Chest X-Ray Flashcards
(22 cards)
How would you technically evaluate a CXR?
Sternoclavicular joints equidistant from the spinous process?
Clavicle in the same horizontal plane
Maximum of ten posterior ribs are visualised above the diaphragm
Ribs and t.cage only faintly visible over heart
Clear vascular markings of lungs
Differentiate between an AP and PA CXR?
Scapula within lung field in AP
Ribs more parallel
What is RIPE?
Rotation? medial clavicle should end equidistant from spinous process
Inspiration? 5-6 anterior ribs in MCL or 8-10 posterior ribs above diaphragm , poor inspiration or hyperexpanded?
Picture? Straight vs oblique, entire lung fields, scapula outside lung fields, angulation (tilt in vertical plane, for example)
Exposure (penetration)? IV disc spaces, spinous processes to T4, hemidiaphragm visible through cardiac shadow
Explain pneumonic DRABCDE
Details RIPE Airways and Mediastinum Breathing Circulation (position, borders, shape and size) Diaphragm Extras
What are the extras??
Apices- pneumothorax Bones/soft tissue: fractures/density? Cardiac shadow? Consolidation/mass Diaphragm- pneumoperitoneum Edge of image- anything unexpected?
Key aspect of ‘details’
Name, DOB, sex
PA or AP, erect or supine, L/R correct? inspiratory or expiratory?
Date and time of study
What do you need to look for in terms of airway and mediastinum?
Central trachea: pushed or pulled? should slightly deviate to the right around aortic knuckle
Paratrachael stripe: widened in lymphadeonopathy
Hilar regions, Left should be higher but similar density on both sides 1cm and concave to heart
right side hilum higher?
upper lobe collapse
abnormal hilium?
sarcoid, lung ca, lymphoma, TB
Key things to consider regarding breathing and CXR?
Divide into three zones: the lower one extends beyond the diaphragm as lungs pass behind the domes of it
Right lung has three lobes and two fissures, one being horizonal separating upper and middle lone
both have oblique fissure, with own pleural covering
Look at costophrenic angles, any blunting?
Compare lung volume both sides
Start at apices and work down
What is the Silhouette Sign?
“An intrathorac lesion touching a border of the heart, aorta or diaphragm will obliterate that border… An intrathoracic lesion NOT anatomically contiguous with a border of one of these structures will not obliterate that border”
Look for which borders are obscured
Work out what structure(s) normally lie at that borders
This must be the part where the mass is
What is lobar loss?
Volume loss
Hyperinflation of adjacent lobes
Change in position of the hila
Effacement of certain borders – Silhouette sign
Rib crowding (if prolonged)
Underlying cause – foreign body, mass, pneumothorax
What is the golden S sign?
S shape opacity in upper middle zones
Typically seen in RUL collapse
Central mass obstructing upper lobe bronchus
DDx:
BRONCHOGENIC CARCINOMA
Mets, mediastinal tumour, enlarged LN
What should you be mindful of with regards to ‘Circulation’?
Are the heart borders clear, or obscured?
Is the width of the heart no more than half of the chest?
Measure the cardiothoracic ratio: the largest cardiac diameter and the largest thoracic diameter
Stage 1 Congestive heart failure signs
‘Redistribution’
Redistribution of pulmonary vessels
Cardiomegaly
Broad Vascular Pedicle
Stage 2 Congestive heart failure signs
'Interstitial oedema' Kerley lines Peribronchial cuffing Hazy contour of vessels Thickened interlobar fissure
Stage 3 Congestive heart failure signs
'alveolar oedema' Consolidation Air bronchogram Cottonwool appearance Pleural effusion
What are Septal/Kerley Lines?
Sign of interstitial oedema. Perhaps pathology of LVF caused by thickening of intertitial septa
What is the Bat Wings pattern?
Alveolar oedema: caused by leaking from interstitial tissue into the alveoli and small airways, manifesting as airspace shadowing
Radiates symmetrically from the hilar regions in a bat’s wing distribution of airspace shadowing
How would you spot pleural effusion due to LVF?
Heart is enlarged, and the upper zone vessels appear prominent. Obviously the costophrenic angles are blunted
CXR of an ASD? what symptoms might you find?
Atrial Septal Defect: pulmonary artery large relative to aortic knuckle. Combination associated with increased pulmonary blood flow, left to right shunt
Adult patient had mild shortness of breath and a subtle systolic murmur
Symmetrical enlargement of hilium?
Sacroidosis
If unilateral, tends to be cancer
