Tearshapedspinousprocess

1. Check the Spinal Processes to Assess

for Rotation is
◦Objective: Checking the spinal process ensures
that the patient is not rotated in in the X-ray lm
for an accurate reading
◦If the patient is rotated then that can result in
‣ Di erence in lung size
‣ Heart may appear enlarged
‣ Misinterpretation due to inaccurate patient
placement

How to Assess?

• Check the spinal processes of the upper spine

• The processes should look straight, vertical, and oval shaped (Tear shaped)
• If the x-ray is rotated it will look like Tucan Beak shape (Horizontal)

Carina Trachea
2. Mediastinum
• Objective: To check if there is a shift in the mediastinum

it
• The Mediastinum is a space in between the right and left
lung that contains structures such as the esophagus,
aorta, and heart.
• The position of the mediastinum (whether regular or
shifted) can be assessed by looking at the Carina which is
where the trachea bifurcates
• What does a shift in the Carina indicate?
◦Pathology of the lung which can either directly or
indirectly a ect the mediastinum
◦Ex. Direct: Tumor growing in the mediastinal space
which can push the Carina to the left or right lung
◦Ex. Indirect: lungs are being a ected (such as lung
scaring) which can pull the mediastinum along with it.
• Splaying of the Carina: The carina is splayed as a result of
the enlarged atrium pushing up from underneath causing
the angle of the Carina to widen over 90 degrees

Borders of the
How to Assess? column

• Check the trachea and the Carina vertebra

• The Carina should be within the con nes of the outline of
the vertebral column
• Abnormal pathology: If the mediastinum is shifted then
the Carina will be outside of the borders
• In the case that the mediastinum is shifted, check the
K
angle of the Carina (around 90 degrees)
◦Abnormal pathology: splayed Carina (over 90
degrees)
3. Costophrenic angle
• Objective: To check for large amount of uid accumulation
(Pleural e usion)
• The costophrenic angle is the area where the diaphragm
meets the ribs
• Pleural space is lubricated with 3ml of uid
• Found only in 2D scans (like a X-ray scan) and will not be
seen in 3D scans (like a CT scan)
• Fluid is found in the costophrenic angle due to gravity

r
• Typically increased amount of uid will not be seen in an X-
ray unless it’s over a minimum of 300 ml (CT scan will
de nitively identify uid accumulation)
• What causes uid accumulation?
u
costophrenicangles
◦Obstruction of the lymphatic vessels
◦Infection and in ammation
◦Pneumonia

How to Assess?

• Check the costophrenic angles and look for a dark downward deep V indentation.
• If the the shape of the costophrenic angle (deep V) is identi able then there is no signi cant
amount of uid
• The costophrenic angle may look hazy due to overlying breast tissue (Normal)
• Abnormal pathology: The costophrenic angle will be blunt (deep V is completely whited out)
which indicates pulmonary e usion

4. Apex of the Lung

• Objective: To check for air accumulation in the lung Interstitiallung markings
(Pneumothorax)
Apex
• The apex is the superior part of the lung that is above
the clavicle
• What causes air accumulation?
◦Injury to the lungs such as a lung puncture

How to Assess?

• Check for lung markings that surpass the clavicle

• Abnormal pathology: If there is air accumulation
(pneumothorax) then the apex will be pitch black and
depending on the size of the pneumothorax then the
lungs will be condensed downwards
 Hilum
5. Hilum of the Lung
• Objective: To check if the hilum is enlarged and to check
the function of the lymphatic system
• The hilum is the area at which structures ( blood vessels,

XP
lymphatic system, airway) enter and leave the lung
• What causes an enlarged Hilum?
◦congestion of the lymphatic Vessels due to cancer,
heart failure, and in ammation

How to Assess?

• Check the hilum of the lung for a kidney bean shape (concave indentation in the middle of the
hilum) which will be fully visible in the right lung with only the top of the left hilum being visible
due to the heart covering the rest of the hilum
• Abnormal pathology: an enlarged hilum will lose its concave indentation and will become
convex (oval shaped)

6. Heart
• Objective: To check if the heart is enlarged
• What causes enlargement of the right side of the heart?
◦Pulmonary embolism escalating the pressure in the
lungs causing pulmonary hypertension
• What causes enlargement of the left ventricle ?
◦Chronic disorder (chronic hypertension)

Y
• What causes enlargement of the left atrium?
◦In the case where there is left atrial enlargement and a
normal sized left ventricle then that indicates the
recent occurrence of heart pathology such as a heart
attack

How to Assess?

• 1. Right side of the heart: Check if the right side of the heart is convex and forms to create an
angle with the diaphragm
◦Abnormal pathology: the outline will be blunted and there will be a loss of the convex shape
• 2. Left side of the heart: Check if there is space between the apex (tip) of the left ventricle and the
chest wall
◦Abnormal pathology: the apex of the left ventricle will stretch out and meet the chest wall
• 3. Left atrium: top chamber of the heart should have two slopes, one going down (represents the
left atrium) and one coming out (represents left ventricle).
◦Abnormal pathology: instead of the typical two slopes, it will only be one slope going down
 7. Lungs
• Objective: To check for in ltrates, opacities, and
consolidation
• Interstitial lung markings will be more prominent the
closer they are to the hilum
◦the vessels in the apex will look faint compared to
the base of lung which will look more prominent
(due to gravity)
◦Blood vessels should be prominent near the hilum
◦Blood vessels should not be visible near the chest
wall
• What causes lung markings near the chest wall?
◦pulmonary vascular congestion brought on usually
by heart failure
• What may cause in ltrates, opacities, and consolidation?
◦Fluid
◦In ammation
◦Infection
◦Blood
◦Pus ( due to in ammation)
◦Mass (consolidation)

Prominent
lung Lungmarkings
markingsnear arenotvisable
thehilumbthe nearthechest
base wall

How to Assess?

• 1. Read the lungs in a zig zag fashion to asses for an overall level of uniformity (separately for
each lung then asses if both lungs look similar to each other)
• 2. Lung markings should be prominent near the hilum but fade out towards the chest wall
◦Abnormal pathology: lung markings are found near the chest wall
• 3. Check for lung in ltrate ( markings going through the lungs)
• 4. Check for opacities (cloudy markings)
• 5. Check for consolidation (completely white mass or marking)
 NORMAL CHEST X-RAY
The patient is not rotated due to the spinous processes not being
rotated themselves. The mediastinum does not appear to be shifted
with no mass e ect. No de nitive pleural e usions are evident. The
apices of the lungs have interstitial markings that extend upwards
with no obvious ndings of a pneumothorax. The hilum looks of
normal shape bilaterally. The heart does not appear enlarged, with
the left and right atrium appearing to be of normal size. In regards to
the lung markings there is a uniformity distribution from top to
bottom with some allowance of more interstitial markings of the
bases.