Chest X ray Interpretation

Question 1

What is an X ray

Answer 1

= describe radiation which is part of the spectrum which includes visible light, gammons rays and cosmic radiation

Question 2

What are the benefits of X ray

Answer 2

• easily available
• non-invasive
• relatively inexpensive

Question 3

What colour is 
- gas
- fat 
- water 
- bone 
- metal and contrast 
in an X ray

Answer 3

• gas = appears black
• fat = dark grey
• water = grey
• bone = white
• metal and contrast = white

Question 4

In what position does the heart appear enlarged AP or PA

Answer 4

AP - heart is a greater distance from the film, it appears more magnified than in a PA

Question 5

Where is the scapulae visible in a Chest X ray

Answer 5

AP

- scapulae are usually visible in the lung fields as they are not rotated out of view as they are in a PA

Question 6

How do you take a lateral position of the X ray

Answer 6

• patient stands upright with the left side of the chest against the film and arms raised over the head
• allows the viewer to see behind the heart an diaphragmatic dome

Question 7

What is a lateral decubitus view of the x ray

Answer 7

• patient lies on either the right or left side than in the standing position as with a regular lateral radiography
• radiograph is labelled according to the side that is placed down
• often useful in revealing a pleural effusion that cannot be observed in a upright view since the effusion will collect in the dependent position

Question 8

What does a normal rotation look like

Answer 8

• can be assessed by observing the clavicular heads and determining whether they are equal distance from the spinous processes of the thoracic vertebral bodies

Question 9

how many ribs should be visible on a chest x ray

Answer 9

• 8-10 posterior ribs should be visible and 5-6 anterior ribs

Question 10

do you take an chest x ray in expiration or inspiration

Answer 10

inspiration

Question 11

How exposed should a chest x ray be

Answer 11

• the lower thoracic vertebrae should be visible through the heart
• the bronchovascular structures should be seen behind the heart - trachea, aortic arch, pulmonary arteries should be seen

Question 12

what pushes away the trachea

Answer 12

• large pleural effusion
• large simple pneumothorax
• tension pneumothorax
• aortic aneurysm
• mediastinal mass

Question 13

What pulls the trachea towards

Answer 13

• extensive collapse
• consolidation
• pulmonary fibrosis
• lobectomy
• pneumonectomy

Question 14

describe the first rib

Answer 14

• most curved and the shortest of all ribs
• broad and salt
• surfaces looking upward and downward
• borders inward and outward
• head is small, rounded, and possess only a single articular facet for articulation with the body of the first thoracic vertebra

Question 15

describe the right hemidiaphrgam

Answer 15

• right is higher than left by 1-3cm

Question 16

what causes both hemidiaphrgams to become flat

Answer 16

• chronic obstructive limitation disease such as emphysema

Question 17

describe the mediastinum

Answer 17

• width <8cm on a PA CVR

Associated with

• AP CXR view which magnifies the heart and mediastinal structures
• unfolded aortic arch or a thoracic aortic aneurysm
• mediastinal lymphadenopathy, retrosternal thyroid, thymoma, paravertebral mass, oesophageal dilatation, ruptured aorta

Question 18

what bones are visible in the chest radiograph

Answer 18

• ribs = posterior aspects of the 10th rib
• clavicles
• scapulae
• vertebrae
• proximal humeri

Question 19

What structure is in contact with the right upper lobe

Answer 19

• ascending aorta

Question 20

What structure is in contact with the right middle lobe

Answer 20

• right heart border

Question 21

What structure is in contact with the left upper lobe

Answer 21

• upper left heart border

- aortic knuckle

Question 22

what structure is in contact with lingual of the left lung

Answer 22

• left heart border

Question 23

What structure is in contact with the lower lobes (anterior)

Answer 23

• anterior hemidiaphragms

Question 24

What conditions are air bronchograms seen in

Answer 24

• lung consoldiation
• pulmonary edema
• non obstructive pulmonary atelectasis
• interstitial disease
• neoplasm

Question 25

What might consolidation contain

Answer 25

- Pus (pneumonia) - fluid (pulmonary edema) - blood (pulmonary haemorrhage) - cells (cancer)

Question 26

What does atelectasis mean

Answer 26

- this means loss of air

Question 27

What happens in absorptive atelectasis

Answer 27

- there is an obstructive lesion on the broncus - there is no ventilation to the lobe beyond the obstruction - gradually the air gets absorbed by pulmonary circulation - the involved lobe eventually is devoid of air and becomes atelectatic

Question 28

What is pneumonia

Answer 28

- air space disease and consolidation

Question 29

What is the typical findings of pneumonia on a chest radiograph

Answer 29

- airspace opacity - lobar consolidation - interstitial opacities

Question 30

what are the two types of pulmonary oedema

Answer 30

- cariogenic pulmonary oedema | - non cardiogenic pulmonary oedema

Question 31

what is cardiogenic pulmonary oedema

Answer 31

- caused by increased hydrostatic pulmonary capillary pressu

Question 32

What is non cardiogenic pulmonary oedema

Answer 32

- caused by either altered capillary membrane permeability or decreased plasma oncotic pressure

Question 33

How does a lung mass present

Answer 33

- lesion with shape margins and a homogenous appearance in contrast to the diffuse appearance in contrast to the diffuse appearance of an infiltrated

Question 34

What are the signs of congestive heart failure on a chest X ray

Answer 34

- alveolar oedema is often present in a classic perihilar bat wing pattern of density - Kerley B lines - interstital oedmea - cardiomegaly - dilated and cephalisation of the pulmonary vessels - pleural effusion

Question 35

how should you interpret the chest X ray

Answer 35

- details- patient name, type of film, date and time of study - RIP - rotation, inspiration, penetration and exposure - Soft tissue - airway and mediastinum - Bones - Cardiac silhouette - Diaphragm - edge of heart border - lung fields and pleura - gastric bubble - hila - instruments

Question 36

what are the chest x ray findings of extrinsic allergic alveolitis

Answer 36

- small bilateral pulmonary nodules | - hilar lymphadenopathy - rare

Question 37

what are the 5 stages of sarcoid

Answer 37

- stage 0 - normal chest radiography - Stage 1 - bilateral Hilar lymph node enlargement - stage 2 - bilateral hilar lymph node enlargement and parenchymal disease - stage 3 - bilateral pulmonary infiltrates - stage 4 - fibrotic change +/- cystic and bullous changes

Question 38

How do you diagnose sarcoidosis

Answer 38

- diagnosis based on a characteristic clinical picture an histological evidence of non-caveating granulomata - bronchoscopy with trans bronchial or endobronchial biopsy may not be necessary and a clinical diagnosis may be sufficient if there is good enough evidence clinically and radiologically that sarcoid is the correct diagnosis

Question 39

what can be used to monitor sarcoid

Answer 39

- Serum angiotensin converting enzyme is helpful in monitoring the activity of the disease

Question 40

how many patients with sarcoid have Hypercalcaemia

Answer 40

- 30% of patients | - not related to the activity of the disease

Question 41

What other organs can be affected by sarcoid

Answer 41

- respiratory system - liver - skin - eye - cardiac - renal involvement - CNS

Question 42

what are the steps to managing a pleural effusion

Answer 42

- perform a pleural aspiration to discover whether it is a simple or complicated parapneumonic effusion or an empyema - send pleural fluid for microbiology, cytology, protein, lactate dehydrogenase, glucose and pH - insert a chest drain - if complicated

Question 43

What does collapse of the right middle lobe look like

Answer 43

- horizontal fissure and lower half of the oblique fissure move towards one another - looks like a triangle coming out from the heart