X-Ray Rounds Plain Chest Radiographs Garry W. K. Ho, M.D. VCU / Fairfax Family Practice July 13,...
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Transcript of X-Ray Rounds Plain Chest Radiographs Garry W. K. Ho, M.D. VCU / Fairfax Family Practice July 13,...
X-Ray RoundsX-Ray RoundsPlain Chest RadiographsPlain Chest Radiographs
Garry W. K. Ho, M.D.Garry W. K. Ho, M.D.
VCU / Fairfax Family PracticeVCU / Fairfax Family Practice
July 13, 2005July 13, 2005
The 12-Step ProgramThe 12-Step Program
11: : NameName22: : DateDate33: Old films: Old films
44: What type of : What type of view(s)view(s)55: Penetration: Penetration66: Inspiration: Inspiration77: Rotation: Rotation88: Angulation: Angulation99: Soft tissues / bony structures: Soft tissues / bony structures1010: Mediastinum: Mediastinum1111: Diaphragms: Diaphragms1212: Lung Fields: Lung Fields
Quality Control
Findings
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Pre-ReadingPre-Reading
11. . Check the nameCheck the name
22. . Check the dateCheck the date
33. . Obtain old films if availableObtain old films if available
44. Which . Which view(s)view(s) do you have? do you have?– PA / AP, lateral, decubitus, AP lordoticPA / AP, lateral, decubitus, AP lordotic
Quality ControlQuality Control
55. . PenetrationPenetration
– Should see ribs Should see ribs through the heartthrough the heart
– Barely see the spine Barely see the spine through the heartthrough the heart
– Should see pulmonary Should see pulmonary vessels nearly to the vessels nearly to the edges of the lungsedges of the lungs
Overpenetrated Film
• Lung fields darker than normal—may obscure subtle pathologies
• See spine well beyond the diaphragms
• Inadequate lung detail
Underpenetrated Film•Hemidiaphragms are obscured
•Pulmonary markings more prominent than they actually are
Quality ControlQuality Control
66. . InspirationInspiration
– Should be able to Should be able to count 9-10 posterior count 9-10 posterior ribsribs
– Heart shadow should Heart shadow should not be hidden by the not be hidden by the diaphragmdiaphragm
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9-10 posterior ribs are showing
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About 8 posterior ribs are showing
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Poor inspiration can Poor inspiration can crowd lung crowd lung
markings producing markings producing pseudo-airspace pseudo-airspace
diseasedisease
With better inspiration, the “disease process” at the lung bases has cleared
Quality ControlQuality Control
77. . RotationRotation
– Medial ends of Medial ends of bilateral clavicles are bilateral clavicles are equidistant from the equidistant from the midline or vertebral midline or vertebral bodiesbodies
If spinous process appears closer to the right clavicle (red arrow), the patient is rotated toward their own left side
If spinous process appears closer to the left clavicle (red arrow), the patient is rotated toward their own right side
Quality ControlQuality Control
8.8. AngulationAngulation
– Clavicle should lay Clavicle should lay over 3over 3rdrd rib rib
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Pitfall Due to AngulationPitfall Due to Angulation
A film which is apical lordotic (beam is angled up toward A film which is apical lordotic (beam is angled up toward head) will have an unusually shaped heart and the usually head) will have an unusually shaped heart and the usually
sharp border of the left hemidiaphragm will be absentsharp border of the left hemidiaphragm will be absent
Apical lordotic Same patient, not lordotic
FindingsFindings
99. . Soft tissue and Soft tissue and bony structuresbony structures– Check for Check for
SymmetrySymmetry
DeformitiesDeformities
FracturesFractures
MassesMasses
CalcificationsCalcifications
Lytic lesionsLytic lesions
FindingsFindings
1010. . MediastinumMediastinum
– Check for Check for CardiomegalyCardiomegaly
Mediastinal and Mediastinal and Hilar contours for Hilar contours for increase increase densities or densities or deformitiesdeformities
FindingsFindings
1111. . DiaphragmsDiaphragms
– Check sharpness of Check sharpness of bordersborders
– Right is normally Right is normally higher than lefthigher than left
– Check for free air, Check for free air, gastric bubble, pleural gastric bubble, pleural effusionseffusions
FindingsFindings
1212. . The Lung Fields!The Lung Fields!– To help you determine To help you determine
abnormalities and their abnormalities and their location…location…
Use silhouettes of other Use silhouettes of other thoracic structuresthoracic structures
Use fissuresUse fissures
Lung Fields: Using Structures / Lung Fields: Using Structures / SilhouettesSilhouettes
Silhouette / Structure Contact with Lung
Upper right heart border/ascending aorta
Anterior segment of RUL
Right heart border RML (medial)
Upper left heart border Anterior segment of LUL
Left heart border Lingula (anterior)
Aortic knobApical portion of LUL
(posterior)
Anterior hemidiaphragms Lower lobes (anterior)
Lung Fields: Using Structures / Lung Fields: Using Structures / SilhouettesSilhouettes
Upper right heart border / ascending aorta (anterior RUL)
Right heart border(medial RML)
Anterior hemidiaphragms(anterior lower lobes)
Upper left heart border(anterior LUL)
Left heart border(lingula; anterior)
Aortic knob(Apical portion of LUL )
Lung Fields: FissuresLung Fields: Fissures
The fissures can also help you to The fissures can also help you to determine the boundaries of pathologydetermine the boundaries of pathology
Major Oblique FissureSeparates the LUL from the
LLL
Right Major FissureSeparates the RUL/RML from
the RLL
Right Minor FissureSeparates the RUL from the
RML
Now for the Cases…Now for the Cases…
Remember… be systematic!Remember… be systematic!
PA view: RML consolidation and loss of right heart silhouette
Lateral View: RML wedge shaped consolidation
RML pneumonia
RUL infiltrate / consolidation, bordered by minor fissure inferiorly
Patchy LLL infiltrate that obscures the left hemidiaphragm; right and left heart borders obscured
RUL and LLL pneumonia
Underpenetrated; possible nonspecific obscuring of left heart border; mostly normal
Multiple bilateral cavitary lesions with air-fluid levels c/w pulmonary abscesses
Tuberculosis
28 y/o female with sudden onset SOB while jogging this morning
Well demarcated paucity of pulmonary vascular markings in right apex
Left spontaneous pneumothorax
RML consolidation that appears wedge shaped on lateral view
RML pneumonia
RLL infiltrate / consolidation
RLL pneumonia
Increased vascular markings; otherwise normal
Patient BIBA to ER s/p airplane crash.
Widened mediastinum
Concern for aortic injury
Explain the prominence of the right atrium on this AP radiograph
Patient rotated to their right (left shoulder forward)
Dilatation of the main pulmonary artery with decreased peripheral vascular
markings
?? Pulmonary embolism ??
Obscuring of the right and left heart borders; infiltrate at the bases
Bilateral aspiration pneumonia
Diffuse bilateral fluffy interstitial infiltrates
Pneumocystis carinii pneumonia
LUL pneumonia
Severe pulmonary TB
Left lung opacity
Later diagnosed as lung cancer
Cardiomegaly, increased pulmonary vascular markings, fluid in the horizontal fissure
CHF
Kerley B Lines
Short (1 -2 cm) white lines at the lung bases, perpendicular to the pleural surface representing distended interlobular septa
What do the arrows indicate?
The 12-Step ProgramThe 12-Step Program
11: Name: Name22: Date: Date33: Old films: Old films
44: What type of : What type of view(s)view(s)55: Penetration: Penetration66: Inspiration: Inspiration77: Rotation: Rotation88: Angulation: Angulation99: Soft tissues / bony structures: Soft tissues / bony structures1010: Mediastinum: Mediastinum1111: Diaphragms: Diaphragms1212: Lung Fields: Lung Fields
Quality Control
Findings
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The EndThe End
Questions?Questions?