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ADMINISTRATIVE
1. Patient's name. 2. Date exam done (very important if comparing prior exams). 3. Check for position markers - right vs. left, upright.
1. Type of film (plain CXR CT, angio, MRI, etc.) 2. Patients position - supine, upright, top lordotic, lateral, decubitus. 3. Technical quality of exam (over / under Exposed) 4. Inspiration Maximal Optimal minimal 5. Focusing Vibration Motion Cut View 6. Learn what are the acceptable limits for the exam. You can't find a subtle pneumothorax if there is patient motion or the film is overexposed.
INITIAL SURVEY
1. General Body Size, Shape, and Symmetry 2. Male vs. Female 3. Is this an infant, child, young adult, elderly person? 4. Survey for foreign objects - tubes, IV lines, EKG leads, surgical drains, prosthesis, etc., as well as non-medical objects, necklace, button, watch, bangles, metal, bullets, shrapnel, glass, etc.
Evaluation
Trachea: Mediastinum Hillus Cor Diaphragm Costophrenic angel Lung Parenchyma and Pleura Bone and Soft Tissue Other: Corpus Alienum, Artefact
Trachea
In mid line of body Deviation; Size: stricture, dilatation Compress by tumor
SUPERIOR MEDIASTINUM
First, check the overall width for normal size, again look for masses, calcifications, and free air. The rest of the superior mediastinum review is a detailed search for subtle distortion of several major plural mediastinal interfaces. Not all of the following structures are seen on every film, but try to find them.
Hillus
Hillar Enlargement Left Hillar slightly higher than Right One Hillar mediastinal enlargement
Lung
Bronchovascular patern normal - bifurcatio Nodular Recticular - Alveolar Infiltrate Cavity Fibrotic Calcification Air Bronchogram - Bronchiectasis Nodul: soliter, multiple, uni-bilateral Kerley A, B, C line
Pleura
The costophrenic angles laterally should be sharp. The lung should abut right up against the inner margins of the rib cage. If the pleural space is widened by fluid or mass, the lung will be pushed away by soft tissue density. Also check for pleural calcifications, and presence of pneumothorax.
Soft Tissue
Fat structure Emphysema Subcutis Breast and Nipples (female)
Ribs
Compare individual ribs side to side, check specific parts, cortical margins, trabecular patterns. Make a note if the anterior cartilages are calcified, frequently the first one does so irregularly and may obscure or mimic underlying lung lesions. 1. - Posterior Rib 2. - Anterior Rib
Others
Corpus alienum: coin, pin, bone Stent of Lung Button Necklace Catheter: CVC, Double Lumen Cath, Pace Maker, Chemoport, Susuk
Sample One
Hyperinflation Hyperlucency Low set flat diaphragm Vertical heart Pre and infracardiac lungs Barrel shape Emphysema Avascular zones Bleb walls
Summary
Identification Trachea: Mediastinum Hillus Cor Diaphragm Costophrenic angel Lung Parenchyma and Pleura Bone and Soft Tissue Other: Corpus Alienum, Artefact
Check List
1. Check patient name, position, technical quality. 2. Soft tissue including breast, chest wall, companion shadow. 3. Review soft tissues and skeletal structures of shoulder girdles and chest wall. 4. Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc.
1. Review soft tissues and spine of neck. 2. Review spine and rib cage: check alignment, disc space narrowing, lytic or blastic regions, etc. 3. Review mediastinum: A. overall size and shape B. trachea: position C. margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle D. lines and stripes: paratracheal, paraspinal,
1. A. B. C.
Review mediastinum: overall size and shape trachea: position margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle D. lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic E. retrosternal clear space
1. Review lungs and pleura: A. compare lung sizes B. evaluate pulmonary vascular pattern: compare upper to lower lobe, right to left, normal tapering to periphery C. pulmonary parenchyma D. pleural surfaces a. fissures - major and minor - if seen b. compare hemidiaphragms c. follow pleura around rib cage
http://rad.usuhs.mil/rad/chest_review/in dex.html