13. How to Look at a CXR Flashcards
There is a risk of ionising radiation used in X-Rays causing what 2 things?
Roughly what is the equivalent period of natural background radiation to the following X-ray exams:
a) Chest, limbs, teeth
b) Skull, head
c) Breast, hip, abdomen, pelvis, head CT
d) Barium meal/enema, abdo/chest CT
Label A-G of this L lung.
Cancer and genetic defects.
a) Few days
b) Few weeks
c) Few months to a year
d) Few years
A) L brachiocephalic vein
B) Aortic arch
C) Bronchus
D) Oesophagus
E) Thoracic aorta
F) Pulmonary artery
G) Pulmonary veins
Label A-G in this R lung mediastinal aspect.
A) R pulmonary arteries
B) R superior lobar bronchus
C) R bronchial artery
D) R superior pulmonary veins
E) Intermediate bronchus
F) Bronchopulmonary lymph nodes
G) R inferior pulmonary veins
How do X-rays work and what are the 4 broad densities?
Briefly, what sytem should you follow when looking at an X-ray?
Ionising radiation. Darkenss of film reflects exposure to X-rays. Absorption of X-rays in object means less reaches film -> light part of image. Densities: 1) Air - no absorption, black. 2) Fat - little absorption, dark. 3) Water/soft tissue - more absorption, mid grey. 4) Bone/Ca - white.
Patient details, date/time, PA (most common) or AP (mediastinum larger, performed on wards). CRISP = coverage, rotation (spinous processes straight, mid-way between medial head of clavicles), inspiration (7 anterior ribs), skill, penetration (vertebrae just visible behind heart). Image interpretation: Airways (inc. trachea position), Breathing (compare L and R lung densities), Circulation (heart size - CTR ≤0.5, aortic knuckle), Diaphragm, Everything else.
What is A (the red line) showing on this normal CXR?
L carotid, SCA
What are the red lines A and B showing on these normal CXRs?
A) aortic knuckle (shadow of aortic arch)
B) Main pulmonary artery (round, atop carina)
What are the red lines A and B showing on these normal CXRs?
A) L atrial appendage
B) L ventricle
What are the red lines A and B showing on these normal CXRs?
A) SVC
B) Ascending aorta
What are the red lines A and B showing on these normal CXRs?
A) R atrium
B) IVC
What are the red lines A showing in this normal CXR?
What are the ‘review areas’ to look at when analysing a CXR?
What is the lingula?
What air space changes on a CXR may indicate pneumonia?
Hila/hilar point. Always a little higher on LHS. Veins cross over lower lobe arteries, should be cavities - if bulging = LN at hilum?
Sternoclavicular. Heart. Diaphragm. Lung borders. Ribs. Look for masses.
Combined term for the 2 lingular bronchopulmonary segments of the left upper lobe: superior lingular segment and inferior lingular segment (pic).
Consolidation - increased density (whiteness), silhouette sign = loss of normal outlines. Air bronchograms (air-filled bronchi (dark) made visible by the opacification of surrounding alveoli (grey/white)).
What can you see on this CXR?
L upper lobe consolidation. ‘Upper lobe’ b/c can’t see L heart border (lower lobe is behind diaphragm)
What can you see on this CXR?
L upper lobe collapse. Loss of volume b/c tract pulled L, main bronchus pulled up and ribs crowded. (Pic - L upper lobe collapse lateral view. Compensatory hyperinflation of lower lobe)
What can you see on this CXR?
R upper lobe consolidation with collapse. Horizonal fissure moved upwards. Air bronchogram - air in bronchioles surrounded by fluid/pus etc. so can see contrast (pic).
What can you see on this CXR?
R upper lobe collapse with hilar mass. Trachea pulled R.
What can you see on this CXR?
L lower lobe collapse. Hard to see b/c goes down behind heart. Hilum missing. Triangular density “sail sign”.
What can you see on this CXR?
L lower lobe collapse. L pic - something behind heart b/c can’t see diaphragm through midline. R pic - lower lobe collapsed = hyperinflation of lower lobe.
What can you see on this CXR?
L lower lobe consolidation. E.g. pus filling up air space. Can’t see L hemidiaphragm so has to be LLL.
What can you see on this CXR?
L lower lobe consolidation. Air bronchograms.
What can you see on this CXR?
R middle lobe consolidation.
What can you see in these 2 CXRs?
Miliary TB: widespread dissemination of Mycobacterium tuberculosis via hematogenous spread. Classic miliary TB is defined as milletlike (mean, 2 mm; range, 1-5 mm) seeding of TB bacilli in the lung.
Can see enlarged LN in upper R mediastium. Lots of ill-defined nodules. Hematogenous spread of TB.
What can you see in this CXR?
Plombage: surgical method used prior to the introduction of anti-tuberculosis drug therapy to treat cavitary tuberculosis of the upper lobe of the lung. The technique involved surgically creating a cavity underneath the ribs in the upper part of the chest wall and filling this space with some inert material to cause upper lobe of lung to collapse, with the idea that it would heal faster.
Not done anymore.
What can you see in this CXR?
R pleural effusion. Miniscus slop on lateral aspect of R lung. Lost diaphragm due to fluid.
What can you see in this CXR?
Carcinoma L lung base. Increased density behind heart.
What can you see in this CXR?
L pneumothorax. Heart borders ok, compare densities.
What can you see in this CXR?
Tension pneumothorax. Mediastinal shift away from pneumothorax. Medical emg.
What can you see in this CXR?
Big tension pneumothorax. Depressed L hemidiaphragm. Apical blebs (small subpleural thin walled air containing spaces, not larger than 1-2 cm diameter. Walls < 1 mm thick. If rupture -> allow air to escape into pleural space = spontaneous pneumothorax). Diaphragm - scalloping - inverted. Suggests pressure building up -> tension!
What does this arrow indicate?
Chest drain. Pt was breathless and in A and E, thought tension pneumothorax so put drain in, no improvement so did CT, turned out to be huge bullae.
What can you see in this CXR? What pathology does it indicate?
Kerley B lines (hickened, edematous interlobular septa). Little pleural effusion on lower L lobe. CCF - build up of back pressure so lymphatic channels fill.
What pathology does this CXR suggest?
Lymphangitis: inflammation or an infection of the lymphatic channels that occurs as a result of infection at a site distal to the channel. Tumour blocks lymphatic channels.
What can you see in this CXR?
Pulmonary fibrosis. Reduced lung volume. “Shaggy heart” - shaggy heart border is a descriptive term referring to the ill definition of the cardiac silhouette on a chest radiograph.
What pathology does this CXR suggest?
Pneumocystis pneumonia. Normal lung volumes. Acute presentation.
What is unusual about this patient?
R sided aortic arch.
What pathology does this CXR suggest?
Sclerotic bone metastases - prostate cancer
What can you see in these CXRs?
L: Apical consolidation and calcification top L lung - TB
R: Hilum pulled up, contraction, fibrosis - end result of scarring.
What can you see in this CXR?
Calcified granuloma (arrow). Increased density in R midzone, round, dark in centre, suggests air inside -\> cavity. Can be caused by TB (mainly) or other infections e.g. staph. pneumoniae or klebsiella pneumoniae. Non infectious causes: squamous cell carcinoma and Wegner's.
What does this CXR show?
2 borders on both sides of heart = double border sign. Massive hiatus hernia. From stomach? mostly in chest behind heart.
What does this CXR show?
Big pericardial effusion. Massive globular heart, sharp borders.
