Chest X-ray
ID
edit- name
- age
- date
- modality
Marker
edit- Right or Left
Position
edit- Medial ends of the clavicles should be equidistant from the spinous processes at the midline to rule out rotation
Quality
edit- Penetration
- thoracic disc spaces should be just visible through the heart
- overexposure → too dark
- underexposure → too white
- thoracic disc spaces should be just visible through the heart
Respiration
edit- good inspiration → 6th anterior, 10th posterior ribs at MCL
- right hemidiaphragm at 6th anterior rib
- poor inspiration:
- poor aeration, vascular crowding, widened central shadow
Hardware
edit- Comment on any lines, lead placements, tubing, etc.
Bones
edit- C-spine, T-spine → alignment, disc space spacing, lytic or blastic lesions
- shoulder girdle, ribs, humerus, sternum → fractures, osteopenia, deformities
- vertebra OA (lateral view)
- subchondral (beneath the cartilage) sclerosis
- subchondral cysts
- narrowing of joint space
- osteophytes
Extrathoracic soft tissue
edit- breast shadow, nipple
- supra-clavicular, axillary areas → masses
- subcutaneous emphysema
Mediastinum
edit- size, shape
- mainstem and segmental bronchi, lymph nodes
- great vessles
- hila → relationship, size
Trachea
edit- position (centered, some rightward shift at level of carina)
- shift - pneumothorax, mass
- carina widened - LA enlargement, subcarinal node
Heart Shadow
edit- cardiothoracic ratio (only on full inspiration PA views)
- should be < 50%
- enlarged chambers
- LA - double shadow on right border
- RA - ↑ width of right hemidiaphragm
- LV - ↑ heart width
- RV - lateral view: retrosternal space ↓
- calcifications
- aortic knuckle - unfolded due to age
Chest Wall
edit- follow pleura for signs of pneumothorax
- loss of lung markings in the periphery
- line of visceral pleura seen on expiration view
- pleural thickening
- ↑ width of white line along inside of ribcage, esp. near diaphragm
- costophrenic angles → pleural effusion
- small effusions (< 100 mL) may be only seen in the lateral view
Diaphragms
edit- compare hemidiaphragms
- obscured → lower lobe pneumonia, pleural effusion
- flattened → hyperinflation, tension pneumothorax
- elevated → phrenic nerve paralysis, hepatomegaly
- air under diaphragms → perforated GI tract
Lung Fields
edit- compare lung fields in the ICS on L vs. R, up vs. down
Air Space Disease
edit- cardinal features:
- air bronchogram
- fluffy, patchy poorly marginated appearance
- lobar or segmental distribution
- ddx:
- pus (pneumonia)
- fluid (pulmonary edema)
- blood
Interstitial Disease
edit- pathology involves the interlobular connective tissue
- cardial features:
- linear densities - Kerley B lines (< 2 cm long, 1 mm thick, reach lung edge)
- reticular pattern (thin, well defined linear densities, honeycomb arrangement)
- nodular pattern
- ddx: pulmonary edema, collagen disease (fibrosis), sarcoidosis, viral pneumonia
Pulmonary Edema
edit- edema initially collects in the interstitium
- loss of definition of pulmonary vasculature
- peribronchial cuffing
- bronchi seen end-on appear as white rings
- in CHF, the normally thin-walled bronchi become framed in interstitial fluid
- best seen in vicinity of hila
- Kerley B lines
- reticulonodular pattern
- thickening of interlobar fissures
- with progression, fluid begins to collect in the alveoli, causing diffuse air space disease (bat wing or butterfly pattern), tend to spare the intermost lung fields
- ddx: cardiogenic, renal failure
Atelectasis
edit- cardinal signs:
- deviation of a fissure
- crowding of vessels
- hilar, mediastinum shift
- common causes: obstructive, compressive
- in absence of a known etiology, bronchogenic carcinoma must be ruled out
Lymphadenopathy
edit- lymph node groups: paratracheal, hilar, aorto-pulmonary window, subcarinal
- hilar, AP window → widen mediastinum, flatten AP window contour
- lung cancer, lymphoma, sarcoidosis, and tuberculosis
- subcarinal - ↑ angle of tracheal bifurcation to 90°
Abdomen
edit- liver size
- spleen size
- stomach (gastric bubble)
- colon (bowel gas)
- free air under diaphragm - pneumoperitoneum
Misc
editCHF
edit- upper lobe redistribution of vessels
- Kerley B-lines (usually seen near diaphragm)
- right effusion at base
- perivascular cuffing
- pulmonary edema (interstitial, then airspace consolidation)
- venous engorgement
- normally extend 2/3 of the distance to periphery
- vessels seen to extend farther than normal
Unilateral Left Sided Effusion
edit- trauma, infection, SLE, PE, malignancy
Mediastinal Mass
edit- anterior mediastinum
- thyroid masses, thymomas, teratomas, lymphomas
- middle mediastinum
- lymphadenopathy, lymphoma, aortic aneurysm
- posterior mediastinum
- aneurysm of descending aorta, esophageal masses, hiatus hernia
- lateral view
- RVH
- effusion → accentuation of lines of major and minor fissures