Checklist:
  7. 7. Administrative Get in habit of always checking following items before anything else takes a few seconds and is an important legal safe guard as well 1. Patient's name 2. Date exam done (very important if comparing prior exams) 3. Check for position markers - right vs. left, upright 7
  8. 8. Other items to check before commencing w clinical review of film include: 1.Type of film (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 acceptable limits for exam Ex. You can't find a subtle pneumothorax if there is patient motion or the film is overexposed. Administrative (2) 8
  9. 9.  A basic principle to adopt  going from general observations to specific details  sometimes a change may be so major that old saying “missing the forest for the trees” comes true o For instance, an absent breast shadow on a film of a patient after a mastectomy  After completing your administrative housekeeping, get a general overview of film before zooming in on tiny detail Administrative (3) 9
  10. 10. 10  Notice following b/c may change baseline normals you use as reference points, and you may be sensitized to look for specific findings 1.General Body Size, Shape, and Symmetry 2.Male vs. Female 3.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. Administrative (4)
  11. 11. The Chest X-Ray Following radiographic plates are scan-ins from: Felson, B., et al.: Principles of Chest Roentgenology. Philadelphia, W.B. Saunders Co., 1973. Fraser, R., et al.: Diagnosis of Diseases of the Chest, 3rd edition. Philadelphia, W.B. Saunders Co., 1988. 11
  12. 12. Discussion Outline •Densities •Techniques •Anatomy •CXR Interpretation •Common Pathologies 12
  13. 13. Densities The big two densities are: (1) WHITE - Bone (2) BLACK - Air The others are: (3) DARK GREY- Fat (4) GREY- Soft tissue/water And if anything Man-made is on film, it is: (5) BRIGHT WHITE – Man made 13
  14. 14. Techniques - Projection P-A (relation of x-ray beam to patient) 14
  15. 15. Techniques – Projection cont’d. Lateral 15
  16. 16. Techniques - Projection cont’d. Lateral Decubitus 16
  17. 17. 17 Assessment  Assess quality of film using mnemonic PIER:  Position: Is this a supine AP film? PA? Lateral?  Inspiration: Count posterior ribs. You should see 8–9 ribs with a good inspiratory effort  Exposure: Well-exposed films have good lung detail and show a detailed outline of spinal column. Overpenetration leads to a dark film with more spinal detail. Underpenetrated films are whiter with little spinal detail.  Rotation: Space between medial clavicle and margin of adjacent vertebrae should be roughly equal on each side.  Also look for indwelling lines or objects (eg, endotracheal tube, feeding tube, airway obstruction) that may reveal clues to pathology in film “The A-B-C-D Sequence”
  18. 18. Penetration (Exposure) 18 OverpenetratedUnderpenetrated
  19. 19. Inspiration/Expiration 19
  20. 20. Rotation 20
  21. 21. Rotation cont’d. 21
  22. 22. Anatomy 22
  23. 23. Anatomy 23
  24. 24. Anatomy 24
  25. 25. Lobes Right upper lobe: 25
  26. 26. Lobes cont’d. Right middle lobe: 26
  27. 27. Lobes cont’d. Right lower lobe: 27
  28. 28. Lobes cont’d. Left lower lobe: 28
  29. 29. Lobes cont’d. Left upper lobe with Lingula: 29
  30. 30. Lobes cont’d. Lingula: 30
  31. 31. Lobes cont’d. Left upper lobe - upper division: 31
  32. 32. Heart Right border: Edge of (r) Atrium 2. Left border: (l) Ventricle + Atrium 3. Posterior border: Left Ventricle 4. Anterior border: Right Ventricle 32
  33. 33. Heart cont’d 33
  34. 34. Heart cont’d. Valves 34
  35. 35. Mediastinum 35
  36. 36. Hilum Made of: 1. Pulmonary Art. + Veins 2. The Bronchi Left Hilus higher (max 1-2, 5 cm) Identical: size, shape, density 36
  37. 37. Ribs 37
  38. 38. Lateral CXR 38
  39. 39. Lateral CXR cont’d. Tracheoesophageal Stripe 39
  40. 40. Lateral CXR cont’d. 40
  41. 41. CXR Interpretation 41
  42. 42. Technical Details • Type • Orientation • Rotation • Inspiration/expiration • Penetration 42 To be studied along side Reading Chest X-Ray Notes.pdf (“The A-B-C-D Sequence”)
  43. 43. Lungs: •Lungs • Density • Symmetry • Lesions 43
  44. 44. Heart Size: 44
  45. 45. 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 45
  46. 46. Mediastinum: • Width • Contour • AP window • Size • Location 46
  47. 47. Review areas: • Apices • Behind the heart • CP angles • Below diaphragm • Soft tissues ( breast, surgical emphysema) • Ribs & clavicle • Vertebrae 47
  48. 48. Identify the lesion → localize lesion → describe lesion → give a DDx Never stop looking, carry on w your systematic approach!! 48
  49. 49. Pathology 49 Following radiographic plates are scan-ins from: Felson, B., et al.: Principles of Chest Roentgenology. Philadelphia, W.B. Saunders Co., 1973. Fraser, R., et al.: Diagnosis of Diseases of the Chest, 3rd edition. Philadelphia, W.B. Saunders Co., 1988.
  50. 50. RUL pneumonia 50
  51. 51. RML pneumonia 51
  52. 52. RLL pneumonia 52
  53. 53. LUL pneumonia 53
  54. 54. LLL pneumonia 54
  55. 55. • Consolidation on CT 55
  56. 56. Hilar mass 56
  57. 57. The Enlarged Hila • Causes: 1. Adenopathies (neoplasia, infection) 2. Primary Tumor 3. Vascular 4. Sarcoidosis 57
  58. 58. • Multiple Masses 58
  59. 59. Hilar Lymphadenopathy - BL 59
  60. 60. 60Hilar Lymphadenopathy - BL
  61. 61. Pleural Effusion 61
  62. 62. Pulmonary Fibrosis 62
  63. 63. Heart failure 63
  64. 64. Pneumothorax 64
  65. 65. RUL collapse 65
  66. 66. LLL collapse 66
  67. 67. Air under diaphragm 67
  68. 68. Emphysema 68
  69. 69. Cavitating lesion 69
  70. 70. Hiatus hernia 70
  71. 71. Miliary shadowing 71
  72. 72. Chest Tube, NG Tube, Pulm. artery cath. 72
  73. 73. 73See next slide for links to tools and resources for further study.
  74. 74. 74 IVMS CXR Video Education Cloud folder Reading Chest X-Ray Notes.pdf (“The A-B-C-D Sequence”) eBook Eng P, Cheah KF. Interpreting Chest X-Rays: 100 Illustrated Cases. Cambridge: Cambridge University, 2005. Radiology Online Study Resources: RadiologyEducation.com, curated by Michael P. D'Alessandro, M.D. http://www.radiologyeducation.com/ Further study:

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