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MD3001 > Normal Chest X Ray (Use Lecture CXR Images Alongside this to Identify Structures, Abnormalities etc.) > Flashcards

Normal Chest X Ray (Use Lecture CXR Images Alongside this to Identify Structures, Abnormalities etc.) Flashcards

1
Q

Why might it be important to know of any allergies the patient has for a chest X ray ?

A

In case contrast agents are used

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2
Q

Why must the last menstrual period be known before performing a chest X ray ?

A

Because there is a real risk to the fetus if the woman is pregnant

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3
Q

What are the main indications of a chest X ray ?

A
  • Acute deterioration in SOB
  • Acute chest pain (e.g. MI, pulmonary oedema)
  • Suspected malignancy
  • Pneumonia
  • Pleural disease (e.g. mesothelioma)
  • Peritonitis
  • Chronic lung disease
  • Following invasive procedure (e.g. central line, chest drain)
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4
Q

Why would you perform a chest X ray following an invasive procedure ?

A

To ensure:

  1. Position of equipment (e.g. end of tube in the right place)
  2. no damage to patient (e.g. pneumothorax)
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5
Q

What position must the patient be in if an X ray is performed with suspicion of peritonitis ?

A

Erect for at least 10 mins pre image

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6
Q

What position are patients usually in when taking a chest X ray ?

A

Standing up, with arms either on sides, or around machine to move scapulae away to have better look at lung fields

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7
Q

Why do we prefer the patient to be standing up for a chest X ray ?

A

Because want any air in pleural and abdominal cavity to rise up, fluid in pleural cavity to go down to the bottom

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8
Q

Are most chest X rays performed in PA or AP ?

A

PA

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9
Q

What is the main advantage of PA over AP images ?

A

May comment on size of the heart in PA images, not in AP images

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10
Q

What is the main reason an AP image might be performed rather than a PA image ?

A

Because the patient is unwell

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11
Q

What are some technical factors which MUST be done right in order for the X ray to be valid ?

A

1) Erect rather than supine
2) Full breath in (inspiration)
3) Right orientation (R on image really the R of the patient and same for the L)
4) Penetration (well-exposed)
5) Rotation (patient square onto the film)
6) PA or AP (PA able to comment on size of heart)

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12
Q

How may you decide if the patient has had a good inspiration based on the chest X ray image ?

A

If taken with full breath in, should cover 5 to 6 ribs anteriorly

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13
Q

How can you decide if the penetration of an X ray image is good (if it’s well-exposed) ?

A

By ensuring that you see the intervertebral spaces behind heart shadow

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14
Q

What does it mean when a chest X ray is said to be under-exposed ? What patients may you encounter this in (often) ?

A

“Cardiac shadow is opaque, with little or no visibility of the thoracic vertebrae. Lungs appear denser and whiter”

Tends to happen more with obese patient due to Doctor underestimating obesity of patient

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15
Q

What does it mean when a chest X ray is said to be over-exposed ?

A

“Heart becomes radioluscent and lungs become darker”

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16
Q

How can you check whether the rotation of the patient on the X ray is good ?

A

Ends of clavicle equidistant and crossing spines of thoracic vertebrae

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17
Q

Give an example where one may have to work with poor rotation upon taking a chest X ray.

A

Patient with scoliosis

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18
Q

What are possible causes of a chest X ray image being too black or black in the wrong place ?

A
  • Air (e.g. free gas under diaphragm due to perforated disk or laparoscopy)
  • Loss of tissue density (e.g. bony metastasis)
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19
Q

What are possible causes of a chest X ray image being too white or white in the wrong place ?

A
  • Fluid (e.g. too much fluid in pleural space i.e. pleural effusion or fluid in pulmonary cavity i.e. pulmonary oedema)
  • Increased tissue e.g lymphadenopathy, TB
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20
Q

What is it called when a chest X ray image if too black or black in the wrong place ?

A

Increased tranlucency

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21
Q

What is it called when a chest X ray image if too white or white in the wrong place ?

A

Opacification

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22
Q

What are possible causes of really, really white or very radio opaque elements on a chest X ray ?

A 
Pacemaker
ETT
Nasogastric tube
Sternal wiring 
Prosthetic heart valves 
Central Veinous Pressure line
Chest drain
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23
Q

Identify the main “things” to look at when looking at a CXR.

A

First and foremost, answer the question you have (e.g. does this man have a fracture anywhere ?). Then,

A Airway
B Breathing
C Cardiac (heart)
D Diaphragm
E External Structures & Equipment
F Fat and soft tissue
G Great vessels
H Hidden areas
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24
Q

Describe some of the features to be looking for when checking the Airway on a CXR.

A
  1. Trachea should be straight and black (starting at C6)
  2. Carina at T4
  3. Right main bronchus more vertical, wider and shorter than left main bronchus
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25
Q

Identify possible abnormalities in the airway on a CXR.

A
  • Endotracheal tube too close to the carina (i.e. needs to be withdrawn)
  • Mediastinal shift (i.e. trachea moves to one side)
  • Angle of the bronchi increased by pressure from enlarged lymph nodes (Sarcoid, Tumour) or by local tumour.
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26
Q

What are possible abnormalities in breathing ?

A

1) Consolidation (i.e. opacification due to replacement of normal air space gas with fluid or solid material). -Characteristic sign of consolidation is air bronchogram (i.e. large airways are spared so become visible (black) against the white background)
2) Atelectasis Some opacification, mediastinal shift (TOWARDS) and a loss of V (dragging diaphragm/fissures superiorly)
3) Pleural effusion Mediastinal shift AWAY, lower zone uniformly white (on one side or the other), concave upper border (meniscus), no evidence of air bronchograms
4) Asbestos Exposure -Calcified plaque (not malignant itself) on pleural cavity -Mesothelioma (present as pleural effusion, but with holly leaf opacification)
5) Pneumothorax -Black on one side -Mediastinal shift away from blacker area -Visceral pleural line, with no lung markings seen peripheral to this line (abnormal)

27
Q

Describe some of the features to be looking for when checking the Breathing on a CXR.

A
  1. Expansion

2. Check the lung fields (including lung markings and opacities comparing R and L lung for abnormalities)

28
Q

What is a clear sign of good expansion on a CXR ?

A

Anterior 6th rib should cross dome

of right hemi-diaphragm

29
Q

What are possible abnormalities in cardiac portion of CXR ?

A

HEART FAILURE 5 things to look out for:
A - alveolar (interstitial) oedema (bat wing opacities coming out of hilum)
B - Kerley B lines (“thin linear pulmonary opacities caused by fluid or cellular infiltration into the interstitium of the lungs”)
C - cardiomegaly (i.e. diameter of heart > 50% of thoracic diameter)
D - dilated upper lobe vessels
E - pleural effusion (if pleural effusion present, anticipate it to be small and bilateral, with blunting of costophrenic recesses) DEVICES IN HEART Artificial valve Pacemaker STERNOTOMY

30
Q

How many fissures does the R lung have ?

A

2: horizontal and oblique fissure

31
Q

If there is loss of heart shadow on the patient’s right side, we suspect pathology in which part of which lung ?

A

Pathology in the middle lobe of the R lung

32
Q

How is it possible to differentiate RUL and RML on a frontal CXR ?

A

Impossible, due to the oblique fissure (it’s on a slope)

33
Q

Given that it impossible to differentiate RUL and RML on a frontal CXR, how can we differentiate between them ?

A

By doing a lateral chest CXR

34
Q

If we are losing opacification of the diaphragm on the patient’s R side, we suspect a pathology in which part of which lung ? Why ?

A

LL of R lung because it abuts onto diaphragm

35
Q

Which lobes are separated by the oblique fissure on the R lung ?

A

All three

36
Q

What is the spatial relationship between the R lung LL/L lung LL and the diaphragm ? Why is this significant ?

A

LL reaches down behind diaphragm at the back
Significant because sometimes abnormalities in lung field can be visible below diaphragm (e.g. loss of shadow between lung and diaphragm suggests pathology is LL)

37
Q

What are the different lung zones on a CXR ? What is the difference between a zone and a lobe ?

A

Upper zone
Middle zone
Lower zone
(Apical zone, above clavicle)

Better to describe the location of a pathology without committing to a lobar anatomy (e.g. say “opacification of right lower zone which, taking into account the history, is compatible with RLL pneumonia” rather than, “it is RLL pneumonia”

38
Q

What is a lingula ?

A

Part of left lung UL which abuts the cardiac shadow

39
Q

If there is loss of heart shadow on the patient’s left side, we suspect pathology in which part of which lung ?

A

Lingula, L lung

40
Q

What is the name of the fissure on the L lung ?

A

Oblique fissure

41
Q

Does opacity increase, decrease, or stay constant from top to bottom ? Why ?

A

Opacity will increase from top to bottom, because:

  • Thorax is conical so wider as you go down (hence bottom is more opaque)
  • If female patient, increased tissue on surface of thorax that the X ray has to penetrate (breast tissue)
42
Q

Describe the change in visibility of lung markings as you move towards the periphery of the lungs.

A

Diminution of lung markings as you move out (obvious vessels near hilum of lungs, then get finer but should reach the end of the lungs)

43
Q

What are the hairy lung markings ? Which part of those reflects the radiation in an X ray ?

A

Hairy lung markings are the vessels (iron in bloodstream is reflecting the X rays)

44
Q

What would one think of if there is an area which is very black with no lung markings?

A

Pneumothorax

45
Q

Describe some of the features to be looking for when checking the Heart on a CXR.

A
  1. Heart should be <50% diameter of the chest and 1/3 should be visible to the right of the sternum (2/3 to the left) ON A PA IMAGE
  2. Ensure borders of the heart are visible (otherwise possible pathology of middle lobe or lingula)
46
Q

What are the structures which are visible on the R side of the heart a CXR ?

A

R atrium, bit of SVC and IVC

47
Q

What are the structures which are visible on the L side of the heart a CXR ?

A

L hand side is left auricle and left ventricle

48
Q

Which parts of the heart are not visible on a frontal CXR ?

A

Left atrium (posterior structure) and R ventricle (anterior structure, sitting on diaphragm)

49
Q

Identify the chambers which make up the posterior border on a frontal chest CXR.

A

Left Atrium

50
Q

Identify the chambers which make up the anterior border on a frontal chest CXR.

A

Right ventricle

51
Q

Identify the chambers which make up the right lateral border on a frontal chest CXR.

A

Right auricle and right atrium

52
Q

Identify the chambers which make up the left lateral border on a frontal chest CXR.

A

Left auricle and left ventricle

53
Q

Identify the chambers which make up the inferior border on a frontal chest CXR.

A

Right ventricle and left ventricle

54
Q

Describe some of the features to be looking for when checking the Diaphragm on a CXR.

A
  1. Right hemi-diaphragm is one rib (1 cm) higher than the left
  2. Gastric bubble (gas in stomach) under L side of diaphragm
  3. Liver under R side of diaphragm
55
Q

What is a possible abnormality on a CXR regarding the diaphragm ? How would you see this on the CXR ?

A

-Air under both hemi-diaphragms (increased translucence under diaphragms). Could be either because of an operation where patient was exposed to air, or laparoscopic operation, or perforated viscus in abdomen (eg perforated peptic ulcer or perforated cancer of bowel) -A stomach bubble in the left chest (ie above where the diaphragm lies) may indicate diaphragmatic rupture following trauma or a congenital diaphragmatic hernia in infants.

56
Q

Describe some of the features to be looking for when checking the External Structures on a CXR.

A

1) Bones (Ribs, clavicles,
scapulae & humeral heads, thoracic spine, some cervical and lumbar spine)
2) Medical Devices (Oxygen tubing, pacemakers, heart valves, sternotomy wires, chest drains, NG tubes)

57
Q

Is the sternum visible on a PA CXR ? How is it possible to have a look at it ?

A

No

Through an oblique view

58
Q

Describe some of the features to be looking for when checking the Fat and Soft Tissues on a CXR.

A
  1. Breast Shadows

2. Subcutaneous Fat

59
Q

What is a possible abnormality on a CXR regarding the fat and soft tissue ? How would you see this on the CXR ?

A
  • Unilateral breast shadow: may indicate breast cancer (either primary or secondary invasion from primary cancer)
  • Air in soft tissue: subcutaneous emphysema (trauma, severe asphyxia)
60
Q

Describe some of the features to be looking for when checking the Great Vessels on a CXR.

A

1) Aortic arch, pulmonary arteries and veins in the mediastinum
2) Calcium deposits in the elderly
3) Right and left Hilar area (R normally a little higher but same size)

61
Q

What is a possible abnormality on a CXR regarding the great vessels ? How would you see this on the CXR ?

A
  • Increased size or density of hilar area (lymph node enlargement possibly due to cancer which has spread to the lymph nodes, or due to pulmonary oedema)
  • Calcium deposits in the elderly (atheroma, atherosclerosis)
62
Q

Describe some of the features to be looking for when checking the hidden areas on a CXR.

A 
• Neck
• Apices (e.g. TB lodges in apex)
• Mediastinum: widening
• Retro-cardiac area
• Costophrenic angle (Should be nice, sharp, acute. If pleural effusion, the angle will 
become blunt )
• Behind/below diaphragm (Any free gas, anything in lung tissue behind and below the diaphragm)
• Soft tissues
• Bones
63
Q

Which patient details should be checked prior to interpreting the CXR ?

A
  • Correct image
  • Date of image
  • Name and DOB of patient

MD3001 (75 decks)

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