Chest X-Ray and Kidney/Urinary/Bladder X-Ray Flashcards
Things to situate to when viewing CXR (6 c methods of evaluation)
-
Male or female?
- Breast contours (usually) = female
-
Good inspiration?
- Diaphragm should lie at 10th ribs in PA view, 6 ribs in AP view
- R hemidiaphragm is usually higher than L hemidiaphragm because of liver
-
Good penetration?
- Lower thoracic vertebral bodies should be visible thru heart, but intervertebral spaces should not
- Disc spaces SHOULD be visible sup to heart
- Translucent shadow of trachea visible up to clavicles
- Lungs dark, but not black
- Overexposure: vertebral column + intervertebral spaces clearly visible through entire thorax
- Underexposure: Faint shadow of vertebral column will not be visible at all. Translucency of trachea will not be clearly visible. Opaque heart
-
Is pt rotated?
- Spionous processes of thoracic vertebrae should be midway between medial ends of clavicles
-
What view is the image?
- Options: AP, PA, Lateral
- Most are PA, if pt is ambulatory. Significance: heart lacks illusion of enlargement in PA views. If reading an AP view, be sure to accomodate for heart size
-
Right patient and direction (aka, is the film flipped)?
- Read ID and directional markers on scan
See normal x-ray and markers
Structures to evaluate in every PA CXR (8 c descriptions)
-
Mediastinal contours
- Clear
- Are they widened? (If not, mediastinal adenopathy potential)
-
Trachial position
- Midline (If not, pneumothorax potential)
-
Heart Size
-
1/2 of thorax
- 1/3 R of midline
- 2/3 L of midline
- Angles should be clear enough to measure (If not, pericardial effusion or stomach contents)
-
1/2 of thorax
-
R Heart border
- Only applicable in PA view
- Clear and discernable, with SVC just superior
-
Lung fields
- Gray-ish when full of air
- Look for sharp costophrenic angles
- Scan both lungs in a coordinated fashion
- Apex → Base
- Medial → Lateral
-
Hemidiaphragms
- Downward curve
- Should be bottom border of sharp costophrenic and cardiophrenic angles
- White matter underneath (no free air)
-
Ribs
- Intact and congruous
See normal CXR with landmarks below
Things to evaluate on every Lateral CXR (3 c descriptions)
-
Heart lies antero-inferiorly
- Anterior and superior to heart should be gray/black becasue it contains aerated lung tissue
-
Evaluate area superior to heart
-
Posterior to heart should be gray/black down to diaphragms
- If darkened (without posterior darkening), suspect anterior mediastinal or upper lobe disease
-
Posterior to heart should be gray/black down to diaphragms
-
Evaluate area posterior to heart
-
This area should be the same color as superior heart
- If darker, suspect lung collapse or consolidation
-
This area should be the same color as superior heart
Typical CXR Report (read only, unless you really want to memorize it…)
This is a frontal chest radiograph of a young male patient. The patient has taken a good inspiration and is not rotated; the film is well penetrated. The trachea is central, the mediastinum is not displaced. The mediastinal contours and hila seem normal. The lungs seem clear, with no pneumothorax. There is no free air under the diaphragm. The bones and soft tissues seem normal.
Identify Pathology
R. Middle Lobe Pneumonia
Significant findings:
- Airspace opacity consolodated in RML
- Interstitial opacities
- Some pleural effusion present
Explaination:
- Airpsace filled c microbes and pus, creating opacity
- Disease can progress from perihilar consolodation to patchy as disease spreads
Identify Pathology
L. Lower Lobe Pneumonia
Identiy Pathology
R. Upper and Middle Lobe Pneumonia
Significant Findings
- Aggressive “white out” in RUL and RML
- Some opacity at great vessels
Pathophys. Explaination
- Probably legionella pneumonia
- Rapid onset, highly aggressive
Classic CHF Signs on CXR
In conjunction c H&P…
- Cardiomegaly due to ineffective pumping (specifically, L. ventricular hypertrophy)
- Prominant upper lobe vessels from high pressure causing leakage into lung
- This interstitial edema will fall to the costophrenic angles and cause pleural effusion
- Diffuse cloudiness in “bat’s wing” shape from alveolar edema
*Classic PANCE Question
Identify Pathology
Cardiomegaly
- Significant Findings:*
- Heart greater than 1/3 of thorax width
Note:
- Remember that AP views artifically inflate heart size, since the heart is closer to the x-rays. Be sure to check correct orientation and substatiate c relevant s/sx
Identify and Describe Pathology
CHF c Kerley B Lines
Significant Findings:
- Cardiomegaly
- Prominent upper lobe vessels (kind of)
- Pleural effusion c Kerley B Lines - swirled lines congretating in costophrenic angles
- Beginnings of “bat wings”
Note:
- While radiologist will note Kerley B Lines, you do not have to recognize them specifically. Noting pleural effusion is sufficient
Identify Pathology
Severe CHF
Significant Findings: Classic CHF Signs
- Cardiomegaly
- Alveolar edema (advanced past bat winging stage)
- Costophrenic interstitial edema (thick and spreading Kerley B Lines)
- Haziness of vascular margins (slightly more opaque in central vasculature)
Identify Pathology
Pulmonary Edema
Significant Findings:
- Diffuse opacity
- Loss of both hemidiaphragms
- Loss of heart contours
- Loss of vertebral bodies (almost looks underpenetrated)
Identify Patholgoy
Pulmonary Edema (treated)
Significant Findings:
- Diffuse opacity throughout lungs
- Hemidiaphragms still soft
- Heart contours undefined at bottom
Note:
- This is likely after tx c a diuretic
- Lungs heal very quickly, as they deteriorate very quickly
Identify Pathology
LUL Lung Cancer
Significant Findings
- Mass c well-defined borders
- Be careful not to confuse c pneumonia, which has more diffuse borders
- *Note
- Biopsy and CT required for official diagnosis
Identify Pathology
R. 4th Rib Fx s Pneumothorax
Significant Findings
- Irregular margin in costal R. 4th rib
- Normal lung margins, indicating no pneumothorax
Note
- Remember to get multiple views of each pt. Lateral view does not readily expose fx
- You can request a specific CXR for suspected rib Fx, it is just a magnified view of ribs
Identify Pathology
R. Lung Pneumothorax
- Significant Findings*
- Clear visceral line - border between black air and gray/white compressed lung near midline
Identify Pathology
R. Tension Pneumothorax c Right-sided Lucency and Leftward Mediastinal Shift
Significant Findings
- Visceral line near medial border of R. lung
- Left trachial deviation
- *Note
- Medical emergency! Place R. chest tube ASAP to allow venous return
Identify Pathology
L. Lung Pneumothorax
Significant Findings
- Visceral line at L. midclavicular line
- Potential minor R. mediastinal deviation
Identify Pathology
Bilateral Pleural Effusions
Significant Findings:
- Dull costophrenic angles
- General diffuse opacity
- Thickening at pulmonary vessels
- No cardiomegaly (thus, no CHF)
Identify Pathology
R. Pleural Effusion, Pre and Post Tx
Significant Findings
- R. costophrenic angle softening pre-tx
- RLL opacity pre-tx
Identify Pathology
R. Pleural Effusion
Significant Findings:
- Lack of R. costophrenic angles
- Significant opacity in RLL and RML(fluid buildup in line c gravity; does not totally follow lobular lines)
Identify Pathology
COPD/Emphysema
Significant Findings
- Bilateral diaphragmatic flattening
- Significant hyperinflation - 11 ribs visualized
- Also note barrel-chest in lateral view here
Identify Pathologies (each image is different)
1. Bilateral PA Enlargement (left image)
- Significant Findings*
- Smooth contours of pulmonary ateries
2. Bilateral Hilar Adenopathy (right image)
- Significant Findings*
- “Lumpy-bumpy” opacities
Identify Pathology
Tuberculosis
Significant Findings
- Bilateral pulmonary infultrates localized s gravitational influence
- Bilateral coalescing opacities
- Opaque cavities c regular borders (see arrows)
Identify Pathology
Tuberculosis
Significant Findings
- Coalescing bilateral infiltrates
- Cavity w/i infiltrate, mid RML
Identify Pathology (don’t peak at the writing on the picture!)
Pulmonary Embolism
- Significant Findings*
- Hampton’s Hump: Rounded opacities corresonding c clot location (can be anywhere in the lung)
- **Common PANCE Question
Identify Pathology
Normal Abdominal Flat Plate (tricked ya!)
This is a KUB
Identify Pathology
Kidney Stones in R. Renal Pelvis
Significant Findings
- Opacities c sharp borders in RRP
- Plentiful gas, probably due to hyperventilation due to KS pn
Note
- Stone opacity level varies upon stone composition
- If stone is not opaque, follow up c US
- Pt will present c flank/abo pn
Identify Pathology
Kidney Stones in R. Ureter
- Significant Findings*
- Opacities following ureter anatomy (although ureter is not visible)
- *Note
- Must rely on anatomy knowledge to ID location of stones, as tissues may not always be visible
- These are large stones
- Stone opacity level varies upon stone composition
- If stone is not opaque, follow up c US
- Pt will present c flank/abo pn
Identify Pathology
Hydronephrosis c Stone in R. Renal Pelvis
Significant Findings
- Opacity at RRP anatomic location
- Enlarged kidney
- *Note
- Fluid backup due to blockage in renal pelvis
Identify Pathology
Constipation
- Significant Findings*
- Hazy spots in the shape of intestines
- *Note
- Common PC complaint; pt will come in complaining of abdo pn not remembering that his/her last bowel movement was two weeks ago. Be sure to question this in all abdo pn pts
- Typically, only utilize x-ray c geriatrics. Younger populations will almost have more revealing hx
Identify Pathology
Free Air Under Diaphragm, Perforated Viscus (Peptic Ulcer)
Significant Findings
- Air space that reveals R. diaphragm shape compared to superior liver border
- (not sure why this is perforated viscus…just reading my notes)
Note
- Any GI structure that ruptures will send air up to the diaphragmatic level (granted the pt is standing, think gravity)
- This is a medical emergency!
Identify Pathology
Free Air Under Diaphragm, Significant
Significant Findings
- Visible diaphragm shape bilaterally, separated from liver and stomach
- This is significant becuase it is bilateral (more commonly just R. sided)
Note
- Any GI structure that ruptures will send air up to the diaphragmatic level (granted the pt is standing, think gravity)
- This is a medical emergency!
Identify Pathology
Pneumoperitoneum, aka Bowel Perforation
Significant Findings
- Air under R. hemidiaphragm (white arrow)
- Bowel loops air fluid levels (black arrowheads)
- Air fluid level in stomach (black arrow)
Identify Pathology (try not to cheat!)
Small Bowel Obstruction
Significant Findings
- Violated and air-filled intestine proximal to obstruction
- NOTHING (air, fluid, feces) distal to obstruction, as colon is collapsed
Identify Pathology
Small Bowel Obstruction
Significant Findings
- Violated and air-filled intestine proximal to obstruction
- NOTHING (air, fluid, feces) distal to obstruction, as colon is collapsed
Identify Pathology
Small Bowel Obstruction c Air Fluid Levels and Dilated Jejunum
Significant Findings
- Larger jejunum than typical
- NOTHING (air, fluid, feces) in colon, as it is blocked from receiving contents due to SBO
- Visualization of border b/w air and fluid in small bowel - atypical for SBO
