chest x-ray interpretation.ppt
DESCRIPTION
Chest X-RayTRANSCRIPT
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Clinical aspects of CXR Interpretation
Abhiraj KaleDept. of Clinical Pharmacy,
KLES Dr.Prabhakar Kore Hospital & MRC,
Belgaum.
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Objectives
To review ordering a chest x-ray To review the normal findings including
skeletal and soft tissue landmarks To present a systematic procedure for
interpreting chest x-rays To cover common abnormal findings in the
primary care setting.
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Ordering a Chest X-Ray
Order by chief complaint Views: PA (standard frontal chest film)
Lateral (marked by which side of chest is against the film – good to assess the area behind the heart)
Positioning: Lying vs. Upright
Right vs. Left
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Systematic Interpretation
Suggested Routine Label (Verify ID factors) Orientation Quality Skeletal Structures Soft Tissue Structures
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Before Interpreting a Film
Make sure it’s the right patient. Know the patient’s story. Have older films, if available. Place films on the view box as though you are facing
the patient. Check the quality: You should be able to see the
outlines of the vertebral bodies within the heart shadow. Check for rotation (symmetrical clavicles). Know normal anatomy
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Essentials Before Getting Started
Exposure Overexposure Underexposure
Sex of Patient Male Female
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Path of x-ray beam PA AP
Patient Position Upright Supine
Essentials Before Getting Started
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Systematic Approach
Bony Framework Soft Tissues Lung Fields and Hila Diaphragm and Pleural Spaces Mediastinum and Heart Abdomen and Neck
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Systematic Approach
Bony Fragments Ribs Sternum Spine Shoulder girdle Clavicles
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Systematic Approach
Soft Tissues Breast shadows Supraclavicular areas Axillae Tissues along side of
breasts
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Systematic Approach
Lung Fields and Hila Hilum
Pulmonary arteries Pulmonary veins
Lungs Linear and fine nodular
shadows of pulmonary vessels
Blood vessels 40% obscured by other
tissue
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Diaphragm and Pleural Surfaces Diaphragm
Dome-shaped Costophrenic angles
Normal pleural is not visible
Interlobar fissures
Systematic Approach
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Mediastinum and Heart Left side
Left ventricle Left atrium Pulmonary artery Aortic arch Subclavian artery and
vein
Systematic Approach
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Systematic Approach
Abdomen and Neck Abdomen
Gastric bubble Air under diaphragm
Neck Soft tissue mass Air bronchogram
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Opacity
Air < fat < liver < blood < muscle < bone < barium < lead
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Skeletal Structures
Skeletal Structures Scapulae Humeri & Shoulder
Joints Clavicles Ribs (9+ = good
inflation) Spine
Assessment Check for symmetry,
spacing, and fractures. Check for linearity of
the spine.
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Pitfalls to Chest X-ray Interpretation
Poor inspiration Over or under penetration Rotation Forgetting the path of the x-ray beam
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PA View:1. Aortic arch2. Pulmonary trunk3. Left atrial appendage4. Left ventricle5. Right ventricle6. Superior vena cava7. Right hemidiaphragm8. Left hemidiaphragm9. Horizontal fissure
The Normal Chest X-ray
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The Normal Chest X-ray
Lateral View:1. Oblique fissure
2. Horizontal fissure
3. Thoracic spine and retrocardiac space
4. Retrosternal space
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Soft Tissue Structures
Neck and Esophagus Symmetry, masses
Trachea Deviation, ID bifurcation, should not be able to ID airways further out because they are thin walled.
Breasts Symmetry, nipples may be visible
Diaphragm Right usually higher
Costophrenic Angles Should be sharp and clear (no fluid density)
Cardiophrenic Angles Should be fairly clear
Vasculature Check for position and calcification
Hilum- L side generally higher and looks smaller than R
Heart Size (1/2 width of thorax), Ventricles
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Soft Tissue Structures
LungsPleura Closed cavities enveloping
each lung. Visceral layer connects with the lung tissue, while the Parietal layer is thicker and attached to the wall of the thorax.
Right Lung Has 2 fissures separating 3 lobes
Left Lung Has 1 fissure separating 2 lobes
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Chest-Xray TermsSilhouette Sign: When a margin or
structure is masked by another density
Right Side of heart masked by a RML pneumonia
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The Silhouette Sign
An intra-thoracic radio-opacity, if in anatomic contact with a border of heart or aorta, will obscure that border. An intra-thoracic lesion not anatomically contiguous with a border or a normal structure will not obliterate that border.
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Stages of Evaluating an Abnormality
1. Identification of abnormal shadows
2. Localization of lesion
3. Identification of pathological process
4. Identification of etiology
5. Confirmation of clinical suspension Complex problems
Introduction of contrast medium CT chest MRI scan
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Abnormal X-Ray Findings
Upper Respiratory Infections Skeletal Injury Atelectasis Pneumothorax Pleural Effusion Cavitation Masses and/or Nodules Chronic Lung Disease Foreign Body
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Case 1
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Case 1
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A single, 3cm relatively thin-walled cavity is noted in the left midlung. This finding is most typical of squamous cell carcinoma (SCC). One-third of SCC masses show cavitation
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Cavitation:cystic changes in the area of consolidation due to the bacterial destruction of lung tissue. Notice air fluid level.
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Case 5
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Tuberculosis
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Case-4
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Pneumonia: a large pneumonia consolidation in the right lower lobe. Knowledge of lobar and segmental anatomy is important in identifying the location of the infection
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Case-5
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CHF:a great deal of accentuated interstitial markings, Curly lines, and an enlarged heart. Normally indistinct upper lobe vessels are prominent but are also masked by interstitial edema.
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Case-6
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Chest wall lesion: arising off the chest wall and not the lung
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Case-6
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Pleural effusion: Note loss of left hemi diaphragm. Loss of cp angle
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Csae-7
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Lung Mass
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Metastatic Lung Cancer: multiple nodules seen
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Case-8
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Right Middle Lobe Pneumothorax: complete lobar collapse
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PneumoniaBacterial PCP
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Acute Bronchitis
Streaky Densities
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Skeletal InjuryRib Fractures
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Atelectasis
Definition: Air volume loss. Collapse is a synonymous term.
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Right Lung atelectasis and Pneumothorax
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Cavitation:
A pocket of air surrounded by a membrane or wall of varying thickness.
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Tuberculosis
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Masses and/or Nodules .
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COPD
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Pulmonary Edema
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CHF
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Foreign Body
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References
Brass-Mynderse, N. (2004). CXR interpretation. N440 advanced assessment and clinical diagnosis week five diagnostic testing self-study packet. Handout.
Chandrasekhar, A.J. (2005). Chest X-ray. Retrieved November 29, 2005 from http://www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/cxr/cxr.htm.
Ritter, B. Basics of chest x-ray interpretation: A programmed Study. Retrieved November 29, 2005 from
http://www.usfca.edu/fac-staff/ritter/chestxra.htm.
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THANQ U