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Chest Radiograph for Interns

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Reported by Cristal Ann Laquindanum
Chest Radiograph for Interns
TMC Radiology Department

Published in: Health & Medicine
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Chest Radiograph for Interns

  1. 1. Chest Radiograph <br />For Interns <br />Reported by: Cristal Ann G. Laquindanum<br /> ASMPH Class of 2012<br />
  2. 2. References<br />Brant and Helm’s<br />Paul and Juhls<br />Learningradiology.com<br />Clinical Radiology Made Ridiculously Simple<br />School lectures<br />
  3. 3. Outline<br />Normal Chest Radiograph – adult and pediatric<br />Requirement for chest xray film<br />Anatomy<br />Common pathologies – pleural effusion, pneumothorax, pneumonia, PTB<br />
  4. 4. BACKTO*radiology*BASICS<br />
  5. 5. More dense = More Xrays = WHITER / radioopaque<br />Less dense = Less Xrays = BLACKER / radiolucent<br />
  6. 6. Is it good enough? <br />Recognizing a TECHNICALLY ADEQUATE chest radiograph<br />
  7. 7. Penetration <br />Inspiration<br />Rotation<br />Magnification<br />Angulation<br />Factors to Evaluate: <br />
  8. 8. Penetration<br />You should be able to see the thoracic spine through the heart <br />
  9. 9. Underpenetration<br />> Left hemidiaphragm may not be visible on the frontal film; left lung base may appear opaque<br />> Pulmonary markings may appear more prominent<br />Overpenetration<br />> Lung markings may seem decreased or absent<br />
  10. 10. Inspiration<br />
  11. 11. Rotation<br />If the spinous process of the vertebral body is equidistant from the medial ends of each clavicle, there is NO rotation<br />
  12. 12. If the spinous process appears closer to the right clavicle (redarrow), the patient is rotated toward their own left side<br />If the spinous process appears closer to the left clavicle (redarrow), the patient is rotated toward their own right side<br />
  13. 13. Severe rotation may make the pulmonary arteries appear larger on the side farther from the film<br />
  14. 14. Magnification<br />vs<br />PA <br />AP <br />
  15. 15. AP <br />AP vs PA <br />
  16. 16. PA <br />AP vs PA <br />
  17. 17. Angulation<br />If the x-ray beam is angled toward the head (mostly because the patient is semi-recumbent), the film so obtained is called an “apical lordotic” view <br />
  18. 18. Clavicles<br />Unusually shaped heart<br />
  19. 19. Penetration see spine through the heart<br />Inspiration at least 8-9 posterior ribs<br />Rotation spinous process between clavicles<br />Magnification AP films will slightly magnify the heart<br />Angulation clavicle over 3rd rib<br />Factors to Evaluate: <br />
  20. 20. How to read a Chest Xray:<br /> Basics<br /> Technically Adequate<br />☐ Anatomy<br />
  21. 21.
  22. 22.
  23. 23. Trachea<br />Upper Lobes<br />Aortic knob<br />Left <br />Pulmonary Artery<br />Right<br />Atrium<br />Left <br />Ventricle<br />Lower Lobes<br />
  24. 24.
  25. 25. Trachea<br />Upper Lobes<br />Aortic knob<br />Carina<br />Left <br />Pulmonary Artery<br />Right<br />Atrium<br />Left <br />Ventricle<br />Lower Lobes<br />Costophrenic Angle<br />Gastric bubble<br />
  26. 26. Upper lobes<br />Right<br />middle lobe<br />Lower lobes<br />Lingula<br />
  27. 27. RADIOLOGY<br />
  28. 28. Airway (trachea)<br />Bones (clavicles, ribs)<br />Cardiomediastinalsilhoutte<br />Diaphragms (and the costophrenic angles) <br />Everything Else (lung fields, soft tissues, tubes, lines, wires, devices, etc)<br />
  29. 29. Airway (trachea)<br />
  30. 30.
  31. 31. Bones (clavicles, ribs)<br />
  32. 32.
  33. 33. Cardiomediastinalsilhoutte<br />
  34. 34. Cardiomediastinalsilhoutte<br />
  35. 35. Diaphragms (and the costophrenic angles) <br />
  36. 36. Diaphragms (and the costophrenic angles) <br />
  37. 37. Everything Else (lung fields, soft tissues, tubes, lines, wires, devices, etc)<br />
  38. 38.
  39. 39. Lungs more radiolucent<br />Thymus is often large,<br />Widening of superior mediastinum<br />Ribs angulate downward<br />Heart is globular and large<br />Left ventricle more prominent with age<br />Diaphragm is higher<br />Left > Right<br />
  40. 40. Pathologies<br />Pleural effusion<br />Atelectasis<br />Pneumothorax<br />Pneumonia<br />Pulmonary Tuberculosis<br />
  41. 41. Pleural Effusion<br />complete opacification of the right mid and lower zones is due to fluid in the pleural cavity<br />meniscus sign - concavity of the fluid level due to surface tension with the pleura<br />Blunting of costophrenic angle may be due to a small pleural effusion or focal pleural thickening.<br />May coexist with pneumothorax or entrapped within fissures mimicking a tumor.<br />Right pleural effusion in a patient with nephrotic syndrome<br />The flattened and laterally displaced curvature of the right hemidiaphragm indicates presence of subpulmonic pleural fluid<br />
  42. 42. Pleural Effusion<br />Patient cannot stand? <br />lateral decubitus<br />Ultrasound or CT thorax as alternative modalities for early detection of small pleural effusion. <br />Ultrasound advantage: no radiation; can be used to guide drainage<br />CT advantage: evaluate the underlying lung and mediastinal structures to identify the cause of the effusion<br />
  43. 43. Pneumothorax<br />Pneumothorax represents abnormal air accumulation within pleural cavity. This may be due to trauma (accidental or iatrogenic), underlying pulmonary disease (e.g. asthma) or idiopathic in origin<br />Erect chest radiograph in full expiration is diagnostic in majority of cases<br />If the patient is unable to stand erect, lateral decubitus view may be helpful<br />
  44. 44. Pneumothorax<br />Radiologic Findings:<br />Contralateral mediastinalshift<br />Depression of ipsilateralhemi-diaphragm<br />Compressive atelectasis of adjacent normal lung<br />presence of significant increased intrathoracic pressure<br />Role of imaging in patients with pneumothorax:<br />1. Confirm the clinical diagnosis<br />2. Assess extent of pneumothorax <br />3. Detect signs of tension<br />4. Follow-up examination to monitor resolution of pneumothorax after drainage<br />
  45. 45. The right lung (white open arrows) has been pushed medially. The mediastinum is shifted to the left (black arrow). This appearance is typical of tension pneumothorax.<br /> Magnified view of a PA chest radiograph of a right pneumothorax. The visceral pleura (arrow heads) is seen as a thin white line. <br />
  46. 46. Pneumonia<br />Role of imaging in patients with pneumonia<br />1. Confirm the clinical diagnosis<br />2. Detect possible complications such as pleural effusion / empyema or lung abscess if clinically not responsive to appropriate antibiotic treatment<br />3. Follow-up CXR to monitor response to treatment <br />may take 4-6 weeks for consolidative changes to resolve<br />Radiologic improvement usually lags behind clinical improvement<br />If radiologic signs still present after adequate treatment, underlying predisposing factors have to be excluded (e.g. central obstructive carcinoma in elderly patients)<br />
  47. 47. Pneumonia<br /><ul><li>Air bronchogram sign- The inflammatory exudate within air-spaces and interstitium of the affected lung causes the opacification and air-filled bronchioles outlined by adjacent fluid-filled alveoli in affected lung
  48. 48. Visualization of air in the intrapulmonary bronchi
  49. 49. Abnormal
  50. 50. Denotes a pulmonary lesion/consolidation (excludes a pleural or mediastinal lesion)
  51. 51. Seen in pneumonia, pulmonary edema or pulmonary infarct </li></ul>Silhouette <br />sign<br />
  52. 52. Pneumonia<br />Pneumonia caused by certain organisms may produce characteristic radiologic features<br />Unilateral lobar involvement in streptococcus infection<br />Bilateral patchy involvement sometimes with cavitation in staphylococcus pneumonia<br />Upper lobe involvement with cavitation in pulmonary TB<br />Bilateral symmetrical perihilar distribution which progresses rapidly over 3-5 days in PCP pneumonia in immunocompromised patients<br />
  53. 53. Bilateral patchy involvement sometimes with cavitation in staphylococcus pneumonia<br />
  54. 54.
  55. 55. Upper lobe involvement with cavitation in pulmonary TB<br />
  56. 56. Bilateral symmetrical perihilar distributionPCP pneumonia in immunocompromisedpatients<br />
  57. 57. Pulmonary Tuberculosis<br />Radiologic Findings in PTB<br />Cavitation and air-fluid level- the opacity represents caseous necrosis in tuberculosis<br />Enlarged hilum– representinggranulomatous inflammation of lymph nodes, usually in primary TB<br />Fibrocalcificchanges in lung apex usually representing healing of previous TB infection<br />Multi-focal air-space opacities representing bronchogenic spread of infection<br />Tiny miliary nodules in both lungs representing miliary TB due to haematogenous spread of infection<br />
  58. 58.
  59. 59.
  60. 60. CASE PRESENTATION<br />
  61. 61. AM, 5year old female <br />CC: fever and cough<br />HPI: 6 days PTC – on and off fever (Tmax 39) + headache<br />3 days PTC – abdominal pain, consult done and was given Cefaclor and Ventolin expectorant<br />Morning PTC – symptoms persisted, one episode of post-tussive vomiting, decreased appetite  admission<br />HISTORY<br />
  62. 62. PAST MEDICAL HISTORY<br />TMC – Dengue and UTI – Oct 2010<br />VRMC – Pneumonia 2006<br />BIRTH HISTORY<br />Born full term via NSD to a 30 year old G2P2 (2002) <br />no fetomaternal complications<br />VACCINATION HISTORY<br />Only BCG, DPT, HepB, MMR x1, no HiB<br />
  63. 63. NUTRITIONAL HISTORY<br />Breastfed until 2 months, on milk formula until 15 months<br />Weaning at months, food preference fish<br />FAMILY HISTORY <br />unremarkable<br />
  64. 64. BP 90/60 , RR 30 , HR 118 , Temp 39.5 <br />Harsh breath sounds, equal chest expansion, rales R>L, no wheezes, no alar flaring, no retractions<br />Hyperactive bowel sounds, epigastric tenderness<br />Tachycardic, normal rhythm<br />PHYSICAL EXAMINATION<br />
  65. 65. PCAP C <br />IMPRESSION <br />
  66. 66. CBC - normal<br />Chest Xray (PA/Lat)<br />DIAGNOSTICS<br />
  67. 67. Patches of hazed densities are noted in the right middle lobe, bordered superiorly by the minor fissure. <br />Hazy densities are likewise seen in the posterior segment of the right lower lobe. <br />The pulmonary vascular pattern is within normal.<br />Cardiac shadow is normal in size and configuration.<br />The retrosternal and retrocardiac spaces are intact.<br />The diaphragm, costophrenic sulci, and the bony thorax are unremarkable.<br />Consider Pneumonia with beginning consolidation, right<br />
  68. 68. Patches of hazed densities are noted in the right middle lobe, bordered superiorly by the minor fissure. <br />Hazy densities are likewise seen in the posterior segment of the right lower lobe. <br />The pulmonary vascular pattern is within normal.<br />Cardiac shadow is normal in size and configuration.<br />The retrosternal and retrocardiac spaces are intact.<br />The diaphragm, costophrenic sulci, and the bony thorax are unremarkable.<br />Consider Pneumonia with beginning consolidation, right<br />
  69. 69. Admitted<br />VS q4<br />DAT<br />Monitor I&O<br />D5Nm 1 L x 69-70 cc/hr (M+10)<br />Paracetamol 250mg/5mL q4<br />Amoxicillin 250mg/5mL at 40mkd<br />Currently on 3rd hospital stay<br />MANAGEMENT<br />
  70. 70. That’s all Folks! <br />

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