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Clin Med IIB Pulmonology > Interpreting a CXR > Flashcards

Interpreting a CXR Flashcards

1
Q

How does an Xray work?

A

Beam of radiation that comes out of machine and goes to a detector
Anything in it’s way absorbs or rejects the radiation
Human absorbs radiation, leading to an image

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2
Q

How does density change the color of the image?

A

Darker = less radiation absorbed
Lighter = most absorbed

Air, fat, soft tissue, bone, metal (dark to light)

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3
Q

How does the beam of radiation determine the size of the structure? How does this differ between AP and PA view?

A

Structures that are closer to where the beam hits will appear bigger, meaning that the heart will appear bigger in an AP view - meaning that a PA view is more accurate (and will appear smaller)

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4
Q

Why do you order a CXR?

A
  1. cough
  2. SOB
  3. Wheezing
  4. Chest pain
  5. Unexplained fever
  6. monitoring disease resolution
  7. lymphadenopathy
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5
Q

What are the benefits to CXR? How do you prepare?

A

Little to no preparation, but need to remove clothes, and metal, and get LMP/pregnancy for females (to make sure that they are not pregnant)

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6
Q

What are the MC CXR? How are these done? Why do you get these views?

A

PA and lateral
PA: Beam hits back first
Lateral: Beam hits axilla essentially

Both views allow interpretation

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7
Q

Why do you order a decubitus and what is this position?

A

Laying on side

Indicated for fluid/air,

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8
Q

If I have a right side that is affected, do I order a right or left lateral decubitus for pneumothorax vs pleural effusion

A

Air (pneomthorax) = left decubitus (opposite)
Fluid = right decubitus (same)

Fluid: Order on effected side - Meaning that if they lay down to the effected side, fluid will travel to the fluid line. Opposite for air

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9
Q

A 56-year-old male presents with complaints of chest pain and shortness of breath that was sudden in onset 1 hour ago. Initial PA CXR is suspicious for a small right pneumothorax vs artifact.

What would be the most appropriate follow up x-ray you would want to order?

A

Want air to rise, want to put them in left lateral decubitus (air rises)

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10
Q

What is an expiratory view and why is it ordered? What is a normal lung?

A

Air trapping that you cannot see (food) on a normal xray
Small pneumothorax (will sometimes show up if you exhale)

Smallest = normal lung, because the other side is not able to exhale all of air, meaning the other side might have a foreign body

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11
Q

What is a lordotic view?

A

When lung apices appear obscured, they beam the radiation up towards the detector so that the image is not superimposed.
Allows you to distinguish if it is bone vs tissue

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12
Q

When would you order an AP view?

A

If the patient is unable to stand upright (because it is ordered laying down)

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13
Q

What are differences between PA and AP? Do you need to tell the difference though?

A

Image labeled PA or AP, so you will likely not need to know.
1. PA = horizontal clavicle (pull arms horizontal)
2. PA = slanted ribs
3. PA = scapula outward of lung
4. PA = smaller heart field

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14
Q

Why does the anatomy appear to be the same in PA vs AP?

A

They rotate image so that it always looking at you.

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15
Q

A 42-year-old female presents with complaints of cough and shortness of breath that was has progressively worsened over the last week. Initial x-ray shows a blunted costophrenic angle on the left. The radiologist is concerned about a pleural effusion.

What would be the most appropriate follow up x-ray you would want to order?

A

Left decubitus (left side on the table) and gravity should pull fluid

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16
Q

What is the general steps to systematically evaluate a CXR?

A
  1. Basic information (make sure it is the right patient)
  2. Image quality (PAIR), penetration, artifact, inclusion, rotation
  3. CXR interpretation ABCDEGH
    Air
    Bones
    Circulation
    Diaphragm
    Extra features
    Gastric bubble/free air
    Hilum
  4. Compare to a former XRAY if they have one
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17
Q

What is penetration, and what should you be able to see?

A

Degree through which xrays have passed through the body
Vertebrae spinous processes are visible behind the heart.
Left hemidiaphragm is visible (can follow the gray line).

Under penetrated = cannot see the spinous process and cannot follow diaphragm

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18
Q

What is an artifact and what is the difference between radiologic vs patient artifact?

A

Something that gets in the way of an image.

Radiologic Artifact
Abnormal rotation of patient
Incomplete inspiration
Incorrect penetration

Patient Artifact
Poor cooperation of patient
Movement
Clothing, hair, jewelry
Metal or implants in the body
Skin folds
Adipose or breast tissue

Should be removed if at all possible

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19
Q

What is inclusion, and what do you look for in PA?

A

5-7 anterior ribs (further away from you) that are angled
10 posterior ribs that are horizontal
Sharp costophrenic angles
See lateral edges of the ribs

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20
Q

What is rotation and what are you looking for?

A
  1. Thoracic vertbrae at midline of trachae
  2. Clavicle (equal distances from each other and same elevation)
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21
Q

What do you first look for in the airway (A) of a CXR?

A
  1. Look at trachea and bronchus, looking for positioning (should be able to follow it, and it deviates to the right passed the carina because the heart gets in the way).
  2. Make sure trachea is midline, and deviation can be indicative of pathology (can feel for this in the sternal notch on PE)

Looking for air, which is dark, and then follow it down

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22
Q

After looking at trachea and bronchus, for airway, what do you look for? How do you follow this? (A)

A

Inspection of the lung in a right to left pattern starting at the apex and moving through the upper, middle, and lower zones looking for symmetry on both sides

Hazyness will be show

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23
Q

How is the left lung different than the right lung?

A

Left lung just has two lobes (upper and lower) and oblique fissure

Right lung has three lobes (upper, middle, and lower) and has an oblique fissure (separating upper from lower) as well as a horizontal lobe (separating right upper from middle)

Only radiologists likely can interpret this

Upper lobe seems to dominate in PA image, but lateral view shows a large lower lobe as well

24
Q

What are the bones that you look for in a CXR? What do you look for? (B)

A

Clavicle (no fractures)
Ribs (should see 10 posterior and at least 5 anterior)
Scapulae
Proximal humerus
Vertebra

Looking for:
fracture
arthritic changes
dislocation
metastatic pathology

25
Q

What do you look for in circulation? (C)

A
  1. Look for heart size in PA view
  2. Mediastinum
26
Q

What cardiac width is abnormal?

A

Cardiac width : Thoracic width (width from side to side) > 50% is abnormal

CANNOT be trusted in AP view, because heart will appear larger

27
Q

What do you look for in the mediastinum and what is normal? (C)

A

Sharp margins and borders of the SVC, IVC, pulmonary arteries

Compartments/spaces are separate

28
Q

What are the compartments of the mediastinum? (C)

A

Superior: above heart
Inferior compartment: anterior mediastinum, middle mediastinum (includes heart), posterior mediastinum

29
Q

What should the diaphragm appear like in CXR? What side is often higher? (D)

A

Should be rounded and domed
Right often sits up higher than the left (because the liver is under it)

30
Q

How far does the lung go?

A

Beyond the diaphragm

31
Q

In the lateral view, how do you know what is the right or left diaphragm?

A

The right will appear higher than the left!

32
Q

What angles do you look for in the diaphragm and what is considered abnormal?

A

Look for costophrenic recesses and angles (formed by hemidiaphragm - the lateral most part of the diaphragm - and chest wall), which should be < 30 degrees (sharp angles)

> 30 = costophrenic blunting

also look at cardiophrenic angle where the heart meets the diaphragm

33
Q

What spaces do you look for when evaluating the diaphragm? What is abnormal?

A

Look for pleura that is not visualized unless during pathology.

You will see a smooth, darker gray image if the lung collapsed pneomthorax

34
Q

What are the extra features of a chest xray? (EF)

A

medical equipment
soft tissues

35
Q

What are the soft tissues seen as extra features (EF)?

A

Breast (looking for symmetry)
Nipple markings (look for symmetry)
Pseudo-blunting if breast tissues seem to go too far and block angle, or if there is poor rotation

36
Q

What do you look for in a gastric air bubble/ free air under diaphragm?

A

Free air under diaphragm is abnormal (air sitting between diaphragm and liver is abnormal!), looks like a white line above the diaphragm

Gastric air bubble is normal and just looks a little darker under the diaphragm

37
Q

What do you look for in the hilum? Which side is higher? (H)

A

Contains major bronchi and pulmonary vessels

Left hilum is often higher than the right due to the anatomy

Hilar structures should be of same size, density, and position

38
Q

What is a consolidation? What can cause these?

A

Liquid or tumor material take up space where lungs are supposed to sit
1. atelectasis (alveoli collapse and appear as consolidation)
2. infection
3. pulmonary edema
4. inflammatory excudate
5. inhaled water
6. blood
7. tumor

39
Q

What does a consolidation look like? What type of images should you use?

A

light or dark gray
PA and lateral view

PA view lets you find which lung
Lateral view will allow you to know what lobe of the lung it is (more posterior = lower lobe of lung)

40
Q

What is hyperexpansion and what do you see it in?

A

Obstructive lung disease leading to hyperinflation

  1. Leads to barel chest
  2. HUGE lungs
  3. flat diaphragm instead of domed
41
Q

What is costophrenic angle blunting and what can cause it?

A

CPA angle > 30 degrees

  1. pleural effusion (MC)
  2. pleural abscess
  3. hemothorax
  4. PE

lung does not open up well

42
Q

What causes pulmonary edema? What does it effect?

A

Fluid collects in the alveoli of the lungs themselves, preventing adequate air exchange.
Typically effect BOTH lungs as a result

Cardiogenic pulmonary edema (MC)
Bilateral PE
Neurogenic
Acute
Viral infections
Lung injury

43
Q

What does pulmonary edema look like in CXR?

A

Consolidation in both lungs all over

44
Q

What does an air bronchogram look like in CXR?

A

Able to see outline of the airway because the rest of the lung is filled with something

Looks like tree branch roots

45
Q

What causes a pneumothorax?

A

Occurs when air leaks into pleural space

  1. idiopathic
  2. chest wall trauma
  3. lung disease
  4. ruptured blebs
  5. mechanical ventilation
46
Q

What are blebs?

A

Little cysts that build-up in the lung tissue. Can rupture leading to pnemothrax

47
Q

What do pneumothorax look like in CXR?

A
  1. A bunch of air build up, which looks black on CXR
  2. Tracheal deviation from midline to the left
  3. No lung markings
48
Q

What is a pleural effusion? What does it look like in CXR?

A

Excess build up of fluid in pleural space

Dull CPA angle d/t fluid buildup

49
Q

What does cardiomegaly look like?

A

Enlarged heart in PA view.

Measure width of thorax to heart, and it is greater than 50%

50
Q

What are septal “Kerley” lines?

A

Reflection of septa between alveoli, which occurs when there is tissue scarring

51
Q

What are the different types of Kerley lines and what do they tell you?

A

Kerley A lines - 2-6 cm oblique lines that course toward the hila

Kerley B lines - 1-2 cm horizontal seen in the periphery of the lungs (perpendicular to the pleural surface)

Kerley C lines - same as Kerley B but coursing ventrally

Kerley D lines - same as Kerley B but seen on the lateral CXR in the retrosternal air space

52
Q

What Kerley line can only be seen in lateral CXR?

A

Kerley D

53
Q

What Kerley line is the MC?

A

Kerley B

54
Q

What is mediastinal widening?

A

An enlargement of mediastinal structures, leading to a wider mediastinum

heart and cardiac vessels

other organs
esophagus
trachea
phrenic and cardiac nerves
the thoracic duct
thymus
lymph nodes of the central chest

55
Q

Link to interpreting chest XRAY with steps

A

Here it is, contains 5 xray images: https://quizlet.com/820357255/interpreting-cxr-practice-flash-cards/?new

Clin Med IIB Pulmonology (12 decks)

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