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  1. 1. 20 Important Xrays Neil Dominic Fernandes 080201054
  2. 2. • First look at the mediastinal contours—run your eye down the left side of the patient and then up the right.• The trachea should be central.• The aortic arch is the first structure on the left, followed by the left pulmonary artery; notice how you can trace the pulmonary artery branches fanning out through the lung• Two thirds of the heart lies on the left side of the chest, with one third on the right. The heart should take up no more than half of the thoracic cavity.• The left border of the heart is made up by the left atrium and left ventricle.• The right border is made up by the right atrium alone. Above the right heart border lies the edge of the superior vena cava.• The pulmonary arteries and main bronchi arise at the left and right hila. Enlarged lymph nodes can also occur here, as can primary tumours. These make the hilum seem bulky.• Now look at the lungs.• Apart from the pulmonary vessels (arteries and veins),they should be black (because they are full of air).• Scan both lungs, starting at the apices and working down, comparing left with right at the same level. The lungs extend behind the heart, so look here too. Force your eye to look at the periphery of the lungs—you should not see many lung markings here; if you do then there may be disease of the air spaces or interstitium.• Don’t forget to look for a pneumothorax.• Make sure you can see the surface of the hemidiaphragms curving downwards, and that the costophrenic and cardiophrenic angles are not blunted—suggesting an effusion.• Check there is no free air under the hemidiaphragm
  3. 3. The Normal Cardiac Borders in the PA View: A) The left cardiac border is formed from above down by: 1. The aortic arch (= knob, knuckle). 2. The main pulmonary artery. 3. The left atrial appendage. 4. The left ventricle. B) The right border of the heart is formed by: 1. In the lower two thirds by the right atrium. 2. In the upper third by the superior vena cava.
  4. 4. How to read• This is a chest radiograph of a young male patient PA view.• The patient has taken a good inspiration and is not rotated; the film is well penetrated.• The trachea is central, the mediastinum is not displaced.• The mediastinal contours and hila seem normal.• The lungs seem clear, with no pneumothorax.• There is no free air under the diaphragm.• The bones and soft tissues seem normal
  5. 5. Pneumocystis jirovecii Pneumonia
  6. 6. Miliary TB
  7. 7. Canon Ball
  8. 8. Aneurysm
  9. 9. Right upper lobe collapse
  10. 10. Features to look for Present features1. Opacification Dense opacification of the right upper zone, V shaped2. Horizontal fissure Has been displaced upwards from its original position3. Hilum enlarged or elevated Right hilum is elevated than left hilum4.Smaller lung, smaller hemithorax Not present5. Compensatory hyperinflation and Presenthyperlucency in other lobes6. Tracheal deviation Absent7. Elevated ipsilateral hemidiaphragm Present
  11. 11. Bronchial carcinoma
  12. 12. air crescent signFungal ball - aspergilloma
  13. 13. Bronchiectasis
  14. 14. CHEST X-RAYS SITI ZAHIDA (O80201057)
  15. 15. Pneumothrax
  16. 16. Pneumothorax  Increased volume of the right hemithorax with tracheal shift to the OPPOSITE side- ”PUSH” effect  Hyperlucency on the right side  Absence of lung markings  Presence of margin of collapsed lung at the hilum  D/D:Unilateral emphysema
  17. 17. Hydropneumothorax
  18. 18. Hydropneumothorax  Horizontal fluid level with hyperlucent area above it  Hyperlucent area with no lung markings  Presence of air+fluid = Hydropneumothorax  Trachea shifted to the SAME side-”PULL “ effect  D/D:lung abscess
  19. 19. Lung Abscess
  20. 20. Lung abscess  Loculated cavity with thin wall(maybe post infective cyst, wall made up of a fibrous tissue)  Presence of air fluid level  Mild trachea shift to the left(probably due to rotation)  Fundic air bubbles separately seen
  21. 21. Lung abscess VSHydropneumothoraxFeature Lung Abscess HydropneumothoraxDefinition Intrapulmonary air- Intrapleural air- fluid collection fluid collectionShape of fluid Round, take up the Take up shape of the shape of cavity wall thoracic cavity & margin of collapsed lungCavity Wall Clearly seen Not seenMargin of collapsed Not seen May be seenlungLength of air-fluid Equal regardless of Length varies withlevel radiographic radiographic projection projection
  22. 22. Pleural Effusion
  23. 23. Pleural effusion  Homogenous opacity of right middle & lower zone = almost totally WHITE OUT LUNG  Minimal tracheal shift to the left  Cardiac shift to the opposite side with reduced left hemithorax size.  Obliteration of right costophrenic & cardiophrenic angles  D/D:consolidation, pleural thickening(heterogenous opacity), collapse.
  24. 24. Chest X-Ray Siti Hawa 080201059
  25. 25. 1
  26. 26. • Cardiothoracic ratio more than 50%.
  27. 27. • Long diameter : – From junction of SVC and right atrium to apex of heart. – Normal : 10.0- 15.5cm.
  28. 28. • Left ventricular enlargement : – Rounding of the apex. – Obtuse angle. – Apex shifted inferiorly and outward.
  29. 29. 2
  30. 30. • Double aortic knuckle.• 3 sign at left margin of the aorta at the level of coarctation. Coarctation of Aorta.
  31. 31. Coarctation of Aorta.• Rib notching: – Due to pressure from tortuous intercostal arteries acting as collaterals. – Becomes evident after the age of 8 years.• Cardiomegaly.
  32. 32. 3
  33. 33. • Dilated right pulmonary artery.• Right ventricular enlargement : – Acute angle. – Apex shifted outward.• Prominent upper lobe veins. [Cephalization] Mitral Valve Disease.
  34. 34. • A: – Straightening of left cardiac border. – Notching at left cardiac border.• B: – Double atrial shadow. – LA shadow seen through the heart inside its right border.
  35. 35. CHEST X-RAY NOR FAZEHAN 080201061
  36. 36. Pulmonary Edema Bat wings/butterfly distribution Pleural effusion
  37. 37. Pulmonary Edema• Produces air space opacities with variable distribution.• Sparing of the apices and extreme lung bases.• “Butterfly” or “Bat wings” distribution – central lungs affected more.• With progression – opacities coalesce to form a “white-out” on chest radiograph.• Blurring of blood vessels occurs.• Air bronchogram – indicating intra alveolar edema.
  38. 38. Sequence of events on CXR in acute pulmonary edema. Early changes. Late changes. 1. Prominent pulmonary artery. 7. Fluffy shadows. 2. Prominent pulmonary lobe 8. Air bronchogram. veins. 3. Interlobar fissure. 9. Bat’s wing appearance. 4. Perivascular cuffing. 10. Cardiomegaly . 5. Peribronchial cuffing. 11. Pleural effusion. 6. Kerley B lines.
  39. 39. Differences..Criteria. Cardiogenic (LVH) Non cardiogenic(ARDS)1. Cardiomegaly . Comman +++ Uncomman+2. Alveolar edema. +++ +++3. Appearance of Bat’s wing /butterfly More patchy shadow . appearance4. Perivascular and More often seen Less likely peribronchial cuffing.5. Tendency for Yes No gravitational distribution.6. Pleural effusion. May be present Unlikely
  40. 40. Silhouette Sign• On the radiograph, loss of normal border of the heart, aorta, or diaphragm by intrathoracic lesions known as silhouette sign. Silhouete signs seen as Intrathoracic lesions Upper right heart Anterior segment of RUL border/ascending aorta Right heart border RML (medial) Upper left heart border Anterior segment of LUL Left heart border Lingula (anterior) Apical portion of LUL Aortic knob (posterior) Anterior hemidiaphragms Lower lobes (anterior)
  41. 41. Free Gas Under Diaphragm
  42. 42. Hiatal Hernia. 67 years old patient complained of chronic cough and mild heartburn with no other symptoms.