19) Chest X-Ray

Question 1

What is a radiograph?

Answer 1

Photographic image of internal composition of body, produced by X-rays being passed through the body part and being absorbed to different degrees by different tissues

Question 2

How do more dense tissues appear on X-ray?

Answer 2

More white

Question 3

In what projection are CXRs usually taken?

Answer 3

PA, X-ray source behind patient

Question 4

Why is AP projection sometimes used?

Answer 4

Patient too unwell to stand

Question 5

What are the problems with AP projection?

Answer 5

X-ray beams are diverted by heart, due to heart being closer to source
Means heart looks bigger

Question 6

What does a chest X-ray need to include?

Answer 6

Region above 1st rib
Lateral margins of rib (incase of lateral nodules)
Costophrenic angles

Question 7

How would you check the rotation of a CXR?

Answer 7

Look if spinous processes are in between medial ends of clavicle

Question 8

What does the patient need to do when a CXR is taken and why?

Answer 8

Needs to breath in and hold breath

Allows ribs 5-7 are in line with MCL

Question 9

What will be seen if incomplete inspiration?

Answer 9

Big heart and increased lung markings

Question 10

What will be seen in exaggerated expansion (obstructive)?

Answer 10

Flattened diaphragm

Question 11

How can you check for adequate penetration?

Answer 11

Vertebrae just visible through heart

Left hemi-diaphragm visible

Question 12

What are the right and left borders of the heart?

Answer 12

Right - RA

Left - LV

Question 13

Where should the trachea be positioned?

Answer 13

Centrally

Question 14

Which side are the hila higher on?

Answer 14

Left

Question 15

What side is the aortic knuckle on?

Answer 15

Left

Question 16

What side can bowel gas been seen on?

Answer 16

Left

Question 17

How should the costophrenic and cardiophrenic angles present?

Answer 17

Sharp and pointy

Question 18

How should you analyse an X-ray?

Answer 18

Adequacy
A - airway 
B - breathing
C - circulation 
D - diaphragm and bones

Question 19

What is a silhouette sign?

Answer 19

Loss of crisp difference between adjacent structures with differing densities e.g. white heart next to black lung

Question 20

What causes a mediastinal shift?

Answer 20

Changes to volume and pressure on one side of the chest

Question 21

What is a pneumothorax?

Answer 21

Air trapped in pleural space causing uncoupling of lung from chest wall

Question 22

What can cause a pneumothorax?

Answer 22

Spontaneous (trauma, fractured rib lacerates VP)
Underlying lung disease
Marfan’s

Question 23

How is a large pneumothorax defined?

Answer 23

> 2cm from chest wall

Question 24

How would a tension pneumothorax present on CXR?

Answer 24

Tracheal and mediastinal shift away from pneumothorax

Depressed diaphragm

Question 25

How does a pleural effusion present on CXR?

Answer 25

Uniform white area due to liquid in pleural spaces Obscures hemi-diaphragm and blunting of costophrenic angles Meniscus at top Mediastinal shift away

Question 26

If patient is supine what will a pleural effusion look like?

Answer 26

Hazy all over

Question 27

What is a lobar lung collapse and what can cause it?

Answer 27

Volume loss within lung lobe | Aspirated foreign material, mucus, carcinoma, compression by mass

Question 28

What are some general findings on X-ray for lobar lung collapse?

Answer 28

Elevation of hemi-diaphragm on same side Crowding of ribs Mediastinal shift towards collapse

Question 29

What specific findings are there for left lower lobe collapse?

Answer 29

Sail's sigh - sharp line behind heart

Question 30

What specific findings are there for left upper lobe collapse?

Answer 30

Veil sign - hazy opacification

Question 31

What specific findings are there for right upper lobe collapse?

Answer 31

Horizontal fissure displaced up

Question 32

What specific findings are there for right middle lobe collapse?

Answer 32

Right border of heart not seen

Question 33

What specific findings are there for right lower lobe collapse?

Answer 33

Horizontal fissure displaced down

Question 34

What is consolidation? | Give some examples

Answer 34

Filling of small airways and alveoli with dense material | e.g. pus (pneumonia), blood, fluid (oedema), cells (cancer)

Question 35

How does a consolidation present on CXR?

Answer 35

Dense and white area | Air bronchogram

Question 36

What is an air bronchogram?

Answer 36

Air-filled bronchi (dark) being made visible by the opacification of surrounding alveoli (grey/white)

Question 37

What space occupying lesions can present on CXR?

Answer 37

Nodule < 3cm, Mass > 3cm | Malignant, inflammatory, bone lesion

Question 38

How do asbestos plaques present on CXR?

Answer 38

Calcified, irregular, well defined, multiple

Question 39

What is pneumoperitoneum?

Answer 39

Air under diaphragm due to bowel perforation

Question 40

How is the cardiothoracic ratio calculated and what is a normal result?

Answer 40

Widest part of heart divided by widest part of ribcage | Normal < 50^%