Radiology Chest X Ray (simplified)

Bambang Heru RS Sumber Waras - 2011 www.bambangheru.net

ADMINISTRATIVE
1. Patient's name. 2. Date exam done (very important if comparing prior exams). 3. Check for position markers - right vs. left, upright.

1. Type of film (plain CXR CT, angio, MRI, etc.) 2. Patients position - supine, upright, top lordotic, lateral, decubitus. 3. Technical quality of exam (over / under Exposed) 4. Inspiration Maximal Optimal minimal 5. Focusing Vibration Motion Cut View 6. Learn what are the acceptable limits for the exam. You can't find a subtle pneumothorax if there is patient motion or the film is overexposed.

INITIAL SURVEY
1. General Body Size, Shape, and Symmetry 2. Male vs. Female 3. Is this an infant, child, young adult, elderly person? 4. Survey for foreign objects - tubes, IV lines, EKG leads, surgical drains, prosthesis, etc., as well as non-medical objects, necklace, button, watch, bangles, metal, bullets, shrapnel, glass, etc.

Evaluation
Trachea: Mediastinum Hillus Cor Diaphragm Costophrenic angel Lung Parenchyma and Pleura Bone and Soft Tissue Other: Corpus Alienum, Artefact

Trachea
In mid line of body Deviation; Size: stricture, dilatation Compress by tumor

SUPERIOR MEDIASTINUM
First, check the overall width for normal size, again look for masses, calcifications, and free air. The rest of the superior mediastinum review is a detailed search for subtle distortion of several major plural mediastinal interfaces. Not all of the following structures are seen on every film, but try to find them.

Aortic Arch - Heart

Aortic knob Elongation aorta: less 2 cm from left clavicula\ Calcification of aorta Aorta dilatation - Aorta disecction Cor Thoracic Ratio

Hillus
Hillar Enlargement Left Hillar slightly higher than Right One Hillar mediastinal enlargement

Diaphragma Costophrenicus Angle

Smooth Flattened Diaphragma Tenting Diaphragma Elevated Diaphragma: mass, liver, paralysis Angle Sharp Angel blunt: effusion, pleuritis sicca

Lung
Bronchovascular patern normal - bifurcatio Nodular Recticular - Alveolar Infiltrate Cavity Fibrotic Calcification Air Bronchogram - Bronchiectasis Nodul: soliter, multiple, uni-bilateral Kerley A, B, C line

Pleura
The costophrenic angles laterally should be sharp. The lung should abut right up against the inner margins of the rib cage. If the pleural space is widened by fluid or mass, the lung will be pushed away by soft tissue density. Also check for pleural calcifications, and presence of pneumothorax.

Soft Tissue
Fat structure Emphysema Subcutis Breast and Nipples (female)

Thoracic Spine and Rib Cage

Vertebra visible till Vertebra Thoracal 6th Vertebra Scoliosis, Lordosis Each vertebra and the disc spaces (frontal and lateral). presence of any lytic or sclerotic areas, normal spacing, versus narrowing or sclerosis Fracture

Ribs
Compare individual ribs side to side, check specific parts, cortical margins, trabecular patterns. Make a note if the anterior cartilages are calcified, frequently the first one does so irregularly and may obscure or mimic underlying lung lesions. 1. - Posterior Rib 2. - Anterior Rib

Others
Corpus alienum: coin, pin, bone Stent of Lung Button Necklace Catheter: CVC, Double Lumen Cath, Pace Maker, Chemoport, Susuk

Sample One

Hyperinflation Hyperlucency Low set flat diaphragm Vertical heart Pre and infracardiac lungs Barrel shape Emphysema Avascular zones Bleb walls

Summary
Identification Trachea: Mediastinum Hillus Cor Diaphragm Costophrenic angel Lung Parenchyma and Pleura Bone and Soft Tissue Other: Corpus Alienum, Artefact

Check List
1. Check patient name, position, technical quality. 2. Soft tissue including breast, chest wall, companion shadow. 3. Review soft tissues and skeletal structures of shoulder girdles and chest wall. 4. Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc.

1. Review soft tissues and spine of neck. 2. Review spine and rib cage: check alignment, disc space narrowing, lytic or blastic regions, etc. 3. Review mediastinum: A. overall size and shape B. trachea: position C. margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle D. lines and stripes: paratracheal, paraspinal,

1. A. B. C.

Review mediastinum: overall size and shape trachea: position margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle D. lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic E. retrosternal clear space

1. Review hila: A. normal relationships B. size

1. Review lungs and pleura: A. compare lung sizes B. evaluate pulmonary vascular pattern: compare upper to lower lobe, right to left, normal tapering to periphery C. pulmonary parenchyma D. pleural surfaces a. fissures - major and minor - if seen b. compare hemidiaphragms c. follow pleura around rib cage

 http://rad.usuhs.mil/rad/chest_review/in dex.html

Soft Tissues and Skeletal Structures

LEFT CHEST WALL Look for overall thickness, subcutaneous emphysema, calcification. Look for sharp, distinct muscle fat planes as illustrated on the annotated image (dots). BREAST TISSUE In males and females, some asymmetry can occur from standing with unequal pressure against the film holder. Notice how the apparent lung density changes from the lung area covered by the soft tissue of the breast to the lung area inferior to the breast.