Dr Ng's CXR workshop Part A

1. CHEST RADIOGRAPHS, A REVISION OF THE FUNDAMENTALS
A WAYANG KULIT Dr Ng Kian Seng
Part One MBBS (Singapore) MCGP (Malaysia)
Second Edition Master Of Medicine (Internal Medicine, Singapore)
February 2012 FAFP (Malaysia) Cert In Occupational Medicine
Ph D (Theology, USA)

2. Hippocrates of Cos, Father of Medicine
ANATOMY IN THE CHEST RADIOGRAPH

3. A Normal Chest Radiograph
Some examiners like you to call x ray films ‘Radiographs’; strictly
speaking you can’t actually see the x rays themselves.

4. Anatomy in the
Chest Radiograph
The right main bronchus is slightly larger than the left & comes
off at a less acute angle than the left (hence septic material &
foreign substances are more likely to be inhaled into the right
lung than into the left).

5. Chest Radiograph,
PA View, No 1
Apex Of Carina
Trachea
Lung
Right para-tracheal stripe
Aortic arch
Main
Pulmonary
Artery
Left Atrial
appendage
Descending
thoracic
aorta
Left
ventricle
Gastric Air Bubble

6. Chest Radiograph,
PA View, No 2
Right upper
lobe pulmonary
vein
Horizontal
fissure
Right hilum
Right lower
lobe pulmonary
artery
Right atrium
Right Right
Costophrenic Cardiophrenic
Angle Angle

7. Chest Radiograph,
PA View, No 3
Spinous Process
Scapula
Anterior Rib
Clavicle
Posterior Rib
Right Main Bronchus
Left Main Bronchus
Breast Diaphragm
Lung Tissue Soft Tissue
Retrocardiac
Superimposed Vertebra
On diaphragm

8. Anatomy Of the Heart In The Chest Radiograph

9. MEDIASTINAL SILHOUETTE IN
MIDDLE AGE & THE ELDERLY

10. Aorto-pulmonary Window
Aorto-pulmonary window. The aorto-pulmonary window lies between
the arch of the aorta and the pulmonary arteries. It contains the ligamentum
arteriosum, the recurrent laryngeal nerve, lymph nodes, and fatty tissue.

11. RIGHT PARA-TRACHEAL STRIPE
From the level of the clavicles to the azygous vein the right edge of the trachea is seen
as a thin white stripe. This appearance is created by air of low density (blacker) lying
either side of the comparatively dense (whiter) tracheal wall. If this stripe is thickened
(normally less than 5 mm) this may represent pathology such as a paratracheal mass or
enlarged lymph node. The left side of the trachea is not so well defined because
of the position of the aortic arch and great vessels.

12. Anatomy
in the
Lateral
Chest
X-ray
1. Ascending thoracic
Aorta
2. Sternum
3. Right ventricle
4. Left ventricle
5. Left atrium
6. Gastric air bubble
7. Right Hemidiaphragm
8. Left Hemidiaphragm
9. Right upper lobe
bronchus
10. Left upper lobe
bronchus
11. Trachea.

13. Anatomy
in the
Lateral
Chest
X-ray
In the lateral CXR, you will see the Right Hemidiaphragm in its entirety
But where the Left Hemidiaphragm is concerned, you can only see a
part of it because anteriorly it “merges” with the inferior border of the heart.

14. NAME THE STRUCTURES
IN THE LATERAL CHEST X-RAY
1.Trachea
2. Aortopulmonary
window
3. Sternum
4. Right ventricle
5. Right Hemidiaphragm
6. Left Hemidiaphragm
7. Left atrium
8. Scapula
9. Right Upper
9
Lobe Bronchus
10. Left upper 10
Lobe Bronchus

15. THE MEDIASTINUM
The mediastinum
is divided by
a plane passing from the
sternal angle to T4-T5 into:
Superior mediastinum and
The inferior mediastinum
The inferior mediastinum is
further subdivided into
three regions namely:
Anterior mediastinum
Middle mediastinum
Posterior mediastinum
These divisions are for
descriptive purposes, they
merge into each other
imperceptibly. There are
no distinct boundaries
between them.

16. ZONES OF THE CHEST RADIOGRAPH
Apex to a line drawn through
UPPER the lower borders of the
ZONE anterior ends of the 2nd costal
cartilage.
From the 1st line to one drawn
MIDDLE through the lower borders of the
ZONE 4th costal cartilage & includes
the Hila of the lungs
From the 2nd line to the
LOWER bases of the lungs.
ZONE

17. THE FISSURES OF THE LUNGS
Oblique Fissure From 4 th Dorsal spine sweeping down
obliquely to the 6th rib in mid mammary line or the 6th
costochondral junction, anteriorly.
Horizontal Fissure. From the 4th costo chondral junction
to meet Oblique Fissure at the mid axillary line.

18. THE LOBES & FISSURES OF THE LUNGS
Base of the Lung: 6th costochondral junction,
obliquely to the 10th rib in Anterior Axillary Line,
then horizontally to 12th thoracic vertebra

19. OBLIQUE FISSURE , HORIZONTAL FISSURE
Oblique Fissure : From 4th Dorsal spine sweeping down
obliquely to the 6th rib in mid mammary
line or the 6th Costochondral junction, anteriorly.
Horizontal Fissure. Runs from the 4th costochondral
junction to meet Oblique Fissure at the mid axillary line.

20. THE RIGHT & LEFT OBLIQUE FISSURES
From 4th dorsal spine sweeping down
obliquely to the 6th rib in mid
mammary line or the 6th
costochondral junction, anteriorly.

21. THE HORIZONTAL FISSURE
Horizontal Fissure. Runs from the 4th costochondral junction
to meet Oblique Fissure at the Mid Axillary Line.

22. WHAT IS THE ABNORMALITY HERE?

23. ACESSORY FISSURE, THE AZYGOS FISSURE
The azygos lobe appears starting in a teardrop shape at around the
level of T5 to the right of the midline as a pale line curving outward .
and upward and then back in to meet the root of the neck, the line
is the infolding of the pleura. Also described as a “curvilinear opacity,
Inverted comma, tadpole.”

24. Hippocrates of Cos, Father of Medicine
THE BLACK & WHITE RADIOLOGICAL TERMS

25. RADIODENSITY SCALE
Radiodensity : Physical quality of an object that determines how much
radiation it absorbs from the X-Ray beam. Radiodensity is determined
by composition ( atomic weight) and thickness
radioLucent = bLack radiopaquE = whitE

26. RADIODENSITY SCALE
“WHITE IMAGES” “BLACK IMAGES”
The greater the density, the lesser The lesser the density, the greater
the penetration of the X-Rays the penetration of the X-Rays
through the object. through the object
The film remains less exposed The film is more exposed
White Image Black Image
Term used : Radiodense Term Used : Radiolucent
Or Radiopaque
Term Density Appearance Example
Radiolucent Low Black Air, Fat
Radiodense High White Bone, Barium
(Opaque)

27. RADIODENSE VERSUS RADIOLUCENT
RADIOLUCENT
RADIODENSE
RADIOPAQUE

28. Collage, Shanghai Girls Series By Ng Kian Seng
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