Clinical Reasoning: Radiology

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1.

Acute vs Chronic Image

7.

AP window (3) and Infrahilar window: what is in each?

2.

Acute vs chronic lung disease ... an easy way to tell is ...

If interstitial markings are ill defined and have normal branching pattern, it's ACUTE If interstitial markings are sharp, then it's CHRONIC

8.

Bony anatomy: acromion, clavicle, posterior rib, anterior rib, spinous process, scapula, humeral head

3.

Alveolar disease: focal vs diffuse: what would cause these?

4.

Aortic Aneurysm

Posterior rib is more horizontal: Anterior rib is more vertical

9.

CT image of lung showing different lobes

5.

Aortic arch, left pulmonary artery, and right pulmonary vascular complex on lateral chest Xray

10. 6.

Diffuse Reticular pattern

AP chest radiograph: patient's position? tube-detector distance? what happens to image?

Notice thickened interstitium

11.

Diffuse Reticulonodular Pattern

17.

How can you judge if you have a good x-ray?

MUST BE TAKEN DURING FULL INSPIRATION MIDPOINT OF THE RIGHT HEMIDIAPHRAGM SHOULD BE AT ABOUT THE LEVEL OF THE 9TH OR 10TH RIBS

12.

Enlarged Lymph node in right paratracheal region

18.

How can you see fissures during X-ray? How can you tell a rib fracture on an Xray?

Xray beam must be tangential to the fissure Ribs should move in smooth direction; If they fall off all of a sudden, then BONGO BINGO!!! you got a fracture

19.

20.

How can you tell when you have pericardial effusion?

13.

Exact Physics of Xray

When you get a water-bottle shaped enlargedment of the entire pericardium

21. 14.

Extrapleural space: what is it? Fissures of the lung: left vs right lung

potential space between rib cage and parietal pleura

15.

How do you justify moderate CHF? What are fluid in interlobular septa called?

when pulmonary vessels enlarge and cephalization, enlargement of left ventricule, but no edema yet Kerley B lines
22.

How does lung react to disease? (4)

Thicken/thin Change in 5 substances(air, water, other fluids)

16.

Heart Anatomy

Focal/diffuse Acute/chronic
23.

How is an X-ray generated?

24.

How should you start reading an x-ray?

Start with right GH joint, clavicle, down right side, up left side, clavicle, GH joint Then look at symmetry of soft tissues

30.

Image of AP chest radiograph in action

25.

Huge anterior mediastinal mass

31.

Image of Hiatal hernia

Anterior mediastinal due to crossing of midline (so no lungs involved) and can't be posterior mass because descending aorta is conserved
26.

If ENTIRE chest isn't on film ... what should you do? If fissures appear thick ... what can you assume? If you have an enlarged left ventricle ..

REPEAT! ... if you can't see diaphragm or angles That there is some fluid in them (CHF)
32. 33.

27.

IN CHF ... you get .. In lateral chest X-ray, what structure is obvious in a COPD patient? IN Right heart failure ... you get .. Interesting pick-ups

pleural effusion aortic arch

28.

34. 35.

pleural effusion

apex moves laterally, and entire heart shifts more inferiorly and laterally
29.

Image of a good x-ray with good inspiratory effort (look at 10th rib and hemidiaphragm)
36.

Lateral Chest X-ray image

37.

Lateral Chest X-ray: 3 main spaces: what would you find in each?

40.

Lateral Chest X-ray: skeletal structures

Retrosternal: 5 t's -terrible lymphoma -thymoma -teratoma and other germ cell tumors -thyroid goiter -thoracic aortic aneurysm Retrotracheal: diseases: esophageal disease, lung cancer Retrocardiac: hiatal hernia!!!
38.

41.

Left lower lobe collapse signs Left upper lobe collapse signs Left/Right major fissures: what type of xray? How can you tell them apart?

major fissure pulled inferoposteriorly major fissure pulled forward

42.

43.

Lateral chest X-ray: position of patient? what gets magnified?

44.

Lobar Interfaces (6)

RLL: right hemidiaphragm RUL: binds the right brachiocephalic vasculature RML: bounded by right atrium LLL: left hemidiaphragm Lingula: allows us to see the left ventricle LUL: binds the aortic knob and left brachiocephalic vein

39.

Lateral Chest X-Ray: pulmonary outflow tract, posterior border of left atrium, posterior border of left ventricle

45.

Lungs: how should you scan? also, what does consolidation look like?

46.

Mediastinum anatomy

52.

Objectives

47.

Mediastinum divides ... Minor and Major Fissures in a lateral chest x-ray: also, name the lobes that you see

right and left lung

53.

48.

PA chest radiograph: Positioning during an X-ray; where does patient face? patient position? Tube-detector distance? Why this distance?

54.

PA chest x-ray: cardiovascular borders

49.

More images of AP window and infrahilar window: what pathology might you be able to see here?

55.

Parietal Pleura vs Visceral Pleura: which can sense pain

You might be able to see tumors

50.

Parietal lines chest wall, while visceral lines lungs Parietal pleura is sensitive to pain

More objectives
56.

Pectus Excavatum

51.

Most great vessels located in the ...

middle mediastinum

57.

Penetration: how can you tell if it's good? In PA view and Lateral view

58.

Pneumothorax: what is it? how can you tell?

64.

Rotation: position of the patient ... why is it important that rotation doesn't happen? Subpulmonic effusion: what is it? how should you view it?

There should be no rotation; so, the distance between the clavicular heads are equidistant from spinous process of the vertebral body when fluid collects between diaphragm and base of lung view it by having patient lay down, which will redistribute fluid throughout cavity

65.

air in the pleural space (between visceral and parietal pleura) Air in pleural space is darker than the air in the lunk
59. 66.

Psuedotumor: what is it, and how do you get it? Seen in ..?

Tension Pneumothorax: what is it? what do you see on xray? biggest danger?

It's left over fluid in the major or minor fissures; disappears in a week CHF
60.

Pulmonary Mass/Nodule: how do you determine the terminology?

Air enters the pleural space with each breath, but can't escape ... leading to increased intrapleural pressure: You see ... depressed diaphragm, collapsed lung, and mediastinum shifted AWAY from pneumothorax biggest danger is having it constrict the IVC/SVC... right heart failure
67.

61. 62.

RADIOLOGY 3 Right and Left Hemidiaphragm relationships

... The Silhouette Sign: what is it?

63.

Right and Left Hilum Relationship: what if it's not correct?

When one of those 6 mediastinal borders is obliterated

68.

Trachea-bronchial images on lateral chest x-ray (4 structures)

75.

What are the 5 things that can fill alveoli?

Air Water (CHF) Pus (pneumonia, infection) Blood (hemorrhage due to embolus) Proteinaceous fluid

69.

Tracheo-bronchial Anatomy: right paratracheal stripe, trachea, carina

76.

What are the four radiographic densities?

Soft tissue (h20)medium gray Fat-darker gray Air - black (low density) Bone (calcium)white, because it's very dense

70.

Usual causes of interstitial lung disease: chronic vs acue

Chrnoic: fibrosis Acute: edema, viral, mycoplasma

71.

What are 5 things that can cause the lung to collapse?

77.

What are the four things you must verify before reviewing the chest x-ray?

Name, date, patient position, and quality of exam Then, determine male/female, and survey for foreign bodies

72.

What are indirect signs of lobe collapse? What are signs of a direct signs of lobe collapse?

Movement of the hilar structures towards sign of collapse

78.

73.

What are the lateral costophrenic angle and posterior costophrenic angles? What happens to these angles during pleural effusion? Which film is best to look at?

Look for a displaced fissure!!!

74.

and they form manisci Look at a lateral Xray

What are the 2 diseases that DO NOT make the lung more dense?

COPD, emphysema

79.

What are the most common causes of acute diffuse alveolar disease and nodules/masses (young vs old)

86.

What is the cardio-thoracic ratio: what should the number be? What if it's too high? What kind of X-ray?

A=transverse diameter of the heart B=diameter of the chest Should be 0.5 or less

80.

What are three factors that favor fluid movement out of a vessel? what are is one factor favoring fluid movement into a vessel?

If too high, then theres cardiomegaly Only valid on PA chest xray

87.

What' the air bronchogram sign? What causes it?

81.

What do you see with collapses? RUL

Right upper lobe collapse: minor fissure moves superiorly and bows upward, and major fissure pulled anteriorly major fissure displaced inferoposteriorly Minor fissure displaced inferiorly, major fissure displaced superiorly/anteriorly

82.

What do you see with right lower lobe collapse? What do you see with right middle lobe collapse

88.

83.

What's the most difficult problem with lateral chest x-rays? What's the most frequent sign of mediastinal disease? focal vs generalized

trying to figure out if it's right or left widening of mediastinum Focal: due to mass (hiatal hernia) General: hemorrhage, fat

89.

84.

What happens after photons pass through patient? Density dictated by ... When a lung collapses ... what is a good sign?

90.

Look for trachea/mediastinal shift towards the collapsed side

91.

Less dense means darker

85.

When can you see minor fissure during chest x-ray?

What is a fissure in the lung? What is pleural space?

Area where two visceral pleura come in contact Area between visceral and parietal pleura is pleural space

During a PA chest xray

92.

Which hemidraphragm disappears in a lateral chest X-ray due to the presence of the heart?

Left
93.

Why do high density objects and low density objects appear the way they are?What's another factor that influences density?

High density absorb lots of photons, so they appear white Low density don't absorb many photons, so they appear black Thickness of an object

94.

Why do people with cancer get pleural effusion? (2)

If you block lymphatics, that diminishes the ability of the lymph to resorb that fluid, leading to increased pleural fluid OR Metastasis into pleural space, blocking lymph outflow, leading to pleural effusion