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X-RAY

INTERPRETATION

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X- RAYS
Definition: They are a Form of Ionizing Radiation That Can Penetrate the Body to
Form an Image On Film.

Types of Chest X- Ray:


* Plain X-Ray (Without Contrast)
* Contrast X-Ray (With Contrast).
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 CHEST X- RAY 
It is the Most Common X-Ray Used in Medicine Field.
It Can Help Us to Diagnose Many Respiratory and Cardiovascular Problems.

 View of Chest X- Ray:


1- Postero-Anterior View (P-A View):
It Means Source of Radiation From Behind of Patient, and the Film From Front.
This View is the Most Common View Used in Chest X-Ray.
and Done For the Patient Who Can Walk and Stand.

2- Antero-Posterior View (A-P View):


It Means Source of Radiation From Front of Patient, and the Film From Behind.
This View Done For the Patient Who Can’t Walk OR Stand OR Patient with Coma
OR in ICU OR Emergency Patients.
This View Show Us False Cardiomegaly.

3- Lateral View:
It Means Source of Radiation From Side of Patient, and the Film From Other Side.

How to Differentiate Between P-A View and A-P View:

P-A Chest X-Ray: A-P Chest X-Ray:


1. The Clavicles Appears Like V- Shape. 1. The Clavicles Appears Horizontal Shape.
2. The Scapula Appears in the Periphery of the 2. The Scapula Appears in the Center of the
Chest. Chest.

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 Detection of Right and Left Lung of Chest X- Ray:

Left Lung Characters: Right Lung Characters:

1. Presence of Aortic Knuckle. Normally the Base of Right Lung is Elevated


2. Presence of Apex (Left Ventricle) of the Heart. More than Left Lung; Because of Right Dome
3. Presence of Gases of the Stomach. Diaphragm is Higher than Left Dome of
Diaphragm.

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 Centralization of Chest X- Ray:

Well Centralized Chest X-Ray: Not Centralized Chest X-Ray:

Means Distance From Vertebral Spine to Medial Also Called  Rotated Chest X Ray.
End of Right Clavicle is Equal to Distance From Means Distance From Vertebral Spine to Medial
Vertebral Spine to Medial End of Left Clavicle. End of Right Clavicle is Not Equal to Distance
From Vertebral Spine to Medial End of Left
Clavicle.

 Quality of Chest X- Ray:

Poor Exposure: Vertebral Spines Behind the Heart Can NOT Be Seen.
Good Exposure: Vertebral Spines Behind the Heart Slightly Seen.
Over Exposure: Vertebral Spines Behind the Heart Clear and Visible.

 Intensity of Chest X- Ray:

*Air: Appear  Black.


*Soft Tissue: Appear  Gray.
*Fluid and Bone: Appear  White.

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 Degree of Inspiration of Chest X- Ray:

Full Inspiration.
Usually Chest X Ray Taken During
Number of Anterior Ribs in X-Ray During Full Inspiration are  6 Ribs.
& Number of Posterior Ribs in X-Ray During Full Inspiration are  10 Ribs

So;
If You Count 6 Anterior Ribs; That Means Chest X-Ray Taken In Full Inspiration.
If You Less than 6 Anterior Ribs; That Means X-Ray Not Take In Full Inspiration.
If You More than 6 Anterior Ribs; That Means Hyper-Inflated Chest X-Ray.

Note:
Chest X-Ray Can Be Taken During Expiration in Case of:
1. Small Pneumonia.
2. Foreign Body Aspiration.

 Zones of Lung in Chest X- Ray:

Upper Zone: Above 2nd Anterior Rib.


Middle Zone: Between 2nd and 4th Anterior Rib.
Lower Zone: Below 4th Anterior Rib.

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
Features of Normal Chest X-Ray:

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Abnormalities of Chest X-Ray:

 Abnormalities of Pleura:
1. Pleural Effusion:Pathological Accumulation of Fluid in Pleural Space (>50ml)
In Chest X Ray Characterized By:-
1. Obliteration of Costo-Phrenic Angle.
2. Homogenous Opacity.
3. Crescent Shape of Lower Border (Meniscus Sign).

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 Massive Pleural Effusion:
1. Homogenous Opacity All Over the Hemi-Thorax (White Lung).
2. Deviation of Mediastinum to the Opposite Side.

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2. Pneumothorax: Accumulation of Air in Pleural Space.

In Chest X Ray Characterized By:-


1. Jet Black Lung Field (Loss of Lung Marking).
2. Lung is Deflated (Collapsed Lung).

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 Tension Pneumothorax:
1. Jet Black Lung Field All Over The Hemi-Thorax.
2. Shifting of Mediastinum to the Opposite Side.

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3. Hydro-Pneumothorax: Could Be Pyo-Pneumothorax (Air + Pus) OR
Heamo-Pneumothorax (Air + Blood).

In Chest X Ray Characterized By:-


Air Fluid Level of Lung Field (Upper Half  Black & Lower Half  White).

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 Abnormalities of Lung Tissue (Lung Parenchyma):
1. Hyper-Inflated Chest: Commonly Presented with COPD Patients.
In Chest X Ray Characterized By:-
1. More Darkness of Lung. 2. Number of Anterior Ribs More than 6 Ribs.
3. Horizontal Anterior Ribs. 4. Wide Inter-Costal Space.
5. Tubular Shape Heart. 6. Flat Diaphragm.

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2. Lung Cavity: Could Be Complete Black Cavity OR Air Fluid Level Cavity.

Complete Black Cavity: Air Fluid Level Cavity:

In Chest X Ray Characterized By:- In Chest X Ray Characterized By:-


Single, Black, Rounded OR Oval Lesion Surrounded Single, Rounded OR Oval Lesion with Black Upper
By White Wall. Half & White Lower Half, Surrounded By
White Wall.

Differential Diagnosis of Complete Black Cavity: Differential Diagnosis of Air Fluid Level Cavity:
1. Pulmonary TB. 1. Lung Abscess (Regular Wall).
2. Broncogenic Carcinoma (Squamous Cell Type). 2. Rupture Hydatid Cyst.
3. Chronic Abscess. 3. Cavitatory Carcinoma.
4. Wegener’s Granulomatosis (Multiple Cavitation). 4. Aspergilloma.
5. Emphysematous Bullae (Multiple Cavitation
Small & Surrounded By Thin Wall).

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3. Lung Mass (>3cm): Could Be Single Mass OR Multiple Masses.

Single Lung Mass: Multiple Lung Masses:

In Chest X Ray Characterized By:- In Chest X Ray Characterized By:-


Single, White to Gray, Rounded OR Oval Lesion. Multiple, White to Gray, Rounded OR Oval Lesion.

Differential Diagnosis of Single Lung Mass: Differential Diagnosis of Multiple Lung Masses:
1. Bronchogenic Carcinoma (Irregular Border). 1. Secondary Lung Metastasis OR Cannon Ball
2. Single Lung Metastasis. (From Renal Cell Carcinoma, Testicular Carcinoma,
3. Hydatid Cyst (Regular Border). Choriocarcinoma).
4. Lymphoma. 2. Septic Emboli.
5. Aspergilloma. 3. Wegener’s Granulomatosis.
6. Others: Hamartoma, Lipoma. 4. Caplan’s Syndrome of Rheumatoid Arthritis.

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4. Reticulo-Nodular Shadow (Lung Nodules <3cm):
Indicate Pulmonary Fibrosis.

In Chest X Ray Characterized By:-


Multiple, White to Gray, Small, Nodules with Reticular Infiltration Starting From
Periphery Up to Center of the Lung.

Differential Diagnosis of Reticulo-Nodular Shadow:


1. Idiopathic Pulmonary Fibrosis (IPF) Most Common 50% (Apical Lung Fibrosis).
2. Silicosis (Apical Lung Fibrosis).
3. Asbestosis (Basal Lung Fibrosis).
4. Sarcoidosis.
5. Connective Tissue Diseases (Rheumatoid Arthritis, SLE).

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Note:

 Miliary TB in X-Ray Characterized By Formation of Multiple, White to Gray, Very Small,


Tiny Nodules (Millimeters in Size).

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5. Reticular Shadow (Trabecular Shadow): Indicate Pulmonary Edema.

In Chest X Ray Characterized By:-


Reticular Infiltration Starting From Center to Periphery of Lung;
Characterized By  ABCD:
A  Alveolar Edema (Butterfly Edema OR Bath Swing Sign).
B  B- Line Due to Interstitial Edema (Reticular Infiltration).
C  Cardiomegaly.
D  Dilated Upper Lobe Vessels.

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 Abnormalities of Trachea & Mediastinum:
1. Deviation of Trachea & Mediastinum: Could Be Pushed OR Pulled;

Pushed Trachea & Mediastinum:


Deviation to the Opposite Side.

Causes:
1. Massive Pleural Effusion.
2. Tension Pneumothorax.

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Pulled Trachea & Mediastnum:
Deviation to the Same Side.

Causes:
1. Lung Collapse.
2. Post Pneumonectomy.

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2. Widening of Mediastinum:

Differential Diagnosis of Wide Mediastinum:


1. Para Tracheal Lymphadenopathy ( Due to; Pulmonary TB, Lymphoma, CA Lung).
2. Aortic Aneurysm. 3. Retro-Sternal Goiter.
4. Achalesia. 5. Thymoma.

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 Abnormalities of Hilum:
1. Enlargement of Hilar Shadow:

Normally the Hilum Lies Between 2nd & 4th Rib,


It Contains: Lymph Nodes, Bronchus, and Blood Vessels.

Differential Diagnosis of Enlarged Hilar Shadow:


1. Pulmonary Sarcoidosis.
2. Lymphoma.
3. Cancer Lung (Bronchogenic Carcinoma).
4. Pulmonary TB.
5. Mycoplasma Pneumonia.

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 Abnormalities of Cardiac Shadow:
1. Cardiomegaly: Measured From P-A View Chest X Ray.
Cardiomegaly Detected in Chest X Ray By Cardio-Thoracic Ratio.

Cardio-Thoracic Ratio  Cardiac Shadow Less than 50% of Thoracic Diameter.


In Case of Cardiomegaly; Cardiac Shadow More than 50% of Thoracic Diameter.

2. Flask Shape Heart: Indicate Pericardial Effusion.

3. Tubular Shape Heart: Indicate COPD.

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 Abnormalities of Diaphragm:
1. Elevation of Diaphragm Dome: Indicate  Phrenic Nerve Palsy, Lung
Collapse, Pneumonectomy OR Lower Lobectomy, Hepatomegaly, Splenomegaly.

2. Air Under Diaphragm: Indicate  Perforated Viscous


(Ex  Perforated Peptic Ulcer).


Differential Diagnosis of Differential Diagnosis of
Homogenous Opacity of the Lung: Hometrogenous Opacity of the Lung:

1. Pleural Effusion. 1. Interstitial Lung Disease.


2. Lung Collpase. 2. Pulmonary Edema.
3. Lobar Pneumonia. 3. Broncho Pneumonia

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How to Read X-Ray Film:
1. Check From  Name, Age, Date.

2. Make Sure If the X-Ray was  Plain OR with Contrast

3. Make Sure From View of X-Ray  P-A View OR A-P View.


 P-A View (Postero-Antero View) (Common View)  Clavicles Appears V- Shape.
 A-P View (Antero-Postero View)  Clavicles Appears Horizontal Shape.

4. Make Sure If the X-Ray was  Well Centralized OR NOT.


Distance From Vertebral Spine to Medial End of Right Clavicle is Equal to
Distance From Vertebral Spine to Medial End of Left Clavicle.

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5. Check From  Quality of X-Ray.
 Poor Exposure: Vertebral Spines Behind the Heart Can NOT Be Seen.
 Good Exposure: Vertebral Spines Behind the Heart Slightly Seen.

6. Now Look For Any Abnormalities in  Pleural Space:

 Look For Any  Obliteration of Costo-Phrenic Angle;


Obliteration of Costo-Phrenic Angle, Homogenous Opacity, Crescent Shape
Lower Border (Meniscus Sign) Indicate  Pleural Effusion.

Pleural
Effusion

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Note:
Obliteration of Costo-Phrenic Angle + Homogenous Opacity All Over the Hemi-Thorax with
Deviation of Mediastinum to the Opposite Side Indicate  Massive Pleural Effusion.

 Look For Any  Jet Black Lung Field;


Jet Black Lung Field with Collapsed Lung Indicate  Pneumothorax.

Pneumothorax

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Note:
Jet Black Lung Field All Over the Hemi-Thorax with Shifting of Mediastinum to the Opposite Side
Indicate  Tension Pneumothorax.

 Look For Any  Air Fluid Lung Field;


Air Fluid Level of Lung Field (Upper Half  Air & Lower Half  Fluid) Indicate
 Hydro-Pneumothorax (Heamo-Pneumothorax OR Pyo-Pneumothorax).

Hydro-
Pneumothorax

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7. Now Look For Any Abnormalities in  Lung Tissue
(Lung Parenchyma Abnormalities):

 Look For Any  Hyper-Inflated Chest;


More Darkness of Lung, Number of Anterior Ribs More than 6 Ribs, Horizontal
Anterior Ribs with Wide Inter-Costal Space, Tubular Heart & Flat Diaphragm
Indicate  Obstructive Airway Disease (Mainly COPD).

Hyper-Inflated Chest:

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 Look For Any  Lung Cavity;
Could Be Complete Black Cavity OR Air Fluid Cavity;

If Complete Black Cavity Indicate  Pulmonary TB, Squamous Cell


Type of Bronchogenic Carcinoma, Chronic Abscess.
If Air Fluid Level Cavity Indicate  Lung Abscess, Cavitatory
Carcinoma, Rupture Hydatid Cyst, Aspergilloma.

Complete Black Cavity:

Air Fluid Level Cavity:

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 Look For Any  Lung Mass;
Could Be Single OR Multiple;

If Single Mass Indicate  Bronchogenic Carcinoma, Single Lung


Metastasis, Hydatid Cyst, Aspergilloma.
If Multiple Masses Indicate  Secondary Lung Metastasis, Septic
Emboli, Wegener’s Granulomatosis.

Single Lung Mass:

Multiple Lung Masses (Cannon Ball):

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 Look For Any  Reticulo-Nodular Shadow;
Multiple, White to Gray, Small, Nodules with Reticular Infiltration Starting
From Periphery Up to Center of the Lung Indicate  Pulmonary Fibrosis.

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 Look For Any  Reticular Shadow (Trabecular Shadow);
Reticular Infiltration Starting From Center Up to Periphery of the Lung
Indicate  Pulmonary Edema.
*Pulmonary Edema* Characterized By:
A  Alveolar Edema (Butterfly Edema OR Bath Swing Sign).
B  B- Line Due to Interstitial Edema (Reticular Infiltration).
C  Cardiomegaly.
D  Dilated Upper Lobe Vessels.

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8. Now Look For Any Abnormalities in  Mediastinum:

 Look For Any  Widening of Mediastinum;


IndicatePara Tracheal Lymphadenopathy (Pulmonary TB, Lymphoma, CA Lung),
Aortic Aneurysm, Retro-Sternal Goiter, Achalesia, Thymoma.

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9. Now Look For Any Abnormalities in  Hilum:

 Look For Any  Enlargement of Hilar Shadow;


Indicate  Pulmonary Sarcoidosis, Lymphoma, Bronchogenic
Carcinoma (CA Lung), Pulmonary TB, Mycoplasma Pneumonia.

Note:
Normally the Hilum Lies Between 2nd & 4th Rib,
It Contains: Lymph Nodes, Bronchus, and Blood Vessels.

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10. Now Look For Any Abnormalities in  Cardiac Shadow:

 Look For Any  Cardiomegaly;

Cardiac Shadow More than 50% of Thoracic Diameter.

 Look For Any  Flask Shape Heart;


Indicate  Pericardial Effusion.

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11. Now Look For Any Abnormalities in  Diaphragm:

 Look For Any  Elevation of Diaphragm Dome;


Indicate  Phrenic Nerve Palsy, Lung Collapse, Pneumonectomy
OR Lower Lobectomy, Hepatomegaly, Splenomegaly.

 Look For Any  Air Under Diaphragm;


Indicate  Perforated Viscous (Ex  Perforated Peptic Ulcer).

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