Chest X-ray

Question 0

Normal chest X-ray

Answer 0

PA and lateral

Note: in the hospital, because the patients are often bedridden an AP and lateral X- rays are taken.

Question 1

Four standard x-ray views

Answer 1

• PosteriorAnterior (PA)
• AnteriorPosterior (AP)
• Lateral (Lat)
• Oblique

Question 2

Abdominal X- rays

Answer 2

typical abdominal X-rays are:

Flat and upright

Question 3

Typical extremity X-rays

Answer 3

Extremity X-rays are generally:

PA/AP, lateral, and oblique

Question 5

Four shades:

Answer 5

• air - dark b/c the more x-ray that hits the film, the darker the image.
• fat
• water
• bone - light b/c the less of the X-ray that hits the film, the lighter the image.

Question 6

Radiopaque

Answer 6

does not permit the passage of s-rays, so the film will be white

Question 7

Radiolucent

Answer 7

Radiolucent permits the passage of x-rays, so the film will be dark.

Question 8

Have a process:

Answer 8

Check:
Name
Date
Look at the entire film every time
If x-ray isn't done well, repeat it.
If jewelry or anything metal shows up, repeat it.

Then:
Check bones
Check soft tissue
Check organs
Check for extra things

Compare previous films to current films

Question 9

Bones should be …

Answer 9

Smooth, if not smooth, then it is fractured.

Question 10

Views, have at least

Answer 10

Two views, to account for the fact that the body is 3 dimensional.

Question 11

Chest X-rays:

Answer 11

PA and Lateral, unless patient is bedridden,
then … AP and lateral
In AP, the heart will appear larger than in a PA.

Question 12

Normal Chest X-ray findings …

Answer 12

• Right hemi-diaphragm s/b 1 - 2 cm higher than left
• Diaphragm should never be paper thin, this indicates free air in the peritoneum.
• Costophrenic angles should be sharp and clear
• Gastric air bubble

Question 13

Normal Chest X-ray, findings, bones …

Answer 13

Are the clavicles symmetrical?
Count the ribs
— Anterior ribs
— Posterior ribs
— Rib spaces - 8 - 10 with normal expansion, 10 + with hyperinflation
Posterior ribs are straight and attach to the vertebral body.
Anterior ribs angle; many attach to the sternum

Question 14

Normal Chest x-ray, findings, cardiac

Answer 14

Cardiac silhouette diameter is less than 1/2 of the intrathoracic diameter.

Question 15

Atelectasis

Answer 15

Atelectasis is the collapse of a portion or entire lung with the re-absorption of air from the alveoli.

Question 16

Bleb and Bullae

Answer 16

Portion of the lung in which there is an air space without alveoli. Bleb is small, bullae is larger than 1 cm.

Question 17

Infiltrate

Answer 17

Alveolar space is filled with pus, fluid, or blood.

Question 18

Pneumonia, Signs on chest x-ray …

Answer 18

Look for infiltrates
Look for loss of sharp cardiac borders.

Patient must always return for test of cure x-ray to prove infiltrates are clear and to be sure that the infiltrate was not the result of something else, or was not hiding something else.

Question 19

Right Lower Lobe Pneumonia ….

Answer 19

Infiltrates will appear posterior to the heart, obscuring the T-spine.

Question 20

Right Upper Lobe Pneumonia …

Answer 20

Heart border disappears with lateral view, as the infiltrate will be anterior to the heart.

Question 21

Left Lung landmarks

Answer 21

Upper lobe is anterior of the heart

Lower lobe is posterior of the heart.

Question 22

Pleural Effusion

Answer 22

Fluid layering in pleural cavity.
If seen on upright x-ray, effusion is at least 100 cc.
Most seen in dependent portions of pleural spaces.
Blunting of costophrenic angles.
Larger effusions compress lung tissue.

Question 23

CHF

Answer 23

CHF usually looks like a big heart with fuzzy borders. Order an echocardiogram.

Blunting of costophrenic angles results from pleural effusions.

Central blood vessels become hazy d/t infiltrates.
Kerley B lines visible on periphery.

Question 24

Kerley B lines

Answer 24

Associated with CHF.  Always located inside the ribs.
Horizontal lines, no longer than 2 cm.
Located in peripheral 1/4 of lung.
Imply destruction of lymphatics.
Mostly visible in costophrenic angles.

Rarely seen, really a “lucky finding” but somehow a frequent test question.

To distinguish between blood vessels, Kerley B lines are seen on the periphery, blood vessels are seen centrally. Kerley B lines are horizontal. Blood vessels aren’t.

Question 25

TB

Answer 25

Normal chest X-ray does not exclude active TB in other sites such as kidney or spine.

Look for infiltrates and cavitations in apices.
Hilar adenopathy most often present.
Healed TB may present as fibrous changes or as calcifications.

Question 26

Empyema

Answer 26

A collection of pus within the pleural space caused by: primary infection, postsurgical, or post-traumatic.

CT scan indicated to locate and confirm diagnosis.

REFER to pulmonologist.

Question 27

Pneumothorax

Answer 27

Air in the pleural space, can be caused by trauma, occur spontaneously, or d/t other causes such as a tumor.
Look for area of lung with no vascularity and a thin white line (visceral pleura separated from parietal pleura.

Question 28

Hemoptysis

Answer 28

Coughing up of blood.
Most common cause: bronchitis.
Initial imaging: PA and lateral chest X-rays.
If x-ray normal, and low CA risk, then CT scan
If x-ray normal, and high CA risk, then bronchoscopy and possibly a CT scan.

Refer to a pulmonologist.

Question 29

PE? What to do?

Answer 29

Spiral CT
if unavailable, then VQ scan.
Plain chest x-ray usually negative, but order for differential diagnosis.