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Check List(1)
1. 2.
o o o
Check patient data, position, technical quality and normal anatomy. Review systematically
Initial survey Review skeletal structures of shoulder girdles and chest wall Review mediastinum:
overall size and shape trachea: position margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic retrosternal clear space
Review hila:
normal relationships size
Check List(2)
o
Check List
1. Check patient data, position, technical quality and normal anatomy. Review systematically
o o o o o o Initial survey Review skeletal structures of shoulder girdles and chest wall Review mediastinum Review hila Review lungs and pleura Soft tissue including breast, companion shadow
2.
1. Data base
1. Name 2. Date - important for comparing prior exams
- Serial image
6. Technical quality
1
3
(erect)
Introduction
Serial image: Doubling time
Point of disease(location/size) Make diagnosis easily
Pneumonia Edema Tumor
Position
Chest x-ray
P-A view A-P A-P supine Lateral (Lt/Rt) Lateral decubitus (Lt/Rt) Lordotic Oblique(Rt/Lt; post/anterior)
Position
Speical position for special purpose
A-P supine: Ambulatory limit A-P Lateral (Lt/Rt): Anatomy reading Lateral decubitus: Effusion or thickening Lordotic: Apical lesion Oblique: Eliminate superimposed lesion
P-A view
Rt Lateral view
Technical quality
Ideal KV exposure
Key points
Apex Retrocardiac lung marking Trachea position Spine Scapula
You can't find a subtle pneumothorax if there is patient motion or the film is overexposed.
Technical quality
Ideal KV exposure 4 basic radiographic densities
Air Fat Water(soft tissue) Bone(metal)
Normal Anatomy
Anatomy & projection
General anatomy Lobar anatomy Segmental anatomy
Normal Anatomy
Anatomy & projection
General anatomy
Posterior process Rib(Ant/Post) Left 2/Right 4 Costothoracic ratio Central trachea Hilar: Lt>Rt Lung field: Central> Peripheral/ Peripheral clear zone Pleura: Linear Diaphragm: Right >left/ Angle/Gastric pattern Subcutaneous tissue
Normal Anatomy
5 8 4 9 11 10
13
6
12 7 16 14 1 2 16 15
Normal Anatomy
Anatomy & projection
General anatomy Lobar anatomy
Fissures
Def: Pleura surround by air 3 main(1 minor; 2 major) 3 accessory(Azygos; inferior & superior accessory) If fissure do not appear a thin line? - Ans: ?
Segmental anatomy
Normal Anatomy
Anatomy & projection
General anatomy Lobar anatomy
Fissures
Def: Pleura surround by air 3 main(1 minor; 2 major) 3 accessory(Azygos; inferior & superior accessory) If fissure do not appear a thin line - Pneumonia(Bulging) - Atelectasis (Deviation) - Pleural effusion (Pseudotumor)
Segmental anatomy
Lobar anatomy
5 3-4-5 3-4-6 6
3-4
Normal Anatomy
Anatomy & projection The sihouette sign
Define
Interface is invisible when two areas of similar radiodensity touch.
Position
Normal Anatomy
Anatomy & projection The sihouette sign
Define Location
Heart/Asending aorta Desending aorta/Diaphragm Airbronchogram Incomplete border
Normal Anatomy
Anatomy & projection
General anatomy Lobar anatomy Segmental anatomy
Rt: 1-10 Lt 1-10 (1+2, 7+8)
1 2 3 1 3 2
4 5
4 5
8 8 10
10
1+2
1+2 3 3
4
5
7 9 + 8 10
Check List
1. Check patient data, position, technical quality and normal anatomy. Review systematically
o o o o o o Initial survey Review skeletal structures of shoulder girdles and chest wall Review mediastinum Review hila Review lungs and pleura Soft tissue including breast, companion shadow
2.
Systematic review
A-B-C-D-E-F-G-H or Try interpret and understand what you see:
D.D. normal v.s. abnormal?
Systematic review
A-B-C-D-E-F-G-H
o o o o o o o o A: Airway B: Bone C: CV D: Diaphragm E: Extra-pulmonary F: Lung field G: Gastric bubble H: Hilum/Hernia
Systematic review
o o o o o o Initial survey Review skeletal structures of shoulder girdles and chest wall Review mediastinum Review hila Review lungs and pleura: Soft tissue including breast, companion shadow. .
Check List
1. Check patient data, position, technical quality and normal anatomy. Review systematically
o o o o o o Initial survey Review skeletal structures of shoulder girdles and chest wall Review mediastinum Review hila Review lungs and pleura Soft tissue including breast, companion shadow
2.
Initial survey
1. General Body Size, Shape, and Symmetry 2. Sex 3. Age(cartilage/aortic arch /asending aorta/Pulmonary trunk)
Infant/ child/ young adult/ elderly person
4. Foreign objects
tubes, IV lines, EKG leads, surgical drains, prosthesis non-medical objects, bullets, shrapnel, glass, etc
Check List
1. Check patient data, position, technical quality and normal anatomy. Review systematically
o o o o o o Initial survey Review skeletal structures of shoulder girdles and chest wall Review mediastinum Review hila Review lungs and pleura Soft tissue including breast, companion shadow
2.
Skeletal structures
Overall size, shape, contour of each bone.
Density( mineralization) Compare cortical thickness to medullary cavity, trabecular pattern, Erosions, fractures, any lytic or blastic regions. Articular relationships Joint spaces narrowed, widened Calcification in the cartilages Air in the joint space, abnormal fat pads
Joints
Trachea
position size
Cervical spine,
alignment note any major congenital abnormalities.
Thoracic spine
Specific parts(Each)
Vertebra Disc spaces
height integrity of cortical margins/pedicles/lamina presence of any lytic or sclerotic areas synovial joints(normal /narrowing /sclerosis spacing )
Thoracic spine
Ribs
1. Posterior Rib 2. Anterior Rib
Ribs
1. Posterior rib, 2.Ant rib
Compare
Side to side, Cortical margins, Trabecular patterns.
7 1 6 4
Check List
1. Check patient data, position, technical quality and normal anatomy. Review systematically
o o o o o o Initial survey Review skeletal structures of shoulder girdles and chest wall Review mediastinum Review hila Review lungs and pleura Soft tissue including breast, companion shadow
2.
Mediastinum
Define
Area between the lung Water density
Surrounded two air filled lungs and Intersected by the air filled trachea and major bronchi.
Key is knowledge of anatomical relationships and how structures project on a radiograph. CT and MRI is helpful. Interfaces of air-soft tissue margins may be distorted by pathological lesion
Masses otherwise
Mediastinum
Define
Area between the lung Water density
Surrounded two air filled lungs and Intersected by the air filled trachea and major bronchi.
Key is knowledge of anatomical relationships and how structures project on a radiograph. CT and MRI is helpful. Interfaces of air-soft tissue margins may be distorted by pathological lesion
Masses otherwise
MEDIASTINUM
Mediastinum
Define
Area between the lung Water density
Surrounded two air filled lungs and Intersected by the air filled trachea and major bronchi.
Key is knowledge of anatomical relationships and how structures project on a radiograph. CT and MRI is helpful. Interfaces of air-soft tissue margins may be distorted by pathological lesion
Masses otherwise
Anatomy
Project
MEDIASTINUM
Anatomy dividing region
SUPERIOR MEDIASTINUM
Begins - root of the neck and Ends - line drawn T-4 vertebrae --- sternomandible junction.
line skims the top of the aortic arch. T
Mediastinum
Begins - this line End- diaphragm Further divided into three regions
Anterior Middle Posterior.
4
1cm
Mediastinum
Overall size and shape Trachea: position Margins Lines and stripes Retrosternal clear space
Mediastinum
Margins
I II III
II
IV
Venography
1. Right Brachiocephalic Vein 2. Superior Vena Cava 3. Left Brachiocephalic Vein
4
1cm
Mediastinum
Overall size and shape Trachea: position Margins Lines and stripes
Paratracheal Paraspinal Paraesophageal (azygoesophageal) Paraaortic
Edge of Superior vena cave (SVC) Seen PA(AP) view only Often only a portion Never bulge into the lung with a convex border.
Medial margin -soft tissue interface /right mucosal surface of trachea. Outer margin -begins medial end of clavicle/formed by plural surface of right upper lobe (RUL). Normal structures in soft tissue density between air trachea and the RUL
Right wall of the trachea Nerves Fat Lymph nodes Pleura of the RUL.
Azygous vein - anteriorly to empty into the posterior surface of the SVC.
CT of Paratracheal stripe
1. Asending aorta 2. Azygous vein 3. Esophagus 4. Desending aorta 5. Pulmonary trunk
Paraspinal stripe
Sometimes(+) on the frontal view Plural edge parallel to the lateral margins of the vertebral bodies. Edge > millimeters beyond the vertebral bodies
Should not be lumpy or bulging.
On the forntal view only Formed by the right lower lobe & Mediastinum, containing
Esophagus Azygous vein.
MEDIASTINUM
Overall size/ shape on PA & lateral views
Decide if it is normal & age.
Look for
Obvious masses Calcifications Double check for foreign projects
Tubes Electrical leads Pacemaker Artificial valves
MEDIASTINUM
Evidence of
Mediastinal shift
Entire or Section of it.
Mediastinum
Define
Area between the lung Water density
Surrounded two air filled lungs and Intersected by the air filled trachea and major bronchi.
Key is knowledge of anatomical relationships and how structures project on a radiograph. CT and MRI is helpful. Interfaces of air-soft tissue margins may be distorted by pathological lesion
Masses otherwise
HEART
1 Edge of superior vena cava 2. Right atrium 3. Aortic arch 4. Edge of main pulmonary artery 5. Left atrial appendage 6. Left ventricle
Superimposed on the frontal view. The major structure is the heart. Pericardium and heart is inseparable on plain film views. Review the heart for overall size and shape. Rough yardstick - cardiac-thoracic ratio
Widest diameter of the heart /widest width of the thoracic cage( inner aspect of rib to rib). > 50%
Check
Calcifications Pneumopericardium Pneumomediastinum Sutures Prosthetic valves etc.,
You may have overlooked on the general survey of the entire mediastinum.
Aorta
Try tracking
Root Distal descending aorta.
Young adult - hidden in the mediastinum Older - swing to the right to cast a soft tissue bulge. Arch- always be seen
make sure left to distal trachea Pushes trachea slightly to the right actually .
Check aortic calcifications and size. Left lateral border of descending aorta
abuts the left lung (column of dots on the pt's. left, on the annotated image).
Pulmonary artery
1. Carina 2. Left Main Stem Bronchus 3. Descending Aorta 4. Main Pulmonary Artery 5. Aorticopulmonary Window 6. Arch of Aorta
Left pulmonary artery- branching of main pulmonary artery Right pulmonary artery Proximal- not seen, ( buried in the mediastinum) Branches can see ( as the right hilum)
Pulmonary artery
Right pulmonary artery
Ovoid branching structure- easily seen, Just anterior to the air column of the trachea and main bronchi.
MISCELLANEOUS
Lateral view
Adult
anterior mediastinum cephalad to the heart Lung-air density, not soft tissue density.
Check List
8. Review hila:
normal relationships size compare lung sizes evaluate pulmonary vascular pattern: compare upper to lower lobe, right to left, normal tapering to periphery pulmonary parenchyma pleural surfaces
fissures - major and minor - if seen compare hemidiaphragms follow pleura around rib cage
Pulmonary veins
Not clearly seen
they are behind the widest parts of the heart, inferior to the hila, where they converge into the left atrium.
Left pulmonary artery always more superior > right, left hilum higher. Calcified lymph nodes may be visible within the hilar shadows.
Check List
8. Review hila:
normal relationships size compare lung sizes evaluate pulmonary vascular pattern
compare upper to lower lobe, right to left, normal tapering to periphery
Lung size
Lung
Compare overall size of one lung bilateral, Also a double check on your earlier look at the rib cage size. Look for major areas of abnormal lucency/or density Train your eyes to look through the heart and upper abdomen to lung posterior to these areas.
PARENCHYMA
PARENCHYMA
Large abnormalities/small lesion
Masses Infiltrates calcifications
Compare- side to side at a time. Now ignore the bone but lung. 3 areas easily overlooked:
Behind the calcified anterior first rib cartilage, Behind the heart Behind the diaphragm
Pleura
PA view
Minor fissue thickness and location
Lateral view
minor fissures major fissures
(even if you do not see them in their entirety which you rarely will).
Soft tissues
1. Overall 2. Following
Calcifications Bony defect Soft tissue companion shadow for the clavicle
Supraclavicular LAP
BREAST TISSUE
Symmetry (Normal variation
Standing(PA view) + unequal pressure against the film holder)
ABDOMEN
Highly variable look for following
Gastric and bowel gas
Amount/ location( normal? )
Organ size
liver, spleen, kidneys
Final Notes
This completes an introduction into the beginnings of chest review. Be aware there are many more detailed observations to learn in the future. Go through the sections until you understand the anatomy, and then start practicing a continuous review looking at a full frontal and lateral view. When you have developed a review system that works for you (remember the order here is only a guide) go to the next section that has the check off list type of review. Many people find it helpful to talk their way through the film, the eye-brain-mouth loop does work. Finally look at films on a variety of normal people of all ages, sizes, and both sexes to develop a data base of normal references. Practice the review sequence that works best for you until it is automatic, and then you can concentrate on the diagnostic findings.
Check patient name, position, technical quality. Initial survey Soft tissue including breast, chest wall, companion shadow.
Review soft tissues and skeletal structures of shoulder girdles and chest wall. Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc. Review soft tissues and spine of neck. Review spine and rib cage: check alignment, disc space narrowing, lytic or blastic regions, etc.
4.
Review mediastinum:
overall size and shape trachea: position margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic retrosternal clear space