S10) Radiology of the Chest Flashcards
Penetration refers to the degree to which the x-rays have passed through the body.
What indicates adequate penetration in a normal CXR?
- Vertebrae just visible through heart
- Complete left hemidiaphragm is visible
Identify 5 external/iatrogenic material which obstructs the view in a CXR
- Clothes
- Buttons
- Hair
- Surgical/vascular lines
- Pacemaker
- female will have Breast shadows
Identify the structures 1-5 in the CXR below:
- Trachea
- Hila
- Lungs
- Diaphragm
- Heart
Identify the structures 6-10 in the CXR below:
- Aortic knuckle
- Ribs
- Scapulae
- Breasts
- Bowel gas
Identify the lung zones in the CXR below:
Identify the pleura in the CXR below:
Identify the costophrenic angles in the CXR below:
if this area becomes less sharp and the angle is obtuse then there is an issue
Identify the cardiophrenic angles in the CXR below:
Identify the cardiac contours in the CXR below:
Outline the systematic ABC approach used to evaluate a CXR
- Patient demographics
- Projection
- Adequacy
- ABCDE (airway, breathing, circulation, diaphragm, dem bones)
- Review areas
What does one look for in the ‘adequacy’ component of the CXR evaluation?
- Rotation – alignment of spinous processes and clavicles
- Inspiratory volume – look for diaphragm between 5th and 7th ribs, incomplete inspiration, hyperinflation, costo-phrenic recesses and angles, flat diaphragm
- Penetration – vertebrae just visible through the heart, complete left hemidiaphragm visible
What does one look for in the ‘airway’ component of the CXR evaluation?
- Trachea
- Bronchi (hila)
What does one look for in the ‘breathing’ component of the CXR evaluation?
- Lungs
- Pleural spaces
- Lung interfaces
What does one look for in the ‘circulation’ component of the CXR evaluation?
- Aortic arch
- Pulmonary vessels (hila)
- Right heart border: right atrium, middle lobe interface
- Left heart border: left ventricle, lingula interface
What does one look for in the ‘diaphragm’ component of the CXR evaluation?
- Free gas
- Nodules
- Fracture/dislocation
- Mass
Identify the 8 review areas in a CXR evaluation as well as the abnormalities one looks for
- Apices – pneumothorax
- Thoracic inlet – mass
- Paratracheal stripe – mass/lymph nodes
- AP window – lymph nodes
- Hila – mass/collapse
- Behind heart – mass
- Below diaphragm – pneumoperitoneum/mass
- Bones – fracture/mass/missing
What abnormality can one observe in the following CXR?
Pneumothorax
Describe 4 radiological findings observed in a pneumothorax
- Tracheal/mediastinal shift away from the pneumothorax (if tension)
- Depressed hemidiaphragm
- Visible pleural edge
- Radiolucent field around collapsed lung
What abnormality can one observe in the following CXR?
Pleural effusion
Describe 4 radiological findings observed in a pleural effusion
- Uniform white area
- Loss of costophrenic angle
- Hemidiaphragm obscured
- Meniscus at upper border
What abnormality can one observe in the following CXR?
Lobar lung collapse
Describe 4 radiological findings observed in a lobar lung collapse
- Elevation of the ipsilateral hemidiaphragm
- Crowding of the ipsilateral ribs
- Mediastinal shift towards the side of atelectasis
- Crowding of pulmonary vessels
Consolidation is the filling of small airways/alveoli various substances.
Identify 4 possible substances as well as their associated conditions
- Pus – pneumonia
- Blood – haemorrhage
- Fluid – oedema
- Cells – cancer
What abnormality can one observe in the following CXR?
Lung consolidation
Describe 3 radiological findings observed in a lung consolidation
- Dense opacification
- Volume preserved ± increased
- Air bronchogram
What abnormality is observed in the following CXR?
Space occupying lesion
What are the two different kinds of space occupying lesions (single/multiple)?
- Nodule < 3 cm
- Mass > 3 cm
What abnormality is observed in the following CXR?
Cardiac enlargement
What is the cardiothoracic ratio?
- CTR, measured on a PA chest x-ray, is the ratio of maximal horizontal cardiac diameter to maximal horizontal thoracic diameter
- A normal measurement should be <0.5
What abnormality is observed in the following CXR?
Pulmonary cavitation
What is cavitation in a CXR?
A pulmonary cavity is a gas-filled area of the lung in the centre of a nodule or area of consolidation due to infectious and non-infectious diseases
Mike, 60 years old, came into A&E with a 3-day history of fever, cough with greenish sputum and pleuritic chest pain.
Referring to the CXR below, answer the following questions:
- CXR abnormalities?
- Right side percussion?
- Right side breath sounds?
- Diagnosis?
- CXR abnormalities: right-sided opacity in middle zone
- Right side percussion: dull
- Right side breath sounds: crepitus & bronchial breathing
- Diagnosis: pneumonia
John, 55 years old presents to his GP with worsening breathlessness of 4 weeks in duration
Referring to the CXR below, answer the following questions:
- CXR abnormalities?
- Right side percussion?
- Right side breath sounds?
- Diagnosis?
- CXR abnormalities: loss of right heart border & right costophrenic angle
- Right side percussion: stony dull
- Right side breath sounds: absent/diminished
- Diagnosis: pleural effusion
Darren, 22 years old, develops sudden onset, sharp right sided chest pain while jogging. This worsens on inspiration and is associated with SOB
Referring to the CXR below, answer the following questions:
- CXR abnormalities?
- Right side percussion?
- Right side breath sounds?
- Diagnosis?
- CXR abnormalities: right lung collapse, artefact (ECG tag)
- Right side percussion: hyperresonance (more air)
- Right side breath sounds: absent/diminised
- Diagnosis: Spontaneous right-sided pneumothorax
Mr Singh, 50 years old, presents with a cough of 3 months in duration, recent haemoptysis, weight loss, night sweats and low grade fever in the evenings.
Referring to the CXR below, answer the following questions:
- CXR abnormalities?
- Abnormality at arrow?
- Diagnosis?
- CXR abnormalities: bilateral consolidation, patchy distribution in left upper and middle zones, slightly obscured left heart border
- Abnormality at arrow: cavitating lesion
- Diagnosis: tuberculosis
Joseph, 64 years old, increasing SOB for 2 years, chronic cough with productive mucoid sputum, 40 pack year history of smoking.
Referring to the CXR below, answer the following questions:
- CXR abnormalities?
- Right side percussion?
- Auscultation?
- Diagnosis?
- Complications?
- CXR abnormalities: flattened diaphragm, hyperinflated lung fields, two ECG tags
- Right side percussion: diffused hyperresonance
- Auscultation: wheezing, stridor
- Diagnosis: COPD
- Complications: pneumonia, pneumothorax
Stephen, 50 years old, presents with dry cough of 3 months duration, recent haemoptysis, 30 pack year history of smoking and finger clubbing.
Referring to the CXR below, answer the following questions:
- CXR abnormalities?
- Diagnosis?
- Other investigations?
- Complications?
- CXR abnormalities: irregular dense opacity in upper left lobe
- Diagnosis: lung cancer
- Other investigations: tumour markers, lung biopsy
- Complications: compression of left phrenic nerve by lung tumour (elevation of left hemidiaphragm, left mediastinal shift)
Michael, 70 years old, presents with loss of appetite, weight loss of 1 month duration, looks emaciated and unwell.
Referring to the CXR below, answer the following questions:
- CXR abnormalities?
- Diagnosis?
- Origin?
- Investigations?
- CXR abnormalities: obscured right cardiophrenic angle, slightly obscured heart borders, wide bilateral soft tissue nodules (irregular edges, size varies)
- Diagnosis: multiple lung metastases (cannonball metastases)
- Origin: primary renal cancer
- Investigations: full body CT, FBC, tumour biopsy
George, 75 years old, presents with increasing SOB for 2 months duration on minimal exertion, SOB at night, previous AMI at 69 years old, past smoker (gave up after heart attack).
Referring to the CXR below, answer the following questions:
- CXR abnormalities?
- Apex beat change?
- Auscultation?
- Diagnosis?
- Accumulation of fluid?
- CXR abnormalities: bilateral hilar shadowing, loss of left costophrenic angle, slightly enlarged heart
- Apex beat change: laterally shifted apex beat
- Auscultation: fine crackles
- Diagnosis: heart failure
- Accumulation of fluid: pulmonary, saccral and peripheral oedema
what is RIPE?
- rotation → clavicles should be equal distances from the spine, spine should be vertically orientated
- inspiration → 5-6 anterior ribs, lung apices, both costophrenic angles and lateral rib edges should be visible
- projection → AP or PA
- Exposure → left hemidiaphragm should be visible to spine and vertebrae visible behind the heart
how to compare between PA and AP
AP:
- heart will appear much larger
- normally patient appears lying down
- sometimes quality is worse as this is ding in the bedside
- (you should still be able to see the spinous process)
PA:
- heart is presented in normal size
- patient is standing
- the scapula will be visible on the sides and far out
- quality is normally better as these are taken in proper x ray rooms
why is a pulse oximeter not always reliable in darker skin
they are calibrated towards lighter skinned people
they use light waves and the melanin will block these signals
what is the ABCDE approach
Airway → trachea deviated
Breathing → observe lungs and pleura
Cardiac → heart size, heart borders
Diaphragm → costophrenic angles, diaphragm in relation to the ribs and the chest
Everything else → Bones, soft tissue, air under diaphragm, pacemaker, wires
what is the gastric bubble
you will be able to see a dark path under the diaphragm on the right side of patient:
this is air at the top of the stomach which is normal
what is an air fluid level?
occurs when air rises above a fluid in a contained space and there is a flat surface at the air - fluid interface
what are some reasons of tracheal deviation
pushing: large pleural effusion or tension pneumothorax
Pulling: lobar collapse
what is a carina
- cartilage situated at the point where the trachea divides into the left and right main bronchus
- right main bronchus is wider, shorter and more vertical so more likely for foreign bodies to enter
why is the hilar point an important landmark
- the hilar consists of vascular structures and main bronchi
- left helium is slightly higher than the right one
- hilar point → where the descending pulmonary artery intersects the superior pulmonary vein
what are some hilar malignancies
hilar enlargement:
- Bilateral symmetrical enlargement → sarcoidosis
- Unilateral enlargement → underlying malignancy
- can be be pushed or pulled
what is pseudo-pneumonperitonem
- abnormal position of the colon between the liver and the diaphragm → gives the appearance of free gas
- seen in chilaiditi syndrome
