Patterson: Radiology of the Lungs

Question 1

Most common orientation for chest X-ray

Answer 1

PA: chest against casette, beams pass from posterior to anterior

**makes heart as normal sized as possible, because the heart is close to the posterior

Question 2

What other films might you use?

Answer 2

Lateral film with the PA: left side against the casette, beams come from right to left

AP: anterior posterior (used in patients who can’t stand, so they are lying supine)
**problem, heart is further away from the casette, so it looks larger

Question 3

What are the 5 densities of chest x-rays from white to black (radiodense)?

Answer 3

metal (white)
bone/calcium
soft tissue/fluid
fat 
air (black)

Question 4

Opacification of what part of the lung will silhouette the left heart border?

Answer 4

lingula

Question 5

How do you assess the rotation on a chest X-ray?

Answer 5

look for the spinous process, make sure it is equidistant from the medial ends of the clavicles

**if spinous process is closer to the right clavicle, the patient is rotated left
if spinous process is closer to left clavicle, the patient is rotated right

Question 6

How do you assess inspiration on a chest X ray? Why is it important to make sure the patient has good inspiration?

Answer 6

you count the ribs, starting with the first rib - you should be able to count 9-10 posterior ribs (horizontal) if adequate inspiration

**if 8 or less ribs visible, this suggests crowding of airspace, and can be mistaken for disease

Question 7

What will the diaphragm be like if you over-inspire on chest X-ray?

Answer 7

flat diaphragm

Question 8

What anatomy should you check for on chest X-ray to determine if it is good or not?

Answer 8

look for:
1st ribs
costophrenic angles
lateral edges of ribs

Question 9

How do you assess the penetration on a chest x-ray?

Answer 9

you should barely be able to see the thoracic vertebral bodies underneath the heart

**if underpenetrated (too white), can be mistaken for pleural disease or infiltrate
if overpenetrated (too dark), can under diagnose pleural disease or infiltrate

Question 10

So, list the four things you would do right away to determine the quality of a chest x-ray

Answer 10

1. spinous process equidistance from the medial clavicular edge
2. 9-10 posterior ribs visible on radiograph
3. look for costophrenic angles, lateral edges of ribs and 1st rib
4. identify thoracic vertebrae underneath the heart (barely)

Question 11

How should you evaluate the size of the heart on chest x-ray?

Answer 11

heart silhouette should be less than 50% of total thoracic width
1/3 diameter on right, 2/3 on left

Question 12

If the heart silhouette is greater than 50% of the total thoracic width, what would you suspect?

Answer 12

left ventricular hypertrophy or pericardial effusion

Question 13

When looking at the heart borders on chest x-ray, what does the right heart border represent? Left heart border?

Answer 13

right heart border is the right atrium, while the left heart border is the left ventricle

Question 14

If the left heart border is indistinct, what do you suspect?

Answer 14

left lingular consolidation

**consolidation means the presence of a liquid

Question 15

If the right heart border is indistinct, what do you suspect?

Answer 15

right middle lobar consolidation

Question 16

What should be visible on the left lateral edge of the aorta?

Answer 16

aortic knuckle

**loss of contour - aneurysm?
loss of definition - infiltrate or mass?

Question 17

What does a widened mediastinum suggest on chest x-ray?

Answer 17

thoracic aneurysm
ruptured aorta
aortic dissection
mediastinal lymphadenopathy

Question 18

What does obliteration of the silhouette of an anatomical border suggest?

Answer 18

pus, blood, or fluid

Question 19

What part of the lung touches the upper right heart border? What part of the lung touches the right heart border?

Answer 19

right upper lobe;

right middle lobe

Question 20

What part of the lung touches the upper left heart border? What part of the lung touches the aortic knob? How about the left heart border in general?

Answer 20

left upper lobe;
left upper lobe;
the lingula

Question 21

What happens to opacity (whiteness) in the lung from top to bottom?

Answer 21

whiteness will increase toward the bottom of the lung

**black (lucid) at the top of the lung

Question 22

You should be able to see lung markings all the way to the edge of the chest wall. If you don’t, and there is a space between the pleural edge and the chest wall, what should you consider?

Answer 22

pneumothorax

Question 23

What is the difference between a simple pneumothorax and a tension pneumothorax?

Answer 23

simple: no shift of midline structures, clinically stable
tension: trachea and mediastinum deviate away from pneumothorax, clinically unstable

Question 24

What does “blunting” of the costophrenic angles suggest?

Answer 24

pleural effusion

Question 25

What will an alveolar infiltrate look like on chest x-ray?

Answer 25

whispy and fluffy

Question 26

Describe a normal trachea on chest xray

Answer 26

should be midline (maybe slightly deviated to the right)

Question 27

If the trachea is pushed to the opposite side of the lung pathology, what would you suspect? If the trachea is pulled to the ipsilateral side, what would you suspect?

Answer 27

pleural effusion or tension pneumo;

total lung collapse or pneumonectomy