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Principles Exam I/Week I > Test 1: Chest X-Rays (Andy's Cards) > Flashcards

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

*Lesions in the mediastinum, interstitium, and in the center of the lung are rarely picked up on physical exam

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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 have normal cxr).
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3
Q

What is the downside to X-ray?

A

Doesn’t rule out pulmonary problems.
Providers have relied on x rays to the point where they lose the skill of physical exam. This is crucial because some pulmonary issues are easier found upon assessment.

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4
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.
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5
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.
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6
Q

When the _________ portion of the breast is _________ the _______________ underexposure should not be an issue

A

inferior
above
hemidiaphragms

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7
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.

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8
Q

How are chest X-rays on ambulatory patients routinely done?

A
  • Patient’s chest up and against the film holder.
  • The X-ray passes from the back and exits in front to the chest.
  • This is called a PA projection (posterior to anterior).
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9
Q

If the patient is lying down, what will be the orientation of the X-ray projection?

A
  • AP Projection (anterior to posterior)
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10
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.
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11
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.
    *marked increase if patient upright as well
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12
Q

What are two reasons why upright film is preferred over supine film?

A
  • Patients can have a greater inspiration allowing for clearer visualization
  • Pleural effusion easier to ID since it will run into the normally deep costophrenic angle.
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13
Q

When standing, most adults can take an inspiration that brings the domes of the hemidiaphragm to which rib number?

A
  • Rib 10
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14
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
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15
Q

If the lungs are hypoinflated, the radiography will show the diaphragm at which rib?

A
  • Rib 7
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16
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)
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17
Q

Pattern of how you will scan the abdomen of a CXR?

A
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18
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.

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19
Q

Pattern of how you will scan the thorax of a CXR?

A
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20
Q

What are you scanning for when looking at the thorax of a CXR?

A
  • Bony Structures
  • Rib
  • Clavicles
  • Scapula
  • Continuity and Malformation (Fractures)
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21
Q

What is the recommended method of identifying/counting ribs based on CXR

A

Start superior and anterior

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22
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.
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23
Q

The pattern of how you will scan the mediastinum and heart of a CXR.

A
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24
Q

What three structures in the mediastinum should be centrally located during a routine CXR?

A
  • Heart
  • Sternum
  • Trachea
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25
Q

Generally, the heart should be no larger than _______ of the chest diameter.

A
  • one-third
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26
Q

The pattern of how you will scan each lung on a CXR.

A
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27
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
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28
Q

What are bony fragments that can be viewed on a CXR?

A
  • 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
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29
Q

On a CXR what structures should the diaphragms be overlying?

A

The diaphragms should be overlying the posterior aspects of the 10th or 11th ribs (in a normal adult).

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30
Q

What soft tissues are inspected on a CXR?

A
  • Breast tissue - breast tissue can hide diaphragmatic problems, fluid accumulation, free air
  • Soft Tissue in the supraclavicular area
  • Axillae
  • Tissue along the breast
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31
Q

What can be viewed in the Hilum on a CXR?

A
  • Pulmonary arteries
  • Pulmonary veins
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32
Q

What is another name for the hilum?

A
  • Lung Root
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33
Q

What should be seen in the lungs of a healthy adult’s CXR?

A
  • 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.
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34
Q

What percent of the lung field and hila will be obscured by the tissue?

A
  • 40%
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35
Q

What kind of shape should the diaphragm form on a normal CXR?

A
  • Dome-shape
  • Costophrenic angle (red circle)
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36
Q

True or False: Normal pleural is not visible in a healthy person’s CXR.

A
  • 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.
    *normal pleura also seen when two layers come together to form interlobar fissures.
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37
Q

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.

A
  • Inferior Vena Cava (bottom)
  • Right Atrium
  • Ascending Aorta
  • Superior Vena Cava (top)
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38
Q

On a Posterior-Anterior CXR, the normal left heart and mediastinal border comprise five structures. Name them from the bottom to the top.

A
  • Left Ventricle (bottom)
  • Left Atrium
  • Pulmonary Artery
  • Aortic Arch
  • Subclavian Artery/Vein (top)
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39
Q

What side is the gastric bubble usually on?

A
  • Left side (unilateral)
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40
Q

What is a serious complication that we are assessing in regards to the abdomen

A

perforation, particularly assessed via the diaphragm or lack thereof

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41
Q

What is assessed on the neck for a CXR?

A
  • Soft tissue mass
  • Air trapping (air bronchogram)
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42
Q

Can you tell the content of a fluid by looking at a X-ray?

A
  • No
  • You can tell that the substance is a fluid, but not what it is made up of (blood, mucous, pulmonary edema).
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43
Q

Describe the appearance of the following on a CXR:

Air
Water
Bone
Tissue

A
  • Air tends to be black
  • Water is solid white
  • Bone is translucent white
  • Tissue is even more solid white than fluid.
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44
Q

What factors can result in a poor quality x-ray film?

A
  • 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
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45
Q

On a properly penetrated posterior-anterior CXR, one can just make out the __________ overlying the image of the heart.

A
  • thoracic vertebrae
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46
Q

How will you check if the patient is not rotated on CXR?

A
  • Check proper orientation by noting equal distance from vertebral spines to medial ends of the clavicle
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47
Q

How many lobes are there on the right lung?

A
  • 3 lobes on the right lung
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48
Q

How many lobes are there on the left lung?

A
  • 2 lobes on the left lung
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49
Q

What type of CXR projection/orientation will have extensive lung overlap?

A
  • Posterior-anterior X-ray projection will show the lower lobes extending high over the lung field.
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50
Q

How much of the right lung does the RUL occupy?

A
  • one-third
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51
Q

Posteriorly, the RUL is adjacent to the first _____ to _____ ribs.

A
  • 3 to 5 ribs
52
Q

Anteriorly, the RUL extends down as far as the _______anterior right rib.

A
  • 4th anterior right rib
53
Q

What is the smallest lobe of the right lung?

What kind of shape does it look like in a lateral CXR?

A
  • The right middle lobe is the smallest lobe
  • Triangular shape with narrowest end near the hilum
54
Q

What is the largest lobe of the right lung?

A
  • RLL
  • RLL is also the most common place pt will develop pneumonia.
  • RLL will also be harder to see in patients with poor inspiration.
55
Q

Posteriorly, the RLL extends as far superiorly as high as the ______ vertebral body and extends inferiorly to the diaphragm.

A
  • 6th thoracic
56
Q

How many fissures separate the lobes of the right lung?

A
  • Two fissures
  • Minor Fissure - separates RUL and RML
  • Major Fissure - separates the RUL/RML from the RLL
57
Q

Which lobe covers most of the anterior portion of the left lung?

A
  • LUL
58
Q

Which lobe covers most of the posterior portion of the left lung?

A
  • LLL
59
Q

What lobe in the lungs is most prone to pneumonia development?

A

RLL

60
Q

What separates the LUL and LLL?

A
  • Major Fissure
61
Q

Label 1

A
  • Aortic Arch
62
Q

Label 1

A
  • Oblique Fissure
63
Q

Label 2

A
  • Horizontal Fissure
64
Q

Label 3

A
  • Thoracic spine/ Retrocardial space
65
Q

Label 4

A
  • Retrosternal space
66
Q

What will cause a Silhouette Sign on a CXR?

A
  • Lungs making contact with the heart or any structure (tumor, mass, lesion) that may obscure the border of a CXR.
67
Q

Visualization of air in the intrapulmonary bronchi on a CXR is called a ________ sign.

A
  • 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.
68
Q

1/3rd of the heart sides on ______ side
2/3rd of the heart sides on the ______ side.

A
  • right side
  • left side
69
Q

Lung injury or pathological states can be either a ________ or _______ process.

A
  • generalized
  • localized
70
Q

What can cause generalized liquid density in a lung?

A
  • Diffused alveolar
  • Diffused interstitial
  • Mixed/Vascular
71
Q

What can cause localized liquid density in a lung?

A
  • Infiltrate
  • Consolidation
  • Cavitation
  • Mass
  • Congestion
  • Atelectasis
72
Q

What can cause increased air density in the lungs?

A
  • Localized airway obstruction
  • Diffuse airway obstruction
  • Emphysema
  • Bulla
73
Q

What is consolidation on a CXR?

A
  • Alveolar space filled with inflammatory exudate (bacteria and WBC).
  • With consolidation, architecture remains the same and the airway is patent
74
Q

How is consolidation seen on x-ray?

A

A density corresponding to a segment or lobe.
Airbronchogram
Or can be seen with no significant loss of lung volume

75
Q

What is the radiologic criteria for Absorptive Atelectasis?

A

A density corresponding to a segment or lobe
significant signs of loss of volume
compensatory hyperinflation of normal lungs

76
Q

What is obstructive atelectasis on a CXR?

A
  • No ventilation to the lobe beyond the obstruction (ie: mucous plug, right main stem intubation)
77
Q

What are the stages of evaluating a CXR abnormality?

A
  • ID the abnormal shadows
  • Anatomically localize lesion
  • ID pathological process
  • ID etiology
  • Confirm clinical suspicion (contrast, CT, MRI)
78
Q

What are the two arrows pointing at?
What does the “^” indicate?

A
  • ETT
  • Central Line
79
Q

What does this CXR show?

A
  • Right mainstem intubation
80
Q

Is this a proper placement of a central line?

A
  • 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.
81
Q

What is this CXR showing?

A
  • Right pleural effusion
  • Notice the loss of the costophrenic angle
82
Q

What is a defining characteristic of pleural effusion that is seen on CXR?

A

The fluid will level out in the space it occupies. The costrophrenic angle will be gone if it is at the base.

83
Q

What is this CXR showing?

A
  • 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
Q

What is this CXR showing?

A
  • RUL pneumonia
85
Q

What is this CXR showing?

A
  • RLL pneumonia
86
Q

What is this CXR showing?

A
  • Free air under the diaphragm
87
Q

What are the four arrows pointing at?

A
  • Cavitary Infiltrate
88
Q

A lesion seen in the lung that is caused by tuberculosis.

A
  • Ghon’s Complex
  • The lesions consist of a calcified focus of infection and an associated lymph node.
  • Very hard to detect.
89
Q

What are the arrows pointing to in this CXR?

A
  • Anterior Mediastinal Mass
  • Need lateral CXR to confirm. It’s hard to see the mass in AP view.
90
Q

What are the arrows pointing to in this CXR?

A
  • LUL Mass
91
Q

What is this CXR showing?

A
  • Pulmonary Metastasis (Cancer)
  • The white circular object on the patient’s right lung is a medication port.
92
Q

What are the two arrows on this CXR indicating?

A
  • 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
Q

What is this CXR showing?

A
  • Left Pneumothorax
  • Notice the air trapping on the patient’s left lung
94
Q

What is this CXR showing?

A
  • Subcutaneous Emphysema
  • Notice the intermittent areas of radiolucency, often representing a fluffy appearance on the exterior borders of the thorax.
95
Q

What is the red arrow indicating?

A
  • Deep Sulcus Sign
  • This is an indirect indicator of a pneumothorax.
96
Q

If a child swallows a large coin, is it more likely to go down the esophagus or trachea?

A
  • Esophagus
97
Q

What is this CXR showing?

A
  • Pulmonary Fibrosis
98
Q

What is this CXR showing?

A
  • Diffused Pulmonary Edema
99
Q

What is the classic sign on a CXR of pulmonary edema secondary to CHF?

A
  • Bat Wing Pattern
  • Enlarged Heart
100
Q

What is this CXR showing?

A
  • Post-op Left Pneumonectomy
  • There is no left lung
101
Q

What is this CXR showing?

A
  • Transverse Aortic Arch Aneurysm
102
Q

What is this CXR showing?

A
  • Cardiomegaly
103
Q

What is this CXR showing?

A
  • Aortic Dissection
  • Notice the wide mediastinum and deviation of the heat to the patient’s left side
104
Q

What sign is present when a large loop of the intestine gets shoved between the diaphragm and the liver?

A
  • Chilaiditi Sign
105
Q

What is this CXR showing?

A
  • Esophageal Rupture (Boerhaave’s Syndrome)
  • Notice small bilateral lung field and infiltrates
  • Wide mediastinum pattern
  • Air visible on bilateral sides of the heart
106
Q

What is hilar adenopathy?

A
  • 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
Q

What is this CXR showing?

A
  • Bilateral Hilar Adenopathy
108
Q

Case Study: 35 y/o male with dyspnea, unplanned weight loss over 3 months.

A
  • 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
Q

Case Study: 65y/o with a month worth of dyspnea, occasional productive cough, and fever

A
  • LUL Atelectasis: Loss of heart borders/silhouetting.
  • Notice over inflation on unaffected lung
  • Inflammatory process or pneumonia in the LUL
110
Q

Case Study: 30yo female with 1 week of fever and cough

A
  • Right Middle Lobe Pneumonia
  • Left Upper Lobe Pneumonia
111
Q

Case Study: 28y/o inmate for CT-guided drainage

A
  • 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
Q

What are the two arrows indicating in this CXR?

A
  • Tuberculosis (stretched out cotton ball appearance)
113
Q

What is this CXR showing?

A
  • 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
Q

What is this CXR showing?

A
  • 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
Q

What is this CXR showing?

A
  • 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
Q

What is this CXR showing?

A
  • 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
Q

What is the CXR showing?

A
  • Chest wall lesion: arising off the chest wall and not the lung
118
Q

What is the CXR showing?

A
  • Pleural effusion: Note loss of left hemidiaphragm.
  • Fluid drained via thoracentesis
119
Q

What is the CXR showing?

A
  • Lung Mass
120
Q

What is the CXR showing?

A
  • Small Pneumothorax: LUL
  • Notice that thin white line, that is the lung being shoved down by the pneumothorax
121
Q

What is the CXR showing?

A
  • Right Middle Lobe Pneumothorax: complete lobar collapse and deep sulcus
122
Q

What is the CXR showing?

A
  • Metastatic Lung Cancer: Multiple nodules seen
123
Q

What is the CXR showing?

A
  • RUL pulmonary nodule
124
Q

What is the CXR showing?

A
  • TB
125
Q

What is the CXR showing?

A
  • Perihilar mass
  • Hodgkin’s disease
126
Q

What is the CXR showing?

A
  • Widened Mediastinum
  • Aortic Dissection
127
Q

What is the CXR showing?

A
  • Pulmonary artery stenosis with cardiomegaly likely secondary to stenosis.

Principles Exam I/Week I (2 decks)

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