Clinical aspects oI CXR

Interpretation
Abhiru| kuIe
Dept of CIinicuI Phurmucy,
kLES DrPrubhukur kore
HospituI & MRC,
ßeIquum
-ectives
To review ordering a chest x-ray
To review the normal Iindings including
skeletal and soIt tissue landmarks
To present a systematic procedure Ior
interpreting chest x-rays
To cover common a-normal Iindings in the
primary care setting.
rdering a Chest X-Ray
rder -y chieI complaint
Views: PA (standard Irontal chest Iilm)
Lateral (marked -y which side oI chest is
against the Iilm good to assess the area
-ehind the heart)
Positioning: Lying vs. Upright
Right vs. LeIt
$ystematic Interpretation
$uggested Routine
La-el (VeriIy ID Iactors)
rientation
Quality
$keletal $tructures
$oIt Tissue $tructures
eIore Interpreting a Film
Make sure it`s the right patient.
Know the patient`s story.
Have older Iilms, iI availa-le.
Place Iilms on the view -ox as though you are
Iacing the patient.
Check the quality: You should -e a-le to see the
outlines oI the verte-ral -odies within the heart
shadow.
Check Ior rotation (symmetrical clavicles).
Know normal anatomy
ssentials eIore Getting
$tarted
xposure
verexposure
Underexposure
$ex oI Patient
Male
Female
Path oI x-ray -eam
PA
AP
Patient Position
Upright
$upine
ssentials eIore Getting
$tarted
$ystematic Approach
ony Framework
$oIt Tissues
Lung Fields and Hila
Diaphragm and Pleural $paces
Mediastinum and Heart
A-domen and Neck
$ystematic Approach
ony Fragments
Ri-s
$ternum
$pine
$houlder girdle
Clavicles
$ystematic Approach
$oIt Tissues
reast shadows
$upraclavicular areas
Axillae
Tissues along side oI
-reasts
$ystematic Approach
Lung Fields and Hila
Hilum
Pulmonary arteries
Pulmonary veins
Lungs
Linear and Iine nodular
shadows oI pulmonary
vessels
lood vessels
40° o-scured -y other
tissue
Diaphragm and
Pleural $urIaces
Diaphragm
Dome-shaped
Costophrenic angles
Normal pleural is
not visi-le
Interlo-ar Iissures
$ystematic Approach
Mediastinum and
Heart
LeIt side
LeIt ventricle
LeIt atrium
Pulmonary artery
Aortic arch
$u-clavian artery and
vein
$ystematic Approach
$ystematic Approach
A-domen and Neck
A-domen
Gastric -u--le
Air under diaphragm
Neck
$oIt tissue mass
Air -ronchogram
pacity
Air · Iat · liver · -lood · muscle · -one ·
-arium · lead
$keletal $tructures
$keletal $tructures
$capulae
Humeri & $houlder
Joints
Clavicles
Ri-s (9¹ ÷ good
inIlation)
$pine
Assessment
Check Ior symmetry,
spacing, and Iractures.
Check Ior linearity oI
the spine.
PitIalls to Chest X-ray
Interpretation
Poor inspiration
ver or under penetration
Rotation
Forgetting the path oI the x-ray -eam
PA View:
1. Aortic arch
2. Pulmonary trunk
3. LeIt atrial appendage
4. LeIt ventricle
5. Right ventricle
6. $uperior vena cava
7. Right hemidiaphragm
8. LeIt hemidiaphragm
9. Horizontal Iissure
The Normal Chest X-ray
The Normal Chest X-ray
Lateral View:
1. -lique Iissure
2. Horizontal Iissure
3. Thoracic spine and
retrocardiac space
4. Retrosternal space
$oIt Tissue $tructures
Neck and sophagus $ymmetry, masses
Trachea Deviation, ID -iIurcation, should not -e a-le to ID
airways Iurther out -ecause they are thin walled.
reasts $ymmetry, nipples may -e visi-le
Diaphragm Right usually higher
Costophrenic Angles $hould -e sharp and clear (no Iluid density)
Cardiophrenic Angles $hould -e Iairly clear
Vasculature Check Ior position and calciIication
Hilum- L side generally higher and looks smaller than R
Heart $ize (1/2 width oI thorax), Ventricles
$oIt Tissue $tructures
Lungs
Pleura
Closed cavities enveloping
each lung. Visceral layer
connects with the lung
tissue, while the Parietal
layer is thicker and
attached to the wall oI the
thorax.
Right Lung
Has 2 Iissures separating 3
lo-es
LeIt Lung
Has 1 Iissure separating 2
lo-es
Chest-Xray Terms
Silhouette Sign: When a margin or
structure is masked -y another density
Right $ide oI heart masked -y a RML pneumonia
The $ilhouette $ign
An intra-thoracic radio-
opacity, iI in anatomic
contact with a -order oI
heart or aorta, will o-scure
that -order. An intra-
thoracic lesion not
anatomically contiguous
with a -order or a normal
structure will not o-literate
that -order.
$tages oI valuating an
A-normality
1. IdentiIication oI a-normal shadows
2. Localization oI lesion
3. IdentiIication oI pathological process
4. IdentiIication oI etiology
5. ConIirmation oI clinical suspension
Complex pro-lems
Introduction oI contrast medium
CT chest
MRI scan
A-normal X-Ray Findings
Upper Respiratory InIections
$keletal Inury
Atelectasis
Pneumothorax
Pleural IIusion
Cavitation
Masses and/or Nodules
Chronic Lung Disease
Foreign ody
Case 1
Case 1
A single, 3cm relatively thin-walled cavity is noted in the leIt
midlung. This Iinding is most typical oI squamous cell carcinoma
($CC). ne-third oI $CC masses show cavitation
Cavitation:cystic changes in the area oI consolidation due to the
-acterial destruction oI lung tissue. Notice air Iluid level.
Case 5
Tu-erculosis
Case-4
Pneumonia: a large pneumonia consolidation in the right
lower lo-e. Knowledge oI lo-ar and segmental anatomy is
important in identiIying the location oI the inIection
Case-5
CHF:a great deal oI accentuated interstitial markings,
Curly lines, and an enlarged heart. Normally indistinct
upper lo-e vessels are prominent -ut are also masked
-y interstitial edema.
Case-6
Chest wall lesion: arising oII the chest wall and not the lung
Case-6
Pleural eIIusion: Note loss oI leIt hemi diaphragm. Loss oI cp
angle
Csae-7
Lung Mass
Metastatic Lung Cancer: multiple nodules seen
Case-8
Right Middle Lo-e Pneumothorax: complete lo-ar collapse
Pneumonia
acterial PCP
Acute ronchitis
$treaky
Densities
$keletal Inury
Ri-
Fractures
Atelectasis
DeIinition: Air
volume loss.
Collapse is a
synonymous term.
Right Lung
atelectasis and
Pneumothorax
Cavitation:
A pocket oI air
surrounded -y
a mem-rane or
wall oI varying
thickness.
Tu-erculosis
Masses and/or Nodules .
CPD
Pulmonary dema
CHF
Foreign ody
ReIerences
rass-Mynderse, N. (2004). CXR interpretation. advanced
assessment and clinical diagnosis week five diagnostic
testing self-studv packet. Handout.
Chandrasekhar, A.J. (2005). hest X-rav. Retrieved
Novem-er 29, 2005 Irom
http://www.meddean.luc.edu/lumen/Medd/medicine/pul
monar/cxr/cxr.htm.
Ritter, . asics of chest x-rav interpretation. A programmed
Studv. Retrieved Novem-er 29, 2005 Irom
http://www.usIca.edu/Iac-staII/ritter/chestxra.htm.
THANQ U

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