clinical skill3 cxr-final

Diagnosis of Congestive Heart Failure

Presented by:Dr. Mahmood Yaseen Hachim

CHEST X-RAY

StepActionFindingsNotes

1Identifications dataa. Patients Namea. Date of Birth (Age)a. Sex

a. Indication for CXRClinical suspicion and provisional diagnosis

Mahmood Yaseen22/9/1076MaleRoutine Check Up

R

PAStanding

2Side Marker (Orientation)

Right Side and Left Side of the CXROne side is labels usually either R=right or L=Left

Look to the CXR as you are looking at the patient = the patient's right side is on your left side and vice versa


R

PAStanding

3Technical Considerations of CXR qualitya. Position of the Patient: Standard

position is standing

Check if any mark stating the patients was not standing during the CXR

Sitting: means severe illness, unable to stando Raised diaphragmo Reduced inflation of lungso Folded soft tissue of the patients front like skin

Supine: means very severe illness, unable to sito The fluid level will be lost


R

PAStanding


R

PAStanding

a. Projection: direction of X-Ray beam passage through the patient

If the cassette is in the back and the beam pass from front to back =(AP)=Anterior -Posterior

If the cassette is in the front and the beam pass from back to front =(PA)=Posterior-Anterior

Either right or left side of the chest = Lateral

Objects near the cassette will appear in their size but the organs far from the cassette will look falsely enlarges as a shadow, it is so importnat in case of heart size assessment

So AP is not used to check heart size, it should be PA


R

PAStanding

Rotation Spinous processes of thoracic vertebra should appear at the center of each

The spinous process of T4 should be between the heads of the clavicle

if it isn't the body is rotated

Rotation can cause abnormal appearance of the mediastinum and other structures

http://en.wikipedia.org/wiki/Spinous_process

http://en.wikipedia.org/wiki/Spinous_process

http://en.wikipedia.org/wiki/Clavicle


R

PAStanding

Quality and Exposure of X-Rays Is the film penetrated properly?

In a properly penetrated film the vertebral interspaces should be visible behind the central (cardiac) shadow

Too little exposure will make lungs appear too white

Too much exposure will make structures more dark and mask the signs


R

PAStanding

a. Inflation : Proper CXR should be taken with full inflation of lungs (deep inspiration and hold breath)

There must be more than 9 ribs visible posterior to say the inspiration was perfect

So count the ribs starting from the 1st rib

If poor inflation then the lung will appear more dense

Trachea will be drawn to the right side

Heart will look abnormally enlarged

Poor Inspiration Good Inspiration


R

PAStanding

a. Inclusions: the CXR felid should include all the chest structures

Check if the lung apices are shown

Check if both costophrenic angles are seen


R

PAStanding

4Look for different intensities Black=gas Dark Grey=fat Light Grey=soft tissue or

fluids White=bone and calcifications Intense white=metal


R

PAStanding

5Clinical Interpretation

a. Mediastinum Examine the Mediastinal Border for abnormality


R

PAStanding

5Clinical Interpretation

a. Mediastinum Look to the trachea and the bronchi


R

PAStanding

Heart Any visible valves (in case of metal valves) Cardiac Size should be less than 50% of the

thoracic width in PA file measured by RULER

The heart size is enlarged in Congestive heart failure


R

PAStanding

a. Mediastinal masses, calcification or free air


R

PAStanding

Examine the hila: regions of lung connection to central circulation, looks opaque on the right and left side of mediastinum, they are made mainly by pulmonary arteries and veins

Hila should be rounded and symmetrical

The right hila is 1 cm lower than the left hila

Look for difference in densities

Asymmetry Loss of normal

concavity

Pulmonary Hypertension


R

PAStanding

Lungs: Lung feilds of equal densities Right hemidiaphragm slightly higher than the left Sharp costophrenic angles and cardiophrenic angel The horizontal fissure in the right lung passes horizontally from

the midpoint of the right hilum to about the 6th rib in the axillary line

The pleura should be thin and symmetrical

In heart failure there will be pulmonary edema Bilateral , lung shadowing classically in the middle

and upper zones causing bat wings appearance Pulmonary vessels engorgement (blood vessles

more than 5 mm in diameter in upper zone Kerley B lines: short horizontal white lines close

to the lung periphery cuased by edema of interlobular septa


R

PAStanding

Look for the remaining structures

a. Bones : examine their densities and trabecular pattern

Examine the shoulder girdle Ribs Clavicles Thoracic vertebrae

Lytic lesions Sclerosis Erosions Fractures Dislocations

a. Soft Tissue Check Surgical Emphysema Air pockets in soft tissue

a. Breasts In females Nipples are rounded opacities that may be

misdiagnosed as lesions

Missing breast by disease or surgery

a. Abdomen See air in the stomach below left hemidiaphragm

Free air under diaphragm

Gastic bubbles seen as rounded top and horizontal base shape

Free air appear between liver and right hemidiaphragm or above gastric bubbles

StepActionFindingsABF

1Identifications data10.50

a. Patients Name

a. Date of Birth (Age)

a. Sex

a. Indication for CXR

2Side Marker (Orientation)0.30.15

Right Side and Left Side of the CXR

3Technical Considerations of CXR quality1.20.50

a. Position of the Patient: Standing Sitting Supine

0.2

a. Projection: (AP or PA or Lateral)0.2

a. Rotation Rotated or not0.2

a. Quality and Exposure of X-Rays Too little exposure Too much exposure

0.2

a. Inflation : Proper inhalation or not0.2

a. Inclusions: lung apices are shown both costophrenic angles are seen

0.2

4Clinical Interpretation1.50.75a. Mediastinum Mediastinal Border for abnormality

Trachea and the bronchi0.25

a. Heart Any visible valves Cardiac Size

0.25

a. Mediastinal masses, calcification or free air0.25

a. Examine the hila: Density Symmetry

0.25

a. Lungs: Lung fields densities costophrenic angles cardiophrenic angel The horizontal fissure The pleura

0.25

5Look for the remaining structures10.5a. Bones Examine the shoulder girdle

Ribs Clavicles Thoracic vertebrae

0.25

a. Soft Tissue Check Surgical Emphysema0.25

a. Breasts Shape Nipples are rounded opacities that may be misdiagnosed as lesions

0.25

a. Abdomen Gastic bubbles Free air under diaphragm

0.25

CXR in Congestive Heart Failure

Kerley B LinesOedema of the interlobar septa

Horizontal, non branching, whiteSeen at periphery above costphrenic angle

clinical skill3 cxr-final

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