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RADIOLOGY EXAMINATION OF THORAX

General objectives:

  • 1. Students are able to explain and give impression of radiology of thorax that relates to some abnormalities dealing with lungs.

  • 2. Students are able to explain and give impression of thorax radiology imaging that relates to some abnormalities dealing with heart and vascular.

Specific objectives:

  • 1. Students are able to explain and impression of radiology imaging of abnormality on lungs.

    • 1.1. non specific inspection: Pneumonia/Bronchopneumonia, Bronchitis, bronchial Asthma, effusion pleura, emphysematous lung

    • 1.2. Trauma : Pneumothorax, Hidropneumothorax

    • 1.3. Mass/Tumour on lungs /mediastinum

  • 2. Students are able to explain and give impression of radiology imaging of heart.

    • 2.1. Hypertension heart disease

    • 2.2. Atherosclerosis

    • 2.3. heart enlargement /cardiomegali

  • NORMAL CHEST X-RAY

    RADIOLOGY EXAMINATION OF THORAX General objectives: 1. Students are able to explain and give impression of
    • I. INFECTION: NON SPECIFIC PROCESS IN LUNGS

    I. INFECTION: NON SPECIFIC PROCESS IN LUNGS A. Bronchitis Commonly bilateral Radiology imaging:  Infiltrate peribronchial
    • A. Bronchitis

    Commonly bilateral Radiology imaging:

    Infiltrate peribronchial

    Air bronchogram imaging ; imaging of lucent lines going to hyllus direction More bronchovascular characteristics, additional 1/3 to lung field lateral Photo of Thorax, PA, erect, symmetrical, inspiration and sufficient condition result:

    • - Hyperaeration is seen (hyperlucency) on both lungs, bronchovasculary characteristics increase.

    • - Left-right Sinus costofrenicus are sharp

    • - Left-right Diafragma are plain and slippery (air trapping +)

    • - Cor : CTR< 0,5, in the form of tear drop

    • - Spatium Intercostae is seen enlarging Impression: chronic Bronchitis with Emphysematous lung

    • B. Bronchial Asthma Radiology imaging: Photo of Thorax, PA, erect, symmetrical, inspiration, and sufficient condition result :

      • - Additional imaging of bronchovascular is seen with imaging

      • - Air bronchogram (+) on both lung fields.

      • - Left-right Sinus costofrenicus are sharp.

      • - Left-right Diaphragm are plain, slippery

      • - Cor ; CTR < 0,5

      • - No abnormality on musculoskeletal system is observed

    IMPRESSION : chronic Bronchitis and cor is normal

    C. Bronchopneumonia

    C.

    Bronchopneumonia

    C. Bronchopneumonia

    -

    can be uni/bilateral

    -

    radiology imaging :

    infiltrate on peribronchial : causing bronchovascular characteristics to improve and air bronchogram (+)

    infiltrate on paracardial, causing heart limit blurred (silhoutte sign)

    On the lateral photo, infiltrate in central heart with unclear limit is seen.

    Photo of Thorax, AP, supine, asymmetrical, inspiration and sufficient condition, result;

     

    -

    Semiopaq inhomogen wrapping with bronchogram water (+) imaging is seen on both lung fields.

    -

    both sinus costofrenicus are sharp.

    -

    both diaphragm are slippery

    -

    Cor ;

    CTR < 0,5

    -

    no abnormalities are seen on musculoskeletal system

    Impression: Bronchopneumonia duplex and cor size are normal.

    D.

    Pneumonia

     

    -

    commonly unilateral

    -

    radiology imaging :

    infiltrate on lung parenchyma, located on periphery (medium on central bronchopneumonia)

    infiltrate limit is obvious (hitting one lobus, segment)

    air bronchogram (+)

    - can be uni/bilateral - radiology imaging :  infiltrate on peribronchial : causing bronchovascular characteristics

    Photo of Thorax, PA, erect, symmetrical, inspiration and sufficient condition result :

    • - Homogeny opacity/wrapping is seen, the limit is obvious on the right lung medius lobus.

    • - Left-right Sinus c.f are sharp

    • - Left-right Diaphragm are slippery

    • - Cor : CTR < 0,5

    • - No abnormalities are observed on musculoskeletal system.

    Impression: Pneumonia is on lobus medius of the right lung normal cor is big

    • E. Pleura Effusion

      • - is the liquid in vacuum pleura with more than normal amount

      • - radiology imaging :

        • 1. Meniscus sign : bending line with periphery part is higher than central part.

        • 2. homogeny wrapping imaging covers the lower structure of the lungs which are normally relatively radioopaq with hollow upper surface, running from upper lateral to lower medial.

    Photo of Thorax, PA, erect, symmetrical, inspiration and sufficient condition result : - Homogeny opacity/wrapping is

    Photo of the position of Right Lateral Decubitus (RLD), sufficient condition result:

    • - homogeny semiopaq is seen on the right hemithorax.

    • - bronchovaskuler characteristics increase

    impression : right pleura effusion cor configuration is normal

    Photo of Thorax AP, supine, symmetrical , sufficient inspiration result ; - Homogeny semiopaq wrapping is

    Photo of Thorax AP, supine, symmetrical , sufficient inspiration

    result ;

    -

    Homogeny semiopaq wrapping is seen on right hemithorax basal aspect with meniscus sign (+) imaging.

    -

    Right Sinus c.f is dull, right diaphragm is unclear.

    -

    Left Sinus c.f is sharp, left diaphragm is slippery

    -

    Cor : CTR > 0,5

    -

    Intact bone systems

    -

    Impression: right pleura effusion and cardiomegali

    II.TRAUMA

    1. Pneumothorax

    -

    is the existence of air on cavum pleura, which occurs as the result of the tearing on pleura parietalis or pleura visceralis that connects cavum pleura with outside air or with lung parenkim. Pressure difference causes outside air come in and fill cavum pleura both from chest wall or lung paremkim. If the amount of air coming in is abundant, it will press pulmo so that it will collapse and even press the mediastinum towards contralateral with the tearing direction.

    Radiology imaging:

    -

    radiolucent imaging without lung characteristics on lung hemithorax is seen.

    -

    On thorax PA photo, clear white line from pleura will be seen, separated from chest wall by radiolucent pleural space.

    -

    Sometimes diaphragm is seen being pressed downward on the lungs experiencing pneumothorax.

    -

    In abundant air amount, lungs can collapse and mediastrinum moves towards contralateral with trachea seen deviated towards contralateral.

    Pneumothorax sinistra

    Pneumothorax sinistra

    Photos of Thorax, AP, supine, symmetrical, inspiration and sufficient condition Result;

    • - Lucent area without lung characteristics is seen on the right hemithorax that moves mediastinum towards the left side.

    • - Left-right Sinus c.f are sharp

    • - Left-right Diaphragm are slippery

    • - Cor : CTR < 0,5

    • - bone system is Intact Impression: right Pneumothorax moves mediastinum towards the left side, Cor size is normal

    2. Haemathothorax

    • - The presence of blood in from thorax.

    cavum pleura that is caused by secondary causes, that is, open or closed trauma

    • - Thorax radiology imaging is often accompanied by fracture on costa.

    • - Radiology imaging : seen like imaging on pleura effusion

    III. LUNGS TUMOUR

    Photos of Thorax, AP, supine, symmetrical, inspiration and sufficient condition Result; - Lucent area without lung
    1. Primary Tumour - can come from mediastinum or parenkim. Ca is the most from bronchus,

    1. Primary Tumour

    • - can come from mediastinum or parenkim. Ca is the most from bronchus, that is, bronchogenic Ca.

    • - Radiology imaging :

      • - The existence of homogeny opaq on lungs

      • - psudopodia imaging: the radier tumour growth towards healthy tissue looks like legs.

      • - Pancoast tumour : tumour on sulcus superior on lung apex, located on posterior and

      • - Os costa experiences erosion.

    2. Secondary Tumour

    • - Nodular type : imaging looks like small balls

    • - pneumonic type: like pneumonia but air bronchogram (-)

    • - reticular type : seen as lymph tissue (limphangitis type)

    • - milier type

    • - pleural Type, pleura effusion

    2. Secondary Tumour - Nodular type : imaging looks like small balls - pneumonic type: like

    HEART ABNORMALITIES

    The size of heart radiologically depends on some conditions, some of the others are:

    • 1. age : baby’s size is relatively big (CTR up to 60% still considered normal)

    • 2. respiration; on inside cor inspiration is seen long.

    • 3. Projection (photo positioning); on the posteroanterior position, magnification factor is 5%, while on AP position, magnification may be more than 5%

    • 4. body size; thin (heart size is like a pendulum) ; fat (the heart is large)

    To analyze any heart abnormalities, photos of posteroanterior, left lateral, Left Anterior Oblique, Right Anterior Oblique are used.

    • 1. Posteroanterior, in this position, heart position is near the film so that it can downsize heart magnification.

    • 2. left Lateral; it shows aorta ascendens, arcus aorta and aorta descendens is better

    • 3. RAO (450-600) ; showing pressure of left atrium towards oesophagus

    • 4. LAO (600-700) ; can show the heart’s low rear limit by left ventricle.

    Abnormalities often occurring on heart:

    • 1. Hypertension heart disease

    • 2. Aterosklerosis/aortosklerosis

    • 3. heart enlargement /cardiomegali

    • 4. Oedem Pulmo due to cardiogenic (Ventricle hypertrophy)

    1. Hypertension Heart Disease (HHD)

    • - Causing hypertension configuration:

    o o Left ventricle enlarges to lower left side; apex towards lower side, heart waist narrows.
    o
    o
    Left ventricle enlarges to lower left side; apex towards lower side, heart waist narrows.
    aorta widens and lengthens (coartasio aorta), aortic knob bumps in the form of semilunar

    Chronic heart Failure ; Cardiomegali with oedem pulmo, aortic knob (+)

    Photos of Thorax, AP, lateral, sufficient condition result :

    • - Vascular characteristics increases.

    • - Left-right Sinus costofrenicus are sharp

    • - Left-right Diaphragm are slippery

    • - Cor : CTR > 0,56; heart apex is lifted, heart waist is bumpy, retrosternal space is covered (sternal climbing + ).

    • - no abnormalities on musculoskeletal system impression: right ventricular hypertrophy Pulmo is normal

    Photos of Thorax, AP, lateral, sufficient condition result : - Vascular characteristics increases. - Left-right Sinus

    Photos of thorax, AP, supine, symmetrical, sufficient inspiration result :

    • - Vascular characteristics increases

    • - Left-right Sinus c.f are sharp

    • - Left-right Diaphragm are slippery

    Cor : CTR > 0,5, apex cordis is seen as sunk

    • - No abnormalities on musculoskeletal System

    Impression: left ventricular hypertrophy Pulmo is normal

    lung Oedem Paru due to heart abnormalities Image: Oedem pulmo due to decompensation cordis (CTR >

    lung Oedem Paru due to heart abnormalities Image: Oedem pulmo due to decompensation cordis (CTR > 0,5, left ventricle enlargement: heart apex sunk. Vascular characteristics looks increasing, blurring on both lung fields with kerley line (white arrow)

    lung Oedem Paru due to heart abnormalities Image: Oedem pulmo due to decompensation cordis (CTR >

    3.

    Aortosclerosis

    marked by the presence of atherom that experiences calcification, the size looks like crescent (crescent calcification)

    3. Aortosclerosis marked by the presence of atherom that experiences calcification, the size looks like crescent
    • 4. Cardiomegali

    - The heart size is enlarging more than half of thorax cavity (CTR > 0,5)

    3. Aortosclerosis marked by the presence of atherom that experiences calcification, the size looks like crescent

    CHECK LIST PAGE FOR ABNORMALITIES ON LUNGS AND HEART

    NO ASPECTS TO BE SCORED 0 1 2 1 Students are able to give judgement on
    NO
    ASPECTS TO BE SCORED
    0 1
    2
    1
    Students are able to give judgement on the photo position
    (AP/PA/Lateral/RLD symmetrical/asymmetrical, inspiration and
    photo condition)
    2
    Students are able to give judgment on bronchovascular
    characteristics:
    -
    Bronchitis : bronchovaskuler characteristics increases with
    imaging of air bronchogram (+)
    -
    Pneumonia : inhomogen/infiltrate wrapping on
    lobus/segment of lungs with air bronchogram imaging
    -
    Bronchopneumonia : same as Pneumonia , but it’s wider :
    uni/bilateral
    -
    Pneumothorax : lucent imaging without lungs characteristics
    -
    Effusion of pleura/Hidrothorax : homogeny semiopaq
    wrapping on basal/lateral hemithorax
    -
    Tumour/Mass : existence of imaging of homogeny/ lesion
    nodular opacity on the lungs.
    3
    Students are able to give judgement on sinus costophrenicus: dull or
    sharp
    4
    Students are able to give judgement on diaphragm : slippery or not -
    5
    Students are able to give judgement on bone systems ; size of
    thorax, costa, vertebra thorax
    6
    Students are able to give impression / radiology diagnosis
    CHECK LIST PAGE ON CARDIOVASA ABNORMALITIES
    NO
    ASPECTS TO BE SCORED
    0
    1
    2
    1
    Students are able to give judgement on photo position: PA, lateral
    2
    Students are able to give judgement on vascular characteristics: -
    increasing
    - decreasing
    3
    Students are able to give judgment on chamber/heart size
    -
    CTR < 0,5
    -
    CTR > 0,5
    4
    Students are able to give judgment on abnormalities on heart and
    blood vessels.
    -
    aortic knob : aorta bumping
    -
    aterosclerosis : calcification on aorta
    -
    the presence of cardiomegali
    5
    Students are able to give impression/radiology diagnosis on heart
    abnormalities.