Test 1: Chest X-Rays (Andy's Cards) Flashcards
1
Q
In the U.S., CXR is routinely obtained for hospitalized adults. In other countries, due to cost, providers rely on physical examination. What are the inherent limitations to this?
A
- Identifying lesions in the mediastinum, interstitium, and in the center of the lung.
2
Q
What pathologies can be present even with a normal chest x-ray?
A
- Interstitial, airway, and pulmonary vascular disease can not be recognized with CXR (i.e.: asthmatics).
3
Q
Overexposure will cause a film to be too _______.
What structures are well seen in these conditions?
What structures can not be seen?
A
- Dark
- Bony structures can be well seen (thoracic spine, mediastinal structures, retrocardiac areas)
- Small nodules and fine lung structures will be difficult to see.
4
Q
Underexposure will cause a film to be too _______.
What structures are well seen in these conditions?
A
- Bright/White
- Small pulmonary blood vessels will appear prominent and may lead you to think that there are generalized infiltrates when none is really present.
5
Q
How does breast tissue or an overly obese patient affect the X-ray image?
A
Breast tissue and large amounts of fat tissue can absorb X-ray beams which causes underexposure of the tissue in the path.
6
Q
How are chest X-rays on ambulatory patients routinely done?
A
- Patient’s chest up and against the firm holder.
- The X-ray passes from the back and exits in front to the chest.
- This is called a PA projection (posterior to anterior).
7
Q
If the patient is lying down, what will be the orientation of the X-ray projection?
A
- AP Projection (anterior to posterior)
8
Q
For interpretative purposes, what is the main difference between an AP and PA projection?
A
- The heart will be magnified on an AP projection.
- This is the because the projection of the heart is farther from the film and the X-ray beam diverges as it goes farther from the X-ray tube.
9
Q
Why do X-ray techs tell patients to take a deep breath and hold it before they shoot the X-ray?
A
- Inspiration allows for the spreading of the pulmonary vessels and clearer visualization
10
Q
What are two reasons why upright film is preferred over supine film?
A
- Patients can have a greater inspiration.
- Better visualization of pleural effusion since it will run into the normally deep costophrenic angle.
11
Q
When standing, most adults can take an inspiration that brings the domes of the hemidiaphragm to which rib number?
A
- Rib 10
12
Q
When seated, most adults can take an inspiration that brings the domes of the hemidiaphragm to which rib number?
A
- Anywhere from Rib 8 to Rib 10
13
Q
If the lungs are hypoinflated, the radiography will show the diaphragm at which rib?
A
- Rib 7
14
Q
When doing a quick scan at a CXR, we start at the area of least importance to most importance. What will this order be?
A
- Abdomen (first)
- Thorax
- Mediastinum
- Individual Lungs
- Bilateral Lung (last)
15
Q
Pattern of how you will scan the abdomen of a CXR?
A
16
Q
What is the red arrow indicating?
Is this a normal finding on a CXR?
A
- Gastric bubble
- This is a normal finding on a CXR
Free air: Instead of the air being contained inside the stomach to the unitlateral side of the diaphgram, air will be displaced bilaterally on both sides of the diaphragm.
17
Q
Pattern of how you will scan the thorax of a CXR?
A
18
Q
What are you scanning for when looking at the thorax of a CXR?
A
- Bony Structures
- Rib
- Clavicles
- Scapula
- Continuity and Malformation (Fractures)
19
Q
Which type of rib fracture is harder to detect on a CXR (Posterior or Anterior Ribs)?
A
- Posterior Rib fractures are harder to detect.
20
Q
The pattern of how you will scan the mediastinum and heart of a CXR.
A
21
Q
What three structures in the mediastinum should be centrally located during a routine CXR?
A
- Heart
- Sternum
- Trachea
22
Q
Generally, the heart should be no larger than _______ of the chest diameter.
A
- one-third
23
Q
The pattern of how you will scan each lung on a CXR.
A
24
Q
What is the systematic approach (detail) for viewing a CXR?
A
- Bony Fragments/ Framework
- Soft Tissues
- Lung Fields and Hila
- Diaphragm and Pleural Space
- Mediastinum and Heart
- Abdomen and Neck
25
What are bony fragments that can be viewed on a CXR?
* Ribs - start at sternum and trace posteriorly
* Sternum - look for continuity
* Spine - best view on lateral image
* Shoulder girdle - look for displacement
* Clavicles - look for symmetry
26
What soft tissues are inspected on a CXR?
* Breast tissue - breast tissue can hide diaphragmatic problems, fluid accumulation, free air
* Soft Tissue in the supraclavicular area
* Axillae
* Tissue along the breast
27
What can be viewed in the Hilum on a CXR?
* Pulmonary arteries
* Pulmonary veins
28
What is another name for the hilum?
* Lung Root
29
What should be seen in the lungs of a healthy adult's CXR?
* Normal Lung markings
* Linear and fine nodular shadows of pulmonary vessels
* Abnormalities in the lung field are marked by excessive radiolucency, excessive radiopacity, or opacified areas.
30
What percent of the lung field and hila will be obscured by the tissue?
* 40%
31
What kind of shape should the diaphragm form on a normal CXR?
* Dome-shape
* Costophrenic angle (red circle)
32
True or False: Normal pleural is not visible in a healthy person's CXR.
* True
* You should not be able to see the pleural in a normal CXR.
* The only time you should see the pleural is when air is trapping between the chest wall or the mediastinum and lungs.
33
On a Posterior-Anterior CXR, the normal right heart and mediastinal border are made up of four structures. Name them from the bottom to the top.
* Inferior Vena Cava (bottom)
* Right Atrium
* Ascending Aorta
* Superior Vena Cava (top)
34
On a Posterior-Anterior CXR, the normal left heart and mediastinal border comprise five structures. Name them from the bottom to the top.
* Left Ventricle (bottom)
* Left Atrium
* Pulmonary Artery
* Aortic Arch
* Subclavian Artery/Vein (top)
35
What side is the gastric bubble usually on?
* Left side (unilateral)
36
What is assessed on the neck for a CXR?
* Soft tissue mass
* Air trapping (air bronchogram)
37
Can you tell the content of a fluid by looking at a X-ray?
* No
* You can tell that the substance is a fluid, but not what it is made up of (blood, mucous, pulmonary edema).
38
Describe the appearance of the following on a CXR:
Air
Water
Bone
Tissue
* Air tends to be black
* Water is solid white
* Bone is translucent white
* Tissue is even more solid white than fluid.
39
What factors can result in a poor quality x-ray film?
* Poor inspiration (poor visibility/ high diaphragms)
* Over or under-penetration (can exaggerate important findings)
* Rotation (obscure CXR view)
* Forgetting the path of the X-ray beam
40
On a properly penetrated posterior-anterior CXR, one can just make out the __________ overlying the image of the heart.
* thoracic vertebrae
41
How will you check if the patient is not rotated on CXR?
* Check proper orientation by noting equal distance from vertebral spines to medial ends of the clavicle
42
How many lobes are there on the right lung?
* 3 lobes on the right lung
43
How many lobes are there on the left lung?
* 2 lobes on the left lung
44
What type of CXR projection/orientation will have extensive lung overlap?
* Posterior-anterior X-ray projection will show the lower lobes extending high over the lung field.
45
How much of the right lung does the RUL occupy?
* one-third
46
Posteriorly, the RUL is adjacent to the first _____ to _____ ribs.
* 3 to 5 ribs
47
Anteriorly, the RUL extends down as far as the _______anterior right rib.
* 4th anterior right rib
48
What is the smallest lobe of the right lung?
What kind of shape does it look like in a lateral CXR?
* The right middle lobe is the smallest lobe
* Triangular shape with narrowest end near the hilum
49
What is the largest lobe of the right lung?
* RLL
* RLL is also the most common place pt will develop pneumonia.
* RLL will also be harder to see in patients with poor inspiration.
50
Posteriorly, the RLL extends as far superiorly as high as the ______ vertebral body and extends inferiorly to the diaphragm.
* 6th thoracic
51
How many fissures separate the lobes of the right lung?
* Two fissures
* Minor Fissure - separates RUL and RML
* Major Fissure - separates the RUL/RML from the RLL
52
Which lobe covers most of the anterior portion of the left lung?
* LUL
53
Which lobe covers most of the posterior portion of the left lung?
* LLL
54
What lobe in the lungs in most prone to pneumonia development?
RLL
55
What separates the LUL and LLL?
* Major Fissure
56
Label 1
* Aortic Arch
57
Label 2
* Pulmonary Trunk
58
Label 3
* Left atrial appendage
59
Label 4
* Left Ventricle
60
Label 5
* Right Ventricle
61
Label 6
* Superior Vena Cava
62
Label 7
* Right hemidiaphragm
63
Label 8
* Left hemidiaphragm
64
Label 9
* Horizontal fissure
65
Label 1
* Oblique Fissure
66
Label 2
* Horizontal Fissure
67
Label 3
* Thoracic spine/ Retrocardial space
68
Label 4
* Retrosternal space
69
What will cause a Silhouette Sign on a CXR?
* Lungs making contact with the heart or any structure (tumor, mass, lesion) that may obscure the border of a CXR.
70
Visualization of air in the intrapulmonary bronchi on a CXR is called a ________ sign.
* Bronchogram
* Bronchogram sign indicates an abnormal lung (consolidation).
* With consolidation, pulmonary vessels are no longer visualized b/c they are surrounded by other soft tissue density material.
71
1/3rd of the heart sides on ______ side
2/3rd of the heart sides on the ______ side.
* right side
* left side
72
Lung injury or pathological states can be either a ________ or _______ process.
* generalized
* localized
73
What can cause generalized liquid density in a lung?
* Diffused alveolar
* Diffused interstitial
* Mixed/Vascular
74
What can cause localized liquid density in a lung?
* Infiltrate
* Consolidation
* Cavitation
* Mass
* Congestion
* Atelectasis
75
What can cause increased air density in the lungs?
* Localized airway obstruction
* Diffuse airway obstruction
* Emphysema
* Bulla
76
What is consolidation on a CXR?
* Alveolar space filled with inflammatory exudate (bacteria and WBC).
* With consolidation, architecture remains the same and the airway is patent
77
What is obstructive atelectasis on a CXR?
* No ventilation to the lobe beyond the obstruction (ie: mucous plug, right main stem intubation)
78
What are the stages of evaluating a CXR abnormality?
* ID the abnormal shadows
* Anatomically localize lesion
* ID pathological process
* ID etiology
* Confirm clinical suspicion (contrast, CT, MRI)
79
What are the two arrows pointing at?
What does the "^" indicate?
* ETT
* Central Line
80
What does this CXR show?
* Right mainstem intubation
81
Is this a proper placement of a central line?
* No, the tip (smaller red arrow) is within the right ventricle. Pt will probably experience PVCs.
* The catheter tip should lie between the most proximal venous valves of the subclavian or jugular veins and the right atrium.
82
What is this CXR showing?
* Right pleural effusion
* Notice the loss of the costophrenic angle
83
What is this CXR showing?
* RML pneumonia
* You can rule out RLL pneumonia because there is no accumulation at the base of the lung.
* A lateral CXR will have the best view for confirmation.
84
What is this CXR showing?
* RUL pneumonia
85
What is this CXR showing?
* RLL pneumonia
86
What is this CXR showing?
* Free air under the diaphragm
87
What are the four arrows pointing at?
* Cavitary Infiltrate
88
A lesion seen in the lung that is caused by tuberculosis.
* Ghon's Complex
* The lesions consist of a calcified focus of infection and an associated lymph node.
* Very hard to detect.
89
What are the arrows pointing to in this CXR?
* Anterior Mediastinal Mass
* Need lateral CXR to confirm. It's hard to see the mass in AP view.
90
What are the arrows pointing to in this CXR?
* LUL Mass
91
What is this CXR showing?
* Pulmonary Metastasis (Cancer)
* The white circular object on the patient's right lung is a medication port.
92
What are the two arrows on this CXR indicating?
* Pneumomediastinum
* There should never be that much air between the heart and lungs.
* This can be caused by airway trauma, tracheal or esophageal rupture
93
What is this CXR showing?
* Left Pneumothorax
* Notice the air trapping on the patient's left lung
94
What is this CXR showing?
* Subcutaneous Emphysema
* Notice the intermittent areas of radiolucency, often representing a fluffy appearance on the exterior borders of the thorax.
95
What is the red arrow indicating?
* Deep Sulcus Sign
* This is an indirect indicator of a pneumothorax.
96
If a child swallows a large coin, is it more likely to go down the esophagus or trachea?
* Esophagus
97
What is this CXR showing?
* Pulmonary Fibrosis
98
What is this CXR showing?
* Diffused Pulmonary Edema
99
What is the classic sign on a CXR of pulmonary edema secondary to CHF?
* Bat Wing Pattern
* Enlarged Heart
100
What is this CXR showing?
* Post-op Left Pneumonectomy
* There is no left lung
101
What is this CXR showing?
* Transverse Aortic Arch Aneurysm
102
What is this CXR showing?
* Cardiomegaly
103
What is this CXR showing?
* Aortic Dissection
* Notice the wide mediastinum and deviation of the heat to the patient's left side
104
What sign is present when a large loop of the intestine gets shoved between the diaphragm and the liver?
* Chilaiditi Sign
105
What is this CXR showing?
* Esophageal Rupture (Boerhaave's Syndrome)
* Notice small bilateral lung field and infiltrates
* Wide mediastinum pattern
* Air visible on bilateral sides of the heart
106
What is hilar adenopathy?
* Hilar adenopathy is the enlargement of lymph nodes in the hilum.
* It can be caused by conditions such as tuberculosis, sarcoidosis, drug reactions, infections, or cancer.
107
What is this CXR showing?
* Bilateral Hilar Adenopathy
108
Case Study: 35 y/o male with dyspnea, unplanned weight loss over 3 months.
* Pulmonary lesion on patient's left lung
* Thin-walled cavity is noted in the left midlung. Most likely cancerous.
* This finding is most typical of squamous cell carcinoma (SCC).
109
Case Study: 65y/o with a month worth of dyspnea, occasional productive cough, and fever
* LUL Atelectasis: Loss of heart borders/silhouetting.
* Notice over inflation on unaffected lung
* Inflammatory process or pneumonia in the LUL
110
Case Study: 30yo female with 1 week of fever and cough
* Right Middle Lobe Pneumonia
* Left Upper Lobe Pneumonia
111
Case Study: 28y/o inmate for CT-guided drainage
* Cavitation: cystic changes in the area of consolidation due to the bacterial destruction of lung tissue.
* Pleural Effusion in RML
* Notice air-fluid level.
112
What are the two arrows indicating in this CXR?
* Tuberculosis (stretched out cotton ball appearance)
113
What is this CXR showing?
* COPD: increase in heart diameter, flattening of the diaphragm, and increase in the size of the retrosternal air space.
* In addition, the upper lobes will become hyperlucent due to the destruction of the lung tissue.
114
What is this CXR showing?
* Pseudotumor: fluid has filled the minor fissure creating a density that resembles a tumor (arrow). Recall that fluid and soft tissue are indistinguishable on plain film.
* Further analysis, however, reveals a classic pleural effusion in the right pleura.
* Note the right lateral gutter is blunted and the right diaphram is obscurred.
115
What is this CXR showing?
* Pneumonia: a large pneumonia consolidation in the right lower lobe.
* Knowledge of lobar and segmental anatomy is important in identifying the location of the infection.
116
What is this CXR showing?
* Pulmonary Edema secondary to CHF
* A great deal of accentuated interstitial markings, curly lines, and an enlarged heart.
* Normally indistinct upper lobe vessels are prominent but are also masked by interstitial edema.
117
What is the CXR showing?
* Chest wall lesion: arising off the chest wall and not the lung
118
What is the CXR showing?
* Pleural effusion: Note loss of left hemidiaphragm.
* Fluid drained via thoracentesis
119
What is the CXR showing?
* Lung Mass
120
What is the CXR showing?
* Small Pneumothorax: LUL
* Notice that thin white line, that is the lung being shoved down by the pneumothorax
121
What is the CXR showing?
* Right Middle Lobe Pneumothorax: complete lobar collapse and deep sulcus
122
What is the CXR showing?
* Metastatic Lung Cancer: Multiple nodules seen
123
What is the CXR showing?
* RUL pulmonary nodule
124
What is the CXR showing?
* TB
125
What is the CXR showing?
* Perihilar mass
* Hodgkin’s disease
126
What is the CXR showing?
* Widened Mediastinum
* Aortic Dissection
127
What is the CXR showing?
* Pulmonary artery stenosis with cardiomegaly likely secondary to stenosis.
