Chest X Ray

Diaphragmatic hernia

3 types Hiatal hernia: slips through the esophageal hiatus into chest Bochdalek hernia: weakness in the diaphragm and occurs on the left side posteriorly morgagni hernias: occur medially, weakness of the diaphragm can occur witout frank herniation of abdominal contents eventration: not frank herniation and ususally occurs on the right with a protion of the liver bulging

Left lower lobe atelectasis

Right or left will show silhouetting of the corresponding hemidiaphragm, crowding of vessels and air bronchograms sometimes. Silhouetting of descending aorta on lft.

Review a Chest xray what do you check

Right patient Right test Right Date

Right Lower lobe atelectasis

Silhouetting of the right hemidiaphagma nd triangular density posteromedially are common signs of right lower love atelectasis. Right distinguished from RLL by the persistance of the right heart border

Lobular Pneumonia

Staphlococcus Multifocal, patchy

Finding of pheumodediastimum

Streaky lucencies over the mediastinum that extend into the neck and elevation of parietal pleura along mediastinal borders Cause: asthma, post op complicaiton, traumatic tracheobronchial rupture, abrup changes in intrathoraci pressure vomiting, coughing exercise ruptured esophagus barotrauma

Different Hematomas

Subdural: Between the dura and arachnoid space Epidural: Between the skull and the dura Acute hemorrhage: SAH, Ruptured aneurysm, AVM AV malformation, Hydrocephalus, Evaluation of neurologic symptom

The supine AP

Supine anterior posterior. The machine is 40 inches

Anterior Diaphram

The diaphram is viewed on the lateral Xray. The left portion of the diaphram is silhouetted by the heart. So the right is viewed higher and the left is lower

Lateral view

The lateral is with the left side placed against the cassette. You can see the ribs on the posterior side. the right ribs are seen on the right side of the xray. Left posterir ribs are in from of them. this view is good for pleurisy

The Lateral decubitus position

To assess volume of pleural effusion and if it is mobile or not. show effusions and pneumothorax and atelectasis. shows if mobile or not Patient is laid on side

Doppler

Transcranial: evaluate cerebral blood flow and Detect aneurysm Carotid: eval of atherosclerotc and carotid artery disease DVT: clot ABI: assess PAD

Air Bronchogram

Tubular outline of an airway made visible by filling the surrounding alveoli by fluid or inflammatory exudates. Causes: Lung consolidation, pulmonary edema, non-obstructive pulmonary atelectasis, severe interstitial disease, neoplasm, and normal expiration.

How to read a chest X ray

Turn off stray lights, check pt data Routine is AP/PA expsure, rotation supine or erect Trachea: midline or deviated Lungs: abnormal shadowing or lucency Pulmonary vessels: artery or vein enlargement Hila: massess Heart: Thorax, Heart width is 2:1 Mediastinal contour? measure Pleural effusion? thcikening, calcification Bones: lesions or fractures? Soft tissues : don't miss a mastectomy

Pulmonary edema

Two types: Cardogenic edema: increased hydrostatic pulmonary cap pressure Non cardogenic: Caused by altered capillary membrane permeability or decreased plasma oncotic pressure. Not cardiac, near drowning, o2 therapy, aspiration, altitude change etc.

Interstitial

Viral or mycoplasma; latter starts periphilar and can beomc confluent and or patchy as disease progreses. no air bronchograms

If you take and x ray on expiration

Will obscure the heart border and make it appear as if you have pneumonia

Radiographic studies

X rays ultrasounds doppler PET scan: inject isotope to see where it takes up, hematoma and infection risk

Who can NOT get CT scan

previous allergy to contrast Shellfish allergy Renal insufficiency

ABDominal KUB

to rule out acute abdominal process such as perforation, obstruction and ileus

PET scan

used to evaluate metabolic changes in the body tissue. Bood for Brain and CVD, Pulmonary edema, evaluate cyocardial blood flow, solid tumor, O2 utilization

How to detect rotation

you can detect roation from an AP view by looking at the clavicals and making sure they align and match. The sternum will appear distorted

Interstitial Pulmonary Fibrosis

Most common causes of diffuse interstitial pulmonary fibrosis are idiopathic, collagen vascular disease, cytotoxic agents and nitrofurantoin, pneumoconioses, radiation and sarcoidosis Pregressive Exertional dyspnea and nonproductive cough XRAY; hazy gourng glass opacification early and volume loss with linear opacities bilaterally. loneycomb lund in late stages

Tension Pneumo

No known cause really Air enters the pleural cavity and is trapped during expiration usually by some type of ball valve like mechanism. Leads to build up of air increasing intrathoracic pressure. Eventually will collapse the lung and shift the mediastinum away from the tension pTX. Can compromise venous filling of the heart and een death

MRI

Non invasive test that allows visualization of bodys tissues, structure and blood flowCan be more detailed than CT. Need to remain in it for atleast 1/2 hour. Gold standard: Brain and spine (except trauma) Risk: injury from unknown metal in body WHo can't: Intracranial aneurysm clips Metal foreign bodies heart valves before 64 middle ear prosthetics

Congestive heart failure

One of the most common abnormalities evaluated by CXR. Occurs when heart fails to maintain adequate forward flow May progress to pulmonary venous heprtension and pulm edema with leakage Early findings: Cardiomegaly: increased cardiothoracic ratio >50% Later Pulmonary cap wedge pressure 12-18. Means the upper and lower pulmonary veins are equal in size. Lower is normally larger.. Forms bat wing pattern of density

Inspiration on exam

Patient should take picture on full inspiration to visualize fields. When inspired fully will see the diaphram 8-10th posterior rib and 5-6 anterior ribs

Penetration

Penetration in PA, should be enough to see some of the disc and bone around and through some of the heart. Bony features are not seen through heart. Should have enough penetration to see bronchovascular structures. lateral view will show the spine darkening as it lowers. should see 2 sets of ribs, darkening as it lowers because more air in lower lobes

Lobar pneumonia

Pneumococcal pneumonia, enitre lobe consolidates and air bronchograms are common

Pa and Lateral

Posterior anterior: as if the person is facing you with their left side to your right. Lateral is as if they are facing to the left

The PA

Posterior anteriorr. The patient faces the x ray and the machine is 6ft away. The standing PA is better than the AP (supine). The supine shows a wider mediastinum and generalized reserved for very ill patients

Pulmonary embolism

Primary source is thrombus from deep veins in legs. Chest film rules out other diagnosis. Most are normal. Westermarks sign: oligemia in area of involvement Increased size of a hilum: Atelectasis with elevation of hemidiaphragm and disc shaped densities. Main feature is multifocal consolidation a the pleural base

What is a CT scan

Radiographic scan that can be with or without contrast on almost any portion of the body Risk: Include allergic reaction to dye and renal toxicity

Lobes and Fissures

Really can't see the fissure or lobes on an xray. Especially PA Lateral: The left lung has only the major fissure Right: has major and minor

Pleural Effusion

Common cause: CHF, infection, trauma, PE, tumor, renal failure, autoimmune disease 200 ml of fluid needed to detect on xray Supine film will be graded haze that is denser at the base

Middle mediatinal mass

Common cause: lymphadenopathy due to metastases Other: hisatial hernia aortic aneurysm thyroid mass

Diffuse pulmonary infections

Community acquired: mycoplasma, resolves spontaneously nosocomia: pseudomonas: debilitated vent pt, high mortality rate, patchy opacities, ill difeined

Anterior Mediastinal mass

Consist of the 4 T's Terrible lymphadenopathy Thymic tumors Teratoma Thyroid mass Aortic aneurysm pericardial cyst or epicardial fat pad Usually a CT or fine needle aspiration is needed to definitive

Sinus X-ray

Cysts, Rhinitis, sinusitis

Chest Xray

ARDS, atelectasis, bronchiactasis, emphysema, pulmonary edema, malignancy of lungs. pneumothorax, rib and clavicular fracture and spinal fracture

pneumothorax

Air inside the thoracic cavity but outside the lung Spontaneous: occurs w/o incident or cause. ex idiopathic, asthma, COPD, pulmnoary infection, neoplasm, smoking cocaine. Iatrogenic: surgery or central line placement. Truama such a MVA.

Cerebral Hemorrhage

Air is black, bone is white. Blood is brighter than white/gray matter

Pneumonia Definition

Air space disease and consolidation from bacteria or virus Not associated with volume loss Finding on xray: airspace opacity, lobar consolidation, intersitital opacities. Diffuse not defined like a mass

What you see on X-ray

Air: black Fat: dark gray Water: lighter gray Bone: white

Ultrasound

Aorta, gallbladder, biliary system, K<S<L<P< thyroid, bladder and bone Breast for small tumor to diff from cyst Coronary: measure plaque and thrombus

Major differentiating factors between atelectasis and pneumonia

Atelectasis Pnuemonia Volume loss Normal or increased volume Associated ipsilateral shift No shift Linear wedge shaped Consolication, air space Apex a Hilum Not centeed at hilum

CT vs MRI

CT preferred in brain: Distinction between trauma stroke or hemorrhage. CT preferred in Discs: Herniated intravertebral discs or spinal stenosis CT Lung: lesions, retroperitonel tumors, nodal metast., staging and eval of resect in tumors. Opacities, lesions and masses MRI: Preferred in eval of cerebral edema, demyelination of spinal cord, distinction between benign and malignant pathology. Diagnosis of bone and joint disease. Joint and ligament conditions. MRI can evaluate cerebral infarct withing hours of event, sooner than CT

Solitary nodule

Can be benign. or Calcifications or malignant If unchanged in 2 years, benign If irregular calcificaitons or off center, suspicious

Pericardial Effusion

Causes an enlarged heart shadow that is globular shaped, the transverse diameter is disproportionaltely increased. A fat pad sign, a soft tissue stripe wider ten 2 mm between the epicardial fat and anterior mediastinal fat can be seen anterior to heat on lateral view. Must be about 400-500 ml of fluid in pericardium to see on xray.

Angiography

Cerebral aneurysm or vascular disease, atherosclerosis, tumor and TID. may cause embolus or hemorrhage RISK

Think about with MRI

Claustrophobia Patient size Pt with CKD 3-5 if give contrast develop nephrogenic systemic fibrosis Tattoos, some permanent cosmetics and transdermal med patches: BURNS

Atelectasis

Collapse or incomplete expansion of the lung or part of the lung. Most common findings on chest x ray. Cause: bronchial lesion, mucus plug or tumor. Also an extrensic compression by lymphnode or pleural effusion peripheral Linear increased density on chest xray.

Kerley B lines

Horizontal lines less than 2 cm long Found more in the lower zone Thickened, edematous interlobular septa. Cause: pulm edema, lymphangitis, carcinoma, viral and mycoplasmal pneumonea, pulmnonary fibroids

Silhouette sign

Is an elimination of the silhouette or loss of lung tissue caused by a mass or fluid in the lung. The location can help to determine the location anatomically. Heart: RML Lingula: anterior of Upper lobe

Cardiogenic pulmonary edema:

Kerley B lines or septal lines Bat wing pattern patchy shadowing with air bronchograms Increased cardiac size Usual bilateral

Pneumonia

Less defined borders but still looks abnormal.More diffuse

WHy order MRI

Detect: Abscesses, Aortic and ventricular aneurysm, blood clot, brain contusion, cancer and tumor, cerebral infarct, demyelinating disease, skeletal abnormalities, soft tissue infection ,spinal cord injury or compression soft tissue infections Osteomyletis: good pics of spine Stroke pt

Emyphysema

Loos of elastic recoil of lung with destruction of pulmonar capillary bed and alveolar septa Common cause: smoking Functional presentation: hallmark: decreased airflow FEV1 and diffusing capacity (decreased DLCO2) Seen on CXR as diffuse hyperinflation with flattening of diaphragm, and enlargement of PA/RV or cor pulmonale. Hyperinflation and bullae are the best radiographic predictors of emphysema.

Mastectomy

Make note of mastectomy. Can appear as pleural effusion because of graded appearance

Detecting masses

Masses have well defined borders Masses, Intraparanchymal Pleural Extra pleural

WHy order CT of Chest

Evaluate: Solid tumors Asthma, COPD, Metastic tumurs, osteomyelitis of spine, sternum or ribs, Chest trauma, soft tissue sarcomas or lymphomas, abscesses, medistinal infection axillary studies of lymph nodes Lung effusions Empyema Fibrotic pleural disease AA

Why order a ct of the head

Evaluate: brain tumors, CVA, Cerebral atrophy, Infarction, Head Injury, Hematoma

MRA

Focuses on flow Evaluates: Vascular structure and blood flow especially venous system for aneurysms, thrombosies or blockage carotid stenosis congenital heart disease renal or hepatic vascular disorders

Aspiration pneumonia

Follows gravitational flow of aspirate contents, impaired consciousness, post anesthesia, alcoholic, debilitated, dementious,

C-spine

For trauma and cervical tenderness

X ray of bone

Fractures, joint and osteoporosis detection

Trauma and rib fracture

Have the appearance of an abrup discontinuity of smoth outline of the rib. Lucent fracture line may be seen Fracture may not be visible on xr. Is taken to assess for pneumothorax.