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Phase 3B Radiology > Chest XR > Flashcards

Chest XR Flashcards

1
Q

Interpreting CXR.

- RIP RIPE ABCDE

A
  • Right patient?
  • Inclusion - can you see all the relevant anatomy? (costophrenic angles, clavicles, etc.)
  • Projection - PA (if not specified on image, it is PA), AP (if supine/ resus - likely AP), lateral, etc.
  • Rotation (spinous processes should lie halfway between medial ends of the clavicles)
  • Inspiration (diaphragm should be bisected in the midclavicular line by rib 5, 6 or 7. <5: under-expansion; >7: hyper-expansion. A better way of assessing hyperexpansion is if the hemidiaphragms are flattened)
  • Penetration (Is the left hemi-diaphragm visible up to the vertebral column? Can you see ribs behind heart? Can you see the spinous processes?)
  • Exposure: under-exposed (too dark), over-exposed (too bright), or just right
  • Airway - tracheal deviation, tubes
  • Breathing - lung fields (pneumothorax), hilum, apical, upper, middle and lower zones
  • Circulation - heart and aortic knuckle; cardiomegaly
  • Diaphragm - angles, elevation, pneumoperitoneum
  • Everything else - tubes, bones (fractures of ribs, shoulders, clavicles), check everything again
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2
Q

RML vs RUL vs RLL pneumonia

A

RML - Obscured right heart border

RLL - Obscured right hemidiaphragm

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3
Q

Homogenous whiteout of the lung fields

a) Mediastinum central - DDx?
b) Mediastinum shifted towards side of whiteout - DDx?
c) Mediastinum shifted away from side of whiteout - DDx?

A

a) Consolidation (infection), mass (e.g. mesothelioma)
b) Lung collapse, rarer: pneumonectomy, pulmomary agenesis/ hypoplasia
c) Pleural effusion

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4
Q

Chest drain insertion - landmarks

A

5th IC space
Base of axilla
Lateral edge of latissimus dorsi
Lateral edge of pectoralis major

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5
Q

Widespread bilateral patchy alveolar shadowing

a) diagnosis
b) management (OMFG Sit them up)
c) distinguishing cardiogenic from non-cardiogenic

A

a) Pulmonary oedema

b) Rx:
Oxygen
Morphine
Furosemide
GTN
Sit up

c) - Cardiogenic: generally more homogenous opacities, will likely also have cardiomegaly, kerley B-lines, fluid in the fissure, upper lobe diversion, pleural effusions, etc. (ABCDE)
- Non-cardiogenic: more patchy opacities, will lack cardiac features, air bronchograms may be visible

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6
Q

Widespread bilateral multiple rounded opacifications

  • likely diagnosis?
  • secondary to…?
A

Cannonball mets

Renal cell Ca

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7
Q

Cavitating pneumonia

  • 2 causes
  • differential
A
  • Staph aureus, klebsiella

- TB - Ghon’s focus

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8
Q

NG tube

- checking placement

A
  • Aspirate - pH: < 5.5 then safe placement (note: if on PPI/H2RA then could have safe placement with higher pH)
  • CXR - should bisect the carina; tip of NG tube should be visible below level of diaphragm

Note: if feeding through NG - must do CXR beforehand as feeding into lung is a never event

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9
Q

Signs of heart failure (ABCDE)

- explain the appearance on CXR of each one

A
  • Alveolar oedema - patchy bilateral opacities
  • Kerley B lines - thin lines of opacity extending out from the pleura, perpendicular to them
  • Cardiomegaly - cardiothoracic ratio > 0.5
  • Upper lobe diversion - stag antler sign (prominent vessels, not necessarily fluid filled; reflect increased left atrial pressure)
  • Pleural effusions - blunting of costophrenic angles, homoegenous whiteout of lung fields

Sequence of pulmonary oedema: perihilar haze&raquo_space; Kerley B lines&raquo_space; pleural effusion&raquo_space; bat wing oedema (relative sparing of apex and bases)

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10
Q

What findings may be found on CXR of someone exposed to asbestos?

A

Pleural plaques

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11
Q

Pneumonia on CXR - possible findings

A
  • Consolidation
  • Air bronchogram (visible airways; also caused by non-cardiogenic pulmonary oedema)
  • Effusion/ empyema
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12
Q

When should you do a CXR in the context of suspected rib fractures?

A

If worried about pneumothorax/ haemothorax

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13
Q

Lung zones

A
  • Apical (supraclavicular) - look for pneumothorax/ mass
  • Upper zone - clavicle to hilum
  • Mid zone - level of hilar structures
  • Lower zones - bases
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14
Q

Pleural effusion vs elevated hemidiaphragm

A

Effusion - meniscus sign; blunting of CP angles

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15
Q

Consolidation in the upper zone with hilar enlargement - possible diagnosis?

a) If unilateral
b) If bilateral

A

a) TB, primary lung malignancy

b) Sarcoidosis, lung secondaries

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16
Q

Hilar lymphadenopathy: differentials

A
  • Sarcoidosis
  • Infection: TB, mycoplasma
  • Malignancy: lung, lymphoma, leukaemia
  • Heart failure
17
Q

Presenting a CXR.

- prior to ABCDE, what should you comment on?

A

Introduction:

  • Confirm Patient Details
  • Indication for CXR (brief history)

Projection:

  • AP or PA (if it doesn’t say, the scapulae are more within the lung fields in an AP film and out of the way in a PA)
  • Erect or supine
Quality of the film 
•	Rotation 
•	Inspiration (No of ribs)
•	Penetration 
•	Exposure 
•	Adequacy of the film?

Request to see the previous CXR

“The first observation to comment on…”
“… but going through the radiograph systematically…”

ABCDE

18
Q

Presenting a CXR: airway (A)

- 2 thing to comment on

A

The trachea is…
- central, or deviated to the…

Mediastinum is…

  • wide, or normal width
  • central, or deviated to the…
19
Q

Presenting a CXR: breathing (B)

a) Begin by commenting on the…?
b) Comment on any areas of…?
c) And state explicitly if there is or isn’t a…?
d) Comment on lung volume
e) Other things to comment on (2)

A

a) Upper, middle and lower lung fields
b) Areas of opacification / radiolucency
c) Pneumothorax (check apices as well)
d) Hyperinflation / Reduced lung volume

e) - Pleural markings – thickened?
- Pulmonary vascularity
- Hilar structures (bronchi, pulmonary veins and arteries, hilar lymph nodes) – size, shape, position

20
Q

Presenting a CXR: circulation (C)

a) 3 things about the heart to comment on (1 will depend on if it is AP/PA and any rotation)
b) Other possible features to pick up on

A

a) - Heart size – enlarged (cardiothoracic ratio) - may be falsely enlarged in AP film or if rotated to the left
- Heart borders – RA, RV, LA, LV (may be obscured if there is consolidation)
- Heart position? – any displacement?

b) - Anything behind the heart?
- Aortic knuckle
- Hiatus hernia - gas above diaphragm in the cardiac area

21
Q

Presenting a CXR: diaphragm (D)

a) 3 things to comment on

A

a) - Costophrenic angles - are they well-defined or blunted/obliterated (?pleural effusion) - note: hyperexpanded lungs will blunt the costophrenic angles
- Hemidiaphragm elevation or not (could indicate phrenic nerve palsy - may be due to mass compressing/eroding - differentiate from pleural effusion)
- Pneumoperitoneum or not (important negative)

22
Q

Presenting a CXR: everything else (E)

a) Firstly, comment on…?
b) What other things should you comment on if seen? (if not seen, say…?)

A

a) Bones and soft tissues
– bony lesions? #s? (“imaged skeleton is intact)
- cervical rib?
- spine - scoliosis
- surgical emphysema - gas (black) in SC fat

b) - Vascular lines - CVC, PICC
- Tubes - NG, ETT, tracheostomy
- Surgical clips / wires (eg. median sternotomy)
- Other - PPM, SVC filter, cardiac monitoring

23
Q

Summarising a CXR.

  • The type of radiograph
  • The patient details and indication
  • The salient positive findings
  • The important negative findings
  • Comparison with previous CXR?
  • The differential diagnosis

For a 74 year old man who had an erect AP CXR for ?LRTI (2/7 profuctive cough and SOB) and found LLZ consolidation but no other abnormality

A

In summary,

  • This was an erect AP chest radiograph
  • … of a 74 year old gentleman with a 2/7 history of productive cough and SOB (and no prior PMHx)
  • Which found an area of increased opacity in the left lower zone, but no other findings.
  • There were no effusions or pneumothoraces
  • Given the history, this CXR is consistent with an area of LLZ consolidation, likely due to bacterial pneumonia
  • I would like to compare this to previous CXRs
24
Q

Talking about lung shadowing.

a) Types of consolidation
b) Homogenous vs heterogenous
c) Interstitial vs. alveolar
d) When should patients with consolidation have repeat CXR?

A

a) Focal vs diffuse/patchy
- also consider bronchopneumonia vs lobar pneumonia
- multiple foci - consider lung mets

b) - Homogenous - effusion, collapse
- Heterogenous - if multiple foci, consider lung mets

c) Interstitial:
- Reticular: too many lines (DDx: IPF, connective tissue disease)
- Nodular: too many dots (DDx: miliary TB, lung mets, rheumatoid nodules)
- Reticulonodular: too many lines and dots

Alveolar:
more fluffy, cloud-like (DDx: pulmonary oedema)

d) 6 weeks later

25
Q

Lobar collapse.

a) Sail sign
b) Golden ‘S’ or meniscus sign on R lung
c) LUL collapse

A

a) LLL collapse (triangle intersecting with heart)
b) RUL collapse
c) Entire left hemithorax affected

26
Q

Flattening of the hemidiaphragms possibly indicates…

A

Hyperinflation of the lungs

27
Q

Tracheal tubes.

a) Two types
b) Ideally, the tip should be located where?
c) If right-sided endobronchial intubation, what complication may occur? And how will this appear on CXR?
d) What other intubation error must be detected clinically? (not on CXR)

A

a) ETT and tracheostomy (ring visible)
b) 5 - 7 cm above the carina
c) Left lung collapse - homogenous whiteout of entire left hemithorax
d) Oesophageal intubation

28
Q

NG tubes.

a) Where is the gastro-oesophageal junction?
b) Where is the correct NG placement?
c) Where should the tip lie?
d) Give 4 common incorrect placements
e) How should correct placement be confirmed?

A

a) At the level of the diaphragm
b) It should course in the midline, past the carina (avoiding both bronchi) and turn left to insert into the stomach below the level of the diaphragm, 10 cm distal to the GOJ
c) 10 cm distal to the GOJ

d) - Too proximal (not lateral enough on CXR) - i.e. < 10 cm from the GOJ
- Too distal (loops round to the right of the patient) - i.e. into duodenum
- In oesophagus but coiled
- Endobronchial (usually right main bronchus)

e) - Aspiration of gastric fluid on insertion - ?test pH
- If unsure - check placement using CXR (MUST be done if planning on feeding via the NG tube as feeding into the lungs could be fatal)

29
Q

Venous lines.

a) CVCs - purpose? - ideal location? - issues of placement too proximal/ too distal?
b) CVC insertion - via what veins?
c) PICC line - explain possible differences on CXR
d) Misplacement - examples
e) Complications of insertion on CXR

A

a) - Fluid/drug administration or monitoring of central venous pressure
- Within the SVC at around the level of carina (may need to be more distal if for long-term chemotherapy)
- Too proximal placement increases risk of line sepsis and thrombosis
- Too distal placement risks puncturing the pericardial sac and causing cardiac tamponade

b) - Internal jugular (in neck, above clavicle)
- Subclavian (near shoulder, below clavicle)
- Note: usually right-sided - easier access to SVC

c) - Will be below clavicle from direction of upper arm
- If for long-term treatment (eg. chemotherapy), usually lie more distal: inferior to carina at cavo-atrial junction

d) - Too proximal - not below the carina in the SVC
- Too distal - in the right atrium (note: some haemodialysis catheters are intended for placement in RA)
- Into wrong veins (eg. from internal jugular into subclavian vein rather than brachiocephalic to SVC)

e) - Pneumothorax

30
Q

Chest drains.

a) Usual placement
b) Indications
c) Appearance
d) Drain for effusion vs. pneumothorax
e) Complications

A

a) 5th ICS, mid-axillary line

b) - Pneumothorax
- Effusion
- Empyema
- Haemothorax

c) Tube with holes in one side and radio-opaque tip (usually)

d) - Effusion - generally aimed inferiorly (fluid falls)
- Pneumothorax - generally aimed superiorly (air rises)

e) - Pneumothorax
- Surgical emphysema

Phase 3B Radiology (6 decks)

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