Imaging of the Chest - Goldschmidt

Question 1

What aspects of a chest x-ray let you know that an adequate breath was taken?

Answer 1

• 10-11 ribs visible
• Inadequate breath will “crowd” the lung structures and make them look pathologic

Question 2

How do you know if a chest x-ray is adequately penetrated?

Answer 2

• See ribs
• If too high of an energy lungs look very black and gaps in anterior ribs
  
  • could miss a lung nodule

Question 3

What two things do you need to make sure are not cut off in a chest x-ray?

Answer 3

• Costo-phrenic angle
• Lung apex/first rib

Question 4

What four things are important for an adequate chest x-ray film?

Answer 4

1. Adequate breath
2. Reasonable penetration
3. Nothing cut off
4. Patient square, not rotated

Question 5

What should you be suspicious of in an elderly patient with rib pain and no history of injury?

Answer 5

Metastic lesion

(most common in older age group)

Question 6

What is the most common rib lesion?

Answer 6

Callous due to a healing fracture

Question 7

What four things should you look at when evaluating the mediastinum?

Answer 7

1. Heart
2. Aorta
3. Pulmonary vessels
4. Trachea/Esophagus

Question 8

How big should the heart be in a chest x-ray?

Answer 8

Transverse diameter of the heart should be about half the length of the thorax.

Question 9

What things could possibly (falsely) affect the heart size on a chest x-ray?

Answer 9

• Patient position
  
  • supine pictures in ER/ICU will accentuate heart size
• Direction of the x-ray beam
  
  • AP films will accentuate heart size
• Fluid around the heart

Question 10

How can you tell if diaphragm paralysis is evident in an x-ray?

Answer 10

Diaphragm is elevated on one side

(compare inspiration and expiration films)

Question 11

What does air trapping due to COPD look like on chest x-ray?

Answer 11

• Flat diaphragms
• Hyper-expanded lungs
• “Barrel chest”
• Radiolucent lungs

Question 12

What are the possible pathologic conditions when lymph node enlargement is present on chest x-ray?

Answer 12

• Metastatic Disease
• Lymphoma
• Reactive nodes related to infection (TB)
• Granulomatous disease
  
  • sarcoid

Question 13

What specific finding is strongly suggestive of CHF?

Answer 13

Kerley’s B lines

(septal lines)

Question 14

How do you differentiate between a lung nodule and a lung mass?

Answer 14

• Nodule <3 cm
• Mass >3 cm

Question 15

What is a trick for chest x-ray to look for pleural effusion?

Answer 15

take image with patient on side

-fluid line will shift

Question 16

What problems with x-ray are eliminated/improved with CT imaging?

Answer 16

• Eliminates the problems caused by overlap of structures
• Improves differentiation of different types of tissues

Question 17

What is the DDx when patient presents to ER or Clinic with chest pain?

(hint: 4 serious things)

Answer 17

1. Acute Coronary Syndrome (MI, angina)
2. Pneumothorax
3. PE
4. Aortic Dissection

Question 18

How is a CT useful in determining the treatment of an aortic dissection?

Answer 18

• CT can determine the area of involvement
  
  • If ascending aorta: surgical tx
  • If descending aorta: medical tx

Question 19

What form of imaging is first line testing for many common chest and lung disorders?

Answer 19

Chest X-ray

Question 20

What are two nonspecific findings on CXR that may suggest a PE?

Answer 20

• Hampton’s Hump
  
  • wedge-shaped opacity corresponding to lung infarct
• Westermark’s sign
  
  • relative oligemia (less blood flow than normal)