Basics of Chest X.doc

8/21/2019 Basics of Chest X.doc

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Basics of Chest X-ray Interpretation:

A Programmed Study

Acknowledgment is given to eslie !uma" #$" !S$" $P for assistance in prepartion of this learning

module%

&escription The course is designed as an elective to give the advanced practice nurse, involved in the care of patients with cardiopulmonary

problems, a basic introduction to the principles of chest x-ray interpretation. The course is in a self-programmed format whereby the student reviews

chest films with accompanying case histories and answers. The chest films selected represent commonly occurring cardiopulmonary problems in the

primary care setting and provide additional means by which nurses can correlate their knowledge of pathophysiology and cardiopulmonary physical

assessment (theory and skills) with findings demonstrable on a chest x-ray.

'()ectives:

!dentify cardiothoracic anatomical structures demonstrable on a chest film.

"ecogni#e a normal chest radiograph.

"ecogni#e and name the radiographic signs of atelectasis, consolidation, pneumothorax, pleural and pericardial effusions, and hyperinflation

fre$uently seen in patients with cardiopulmonary disease.

%orrelate physical signs and symptoms of cardiopulmonary disease with chest radiographic findings.

Prere*uisites:

&raduate standing.

%onsent of instructor'department chair.

Course #e*uirements:

re-test and ost-test of radiograph interpretation (instructor-administered).

+rading %hoice of letter grade or satisfactory'unsatisfactory. satisfactory grade is obtained by achieving *+ or greater on the post-test. The

post-test may be retaken as many times as necessary in order to achieve a passing grade.

#e*uired ,et:

elson, ., /einstein,., 0 1pit#, 2. (3456) rinciples of %hest "oentogenology7 rogrammed Text. hiladelphia7 1aunders.

8ovelline, ".. (3449) 1$uires:s undamentals of "adiology. %ambridge7 2arvard ;niversity ress.

#e*uired Articles:

ctober ?+, ??-?5.

1chapiro, ".l., 0 =usallam, @.@. (3499) radiologic approach to disorders involving the interstitium of the lung. 2eart 0 Aung, 5, 5?6-5B?.

#e*uired .e( Sites:

Basics of Chest X-ray Interpretation: A Programmed Study

http7''www.usfca.edu'fac-staff'ritter'

#ecommended Articles:
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1ee list at end of syllabus (ppendix ).

#ecommended ,ets:

Clliott, @.. (34*9) Cxercises in %hest D-ray Eiagnosis. >xford, Cngland7 utterworth 2einemann.

#ecommended .e( Sites:

Chest X-ray

http7''edcenter.med.cornell.edu

http7''www.medexpert.net

http7''www.vh.org

,eaching /iles on the #adiology inks Page

http7''www.med.stanford.edu

http7''brighamrad.harvard.edu'education'online'clerkFG'read.html

#ecommendedSchedule for Chest X-ray Practicum:

This schedule is given to be used as a guideline to the practicum. The order of the films has been selected to build and reinforce prior learning. The

material to be read may not follow exactly, but may be utili#ed as a reference. lthough 8ovelline is lengthy at times, it has the best examples of films

throughout the text. elson and asics of %hest D-ray !nterpretation7 rogrammed 1tudy 0BCI1 are self-learning modules which you may use at

your own pace.

/ilms $ovelline Articles /elson BCI

3. "adiographic natomy %hapters 3, G , ?, B 0 6


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n film, taken from the same distance (5J) enlarges the shadow of the heart which is far anterior in the chest and makes the posterior ribs appear

more hori#ontal.

!n a supine film, the diaphragm will be higher and the lung volumes less than in a standing patient.


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S,A$&A#& A,3#A C23S, #A&I'+#AP2 leftside of the chest against filmholder (cassette)H beam from right at a distance of six feetH

lesion located behind the left side of the heart or in the base of the lung are often invisible on the view because the heart or diaphragm shadow

hides itH the left lateral will generally show such lesionsH the left lateral is thus the customary lateral view as it is the best view to visualize lesions in

the left thorax.lso, the heart is less magnified when it is closer to the film.

&ood for viewing area behind heart (retrosternal airspace between the heart and sternum).

=arked with a K"K or KAK according to whether the right or the left side of the patient was against the film left lateral or right lateral.

To visualize a lesion in the left thorax, it is better to get a left lateral view.

To visualize a lesion in the right thorax, it is better to get a right lateral view.


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fundamental rule of roentgenography Try to get the lesion as close to the film as possible.

P'#,AB3 C23S, X-#A4S are views (anterior I posterior)H preferably upright but may be supine, depending on patientJs conditionH taken

with beam at distance of ?5 inches I blurring and magnification

',23# 5I3.S:

Posteroanterior'(li*ue 5iews patient at B6L angle to cassette and beam.

The tracheal bifurcation is best seen in an obli$ue view.

!n bilateral involvement of the lungs (as by lymphoma involvement of the lower lungs), an obli$ue view avoids the superimposition of a lateral view.

1ometimes used in studying the heart or hila of the lungsH also in detailed study of the ribs.


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The optimum degree of obli$uity depends on the site of the lesion being studied and the information desired it may have to be determined by

fluoroscopy.

/hen weJre too tired to think of whether we need a right or a left obli$ue we Must take both obli$ues.

eft Anterior '(li*ue6 eft Anterolateral Chest $et to Cassette


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#ight Anterior '(li*ue6 #ight Anterolateral Chest $et to Cassette

&ecu(itus 5iews KdecubitusK actually means Klying downHK made with thepatient lying on his sideand the x-ray beam hori#ontal (parallel) to the

floor. Cspecially good to confirm air-fluid levels in the lung.

Cross-,a(le ateral 02ori7ontal1 5iews made with patient prone or supine and the beam hori#ontal to the floor.

ordotic 5iews formerly made in the upright position with the patient leaning backward at an angle of N ?+L from the vertical which was very

awkwardH now made with the patient facing the film as for an upright view but the tube is elevated and angled downward B6L.

roMects the lung apices of the lungs below the clavicles and causes the ribs to proMect more hori#ontally.

Cspecially good for viewing the apices of the lungs, lesions that are partially obscured by ribs, or the right middle lobe or lingula of the left lung.

3piratory 5iews on expiration the lungs Kcloud upK and the heart appears larger.


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!f the air on one side cannot be readily expelled, the lung on the obstructed side remains expanded and radiolucent on expiration.

;seful in detecting unilateral obstructive emphysema (as from a unilateral obstruction of a bronchus).

pneumothorax always appears larger on expiration than on inspiration.

1ince the thorax is smaller on expiration, the unchanged volume of pleural air spreads out in the smaller thoracic space.

>ccasionally a small pneumothorax is only visible on expiration.

Bucky /ilms made with a moving grid between the patient and the film which absorbs excess, scattered radiation.

1cattered radiation produces a ha#y, unsharp image, or fog, and detracts from film clarity.

;sed to delineate a thick pulmonary or pleural lesion, bony structures, or to more clearly see structures in an obese patient.

ucky techni$ue also used whenever the abdomen, spine, mediastinum, pelvis, or heavy long bones are studied.

,omography (Aaminagraphy)

n apparatus moves the tube and film synchronously in opposite directionsH the adMustable fulcrum is set to the plane of the lesion to be studiedH blurs

structures in the planes above and below the level being studied.

Cspecially helpful in evaluating pulmonary nodules, demonstrating cavities, and depicting bronchial obstruction.

!f you canJt think of the exact name for a view, be descriptive or draw a picture (i.e., K&et me a cross-table view with the patient lying on his right side

facing the tube.K) or consult with the radiologist.

There are all sorts of ingenious proMections and fascinating special procedures in the armamentarium of the radiologist.

&3$SI,I3S ir O fat O liver O blood O muscle O bone O barium O lead.

Air least denseH most transparent or radiolucentH unobstructed beam or air-filled densities appear black

Aungs, gastric bubble, trachea, P bifurcation of bronchi

/at breasts

/luid most of what you seeH vessels, heart, diaphragm, soft tissues, mediastinal structures

!ineral most dense (or radiopa$ue) of body structuresH mostly %aQQH bones (marrow is aerated), aortic calcifications such as the aortic knob, P

calcification of the coronary arteries, old granulomasH bullets, safety pins, etc.

1tructures which are perpendicular to the plane of the film appear as they were much more dense as the shadows represent the sumof the densities

interposed between the beam source and the film. Aearn to think in terms of those parts that are relatively parallel to the film and those that are

roughly perpendicular to it. Think about it three-dimensionally.

Thicknessas well as compositiondetermine radiodensity. The shadow cast by a thick mass of soft tissues will approach that of bone.

ack to 2ome age

Section ,wo
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P#'C3&8#3 /'# I$,3#P#3,A,I'$ '/ C23S, /I!S

Develop a systematic approach and use it consistently.

(;sually external internal.)

!. AB3 "ead the label on every film to verify the patientJs name, age, and sex.

!!. '#I3$,A,I'$ !dentify the patientJs right side, his position, and determine if he is rotated.

1ymmetrical spacing of the clavicles and other structures on either side of the sternumH clavicles esp. will show whether or not patient is straight or

rotated. 1ymmetry of the clavicles and ribs gives you assurance that no rotation is present. Cven slight rotation is undesirable in a chest film as the

heart and mediastinum are then radiography obli$uely and their shadows appear enlarged and distorted.

!!!. 98AI,4 !n a film of good technical $uality in a patient without gross cardiomegaly, you should be able to see the outlines of the vertebral

bodies within the heart shadowH notice linearity of spine is it straightP

!R. I$,3#P#3,A,I'$: the following should be identified7

. Skeletal Structures what you see of the bones is incidental as the techni$ue used for chest films

has been designed for study of the lungs. lways compare for symmetry.

3. Scapulae and lateralH are there two of eachP

/ith hands on hips, palms out, and elbows forward the scapulae are rotated to the sides to prevent their superimposition upon the upper lung fields.

Therefore only their medial margins are seen.

G. 2umeri and Shoulder oints and lateral.

Aittle of the shoulder girdle and humerus will be seen in films of broad-chested individuals.

%oracoid is seen through the spine of the scapula because they superimpose.

2ead of humerus and the acromium are also seen additively.

re fractures or abnormal calcifications (dense white shadows) seenP

?. Clavicles H symmetrical spacing on either side of sternum only if there is no rotation of the chest. Turned even a few degrees, the clavicles

will exhibit a remarkable degree of asymmetry.

B. #i(s count on every filmto level of diaphragm.

!dentify the first rib carefully by finding its anterior Munction with the manubrium and following this rib backwardto the spine. Then count down the

posterior ribs.

egin at the origin of the first rib at its Munction with the first thoracic vertebra and trace each rib as far anteriorly as you can to the beginning of the

radiolucent (and hence invisible) costal cartilage.

!nterspaces are useful in identifying the location of a precise shadow and are named for the posteriorrib above the interspace unless the anterior rib is

specified as the marker.

S of ribs helps you determine how much lungs are inflated.

4 or more ribs good inflation.

Transverse cardiac shadow smallest used for measurement.

Aungs better filled with airH therefore relatively minor disease is seen better.

3+ or more ribs P hyperinflated

Cxpiratory film see O 4 ribs.


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Eiaphragm higherH lung bases less well seenH transverse diameter of heart is larger.

=inimal pneumothorax can be seen better. lso, obstructive emphysema.

%ompare both sides for symmetry,

8ote width of the intercostal spaces. re they e$ualP

re they continuous or is there a fractureP

eam only KseesK what is parallel to itH anterior ribs are more perpendicular and thus not seen very well.

6. Spine notice linearity is it straightP

1pine and sternum are superimposed upon each other and upon the dense shadows of the mediastinal structures in the view.

1coliosis may mask margin of "H donJt mistake for " with mediastinal shift.

. Soft ,issues 1ymmetry of Eensity.

3. %hest wall (outside of lung fields).

G. 8eck.

?. =ediastinum.

!3&IAS,I$A S,#8C,8#3S

!dentify trachea is it midline, not shiftedP

!dentify bifurcation and position.

1hould not be able to follow airways any further out as they are very thin walledH if visible (air bronchogram sign) - PP pulmonary edema.

B. Breasts symmetrical in si#e, shape, positionH nipples may possibly be visible.

e sure to check whether there are two breasts.


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The lung field under a missing breast will appear a little darker than the other lung field.

%. &iaphragm

3. Eifference in the Aevel of the 2emidiaphragms

"ight hemidiaphragm is normally a bit higher.

!mpaired mobility of diaphragm may be from paralysis of either phrenic nerve, disease in abdomen such as a subdiaphragmatic abscess, pleurisy,

pulmonary infarction, etc.

G. 8ormal osition

Eistance from gastric bubble (if it is visible) to diaphragm should be very small.

?. 1hape of the Eiaphragm.

B. !dentification of Aeft and "ight Eiaphragms lateral film.

6. %ostophrenic ngles

1hould be sharp and clear.

8o fluid density should be visible.

5. %ardiophrenic angle should be fairly clear.

9. !nferior vena cava adds its own little shadow.

E. 2eart and +reat 5essels

Si7e of 2eart measure at widest pointH compare to si#e of thoraxH should be no more than 3'G

the width of the thorax. ;sing any handy piece of paper, determine the width of the heart. Then decide whether this width exceeds the distance from

the midpoint (spine) to the inside of the rib cage (half the transthoracic diameter). 1till more simply, you can measure from the midline to the right

heart border and see whether that distance will fit into the piece of lung field to the leftside of the heart.

ssessment of the cardiovascular anatomy includes assessment of heart and chamber si#e as well as the position and si#e of the great vessels.


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3 right brachiocephalic vessels

G ascending aorta and superimposed 1R%

? right atrium (")

B inferior vena cava (!R%)

6 left brachiocephalic vessels

5 aortic knob'arch

9 pulmonary trunk

* left atrial appendage (A)

4 left ventricle (AR)

$ote:8ormally concave slope between arcs 5 and 4 is often called the Kcardiac waistline.K

3. Aeft trial order and lateral views.

G. Aeft Rentricular order and lateral.

?. "ight Rentricular order and lateral anterior structures and border is not normally visuali#ed.

B. !nferior Rena %ava.

6. "ight trial order .

1coliosis, if present, may mask border of the right atrium.

5. 1uperior Rena %ava .

9. scending orta and lateral.

*. ortic Unob position, calcification.

4. =ain ulmonary rtery lateral.

3+. "elative position of left and right main branches of pulmonary arteries in relation to left and right main bronchi.

33. Csophagus and lateral.

3G. 8ote cardiac si#e normal is 3'G or less of the thoracic width on a film.

C. ungs


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3. Trachea and carina and lateral.

G. =aMor bronchi and lateral.

?. leura.

B. Aeft upper and lower lobe representation and lateral.

=aMor fissure on left between ribs 5 and *. >nly one fissure.

Aingula (tongue-shaped) area adMacent to ARH not a separate lobe.

6. "ight upper, middle, and lower lobe representation and lateral.

>bli$ue or maMor fissure T? T3+.

5. Eifferences in density, upper and lower lung fields.

!n a film the peripheral vasculature is normally seen out to the lateral one inch of the films and is more clearly delineated in the lower lobes than

the apices.

;pright most of perfusion goes to lower lungs so you should see it all the way out.

_ reversal of blood flow with enhancement of apical vascularity.

>lder smoker and vasculature not visible all the way out P emphysema.

Vounger person and not visible all the way out P pneumothorax.

Pneumothora ; a(out the only thing that can (e diagnosed with a(solute certainty with CX#%

9. eripheral vasculature follow it out as far as you can see it.

2ilum (pl. hila).

osition higher or lower.

1ymmetry

Aung fields symmetry re7 amount of density.

*. Silhouette Sign

G densities that are alike with margins adMacent to each other borders will be masked.

!f margin is obliterated, whatever is masked and it has to be in the same plane.

=asking of " would be from " middle lobe.


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=asking of posterior diaphragm would be from " lower lobe.

=asking of AR would be from A upper lobe (anterior).

=asking of descending aorta would be from A lower lobe.

=asking of !R% and 1R% would be from " lower and middle lobes.

!f you can see heart comes from posterior.

4. Air Bronchogram Sign KbutterflyK distribution of the abnormal densities or an anatomic distribution of abnormal densities restricted to lobar or

sublobar portions of the lung.

Temporally rapid (reckoned in days) changes in the appearance of the lung infiltrate.

!ndicative of alveolar disease.

1ee airways out past bifurcation.

ir-filled airway superimposed on air-filled densities.

Eemonstration of the air-filled bronchus as a radiolucent KtubeK is dependent on its close association with alveoli that are fluid-filled rather than air-

filled.

Two contrasting densities make it visible.

irways >U, surround tissues not >U.

3+.


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Trachea is it midline, not shifted.

!dentify bifurcation and position.

1hould not be able to follow airways any further out as they are very thin walledH if visible (air bronchogram sign) - PP pulmonary edema.

E. reasts symmetrical in si#e, shape, positionH nipples may P be visible.

!!!. &iaphragm

. Eifference in the level of the hemidiaphragms.

. 8ormal position.

%. 1hape of the diaphragm.

E. !dentification of left and right diaphragms lateral.

C. %ostophrenic angles.

!R. 2eart and +reat 5essels ssessment of the cardiovascular anatomy includes assessment of heart and chamber si#e as well as the position and

si#e of the great vessels.

. Aeft atrial border and lateral.

. Aeft ventricular border and lateral.

%. "ight ventricular border and lateral anterior structures and border is not normally visuali#ed.

E. !nferior vena cava.

C. "ight atrial border .

1coliosis, if present, may mask border of ".

. 1uperior vena cava .

&. scending aorta and lateral.

2. ortic knob position, calcification.

2ypertension can cause a flat, almost absent aortic arch.


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!. =ain pulmonary artery lateral.

@. "elative position of A and " main branches of pulmonary arteries in relation to A 0 " main bronchi

U. Csophagus and lateral


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A. Cardiac Si7e normal is 3'G or less of the thoracic width on a film.

1imulation of cardiac enlargement films made in expiration (high diaphragm heart tilted upward bringing apex closer to the lateral chest wall

Q less flare of ribs which alters the apparent cardiothoracic ratio)H also any abdominal distention (late pregnancy, ascites, intestinal obstruction)

produces similar resultsH diaphragm also likely to be higher in supine viewsH portable chest films and other views place heart farther away from the

film.

"otation of the patient produces appearance of widening of the heart and mediastinal shadows.

Eeformity of the thoracic cage severe scoliosisH depressed sternum (pectus excavatum) usually displaces heart to the left Q right heart border not

visible.

Eifference between heart volumes in systole and diastole usually not enough to affect rough estimate of the cardiothoracic ratio in adults.

1imulation of deceptively smallheart overdistention of the lungs for any reason (dyspneic patient with low diaphragm or emphysematous patient)

compresses the heart and mediastinal structures from both sides and narrows their shadow.

=ediastinal disease, pulmonary disease, or any density (consolidation, effusions, true mediastinal shift) may render the dimensions of the heart

unobtainable.

#A&I''+IC SI+$S '/ CA#&IAC &IS3AS3

Posteroanterior Projection

The upper right border is formed by the 1R% and the lower cardiac border is formed by the ". The left border has three well-defined segments7 The

uppermost is formed by the aortic arch, the main pulmonary artery lies immediately below the aortic knob, and the lower left cardiac border is formed

by the AR and the apex. The A appendage lies between the pulmonary artery segment and the AR and is usually not seen as a separate bulge.


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ateral Projection

"R is the most anterior cardiac chamber and is in direct contact with the lower sternum.

There should be a clear space (lung tissue) between the sternum, the "R outflow tract, and the root of the pulmonary artery, but pectus excavatum as

well as "R enlargement can impinge on this space.

The posterior cardiac border is made up of the A above and the AR below.

3 right brachiocephalic vessels

G ascending aorta and superimposed 1R%

? right atrium (")

B inferior vena cava (!R%)

6 left brachiocephalic vessels

5 aortic arch

9 pulmonary trunk

* left atrial appendage (A)

4 left ventricle (AR)

,echnical /actors

The heart appears larger on than views.

ilm during expiration simulates pulmonary edema and the heart appears larger.

>ne should check side markers for dextrocardia.

>ne should check the clavicles for angulation.

>verpenetrated films may miss heart failure.

3tracardiac Structures

!ib notching indicates coarctation of the aorta."ib notching saucered erosions of the undersurface of the ribs where dilated intercostal arteries

have developed as collateral pathways. 1eldom present in children younger than 3+. >ther conditions such as neurofibromatosis can also cause rib

notching.

ectus excavatum simulates cardiac enlargement by displacing heart to the left. Aateral view shows


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depression of the sternum at the level of the heart. dimension of the chest at heart level and the heart is displaced posteriorly (posterior margin

behind the inferior vena cava).

1traight back is a'w mitral valve prolapse and aortic insufficiency.

"ight-sided pleural effusion occurs with %2.

Physiologic Analysis of the Pulmonary 5asculature appearance of the hilar and pulmonary vessels is an excellent indicator of the physiologic

state of the heart.

Congestive Heart Failure

_ si#e, shapelessness of heart, Q evidence of pulmonary venous engorgement the vessels are seen to extend farther than normal into the lung field.

ronchi become KframedK in the interstitial fluid accumulating around them and, when seen end-on, appear as white rings. This is often called

Kperibronchial cuffingK and can be observed to decrease as the patient improves.

leural effusion in cardiac failure may be bilateral or unilateral and is more fre$uent on the right.

Aungs appear ha#y and less radiolucent than normal because of retained waterH lattice pattern.

UerleyJs lines appear short, hori#ontal white linear densities very close to the peripheral margin of the lungH have been proven to represent the

thickened, edematous interlobular septaH also seen in lymphangitic spread of malignancies within the lung parenchyma and interstitial pulmonary

disease.

"apid accumulation of fluid spills over into the alveoli and causes the development of alveolar (air-space) pulmonary edema.

ulmonary edema the so-called Kbat-wingK appearance about both hilaH superimposed shadowsof innumerable fluid-filled alveoli may cause

disappearance of the vessels of the hilumH interstitial pulmonary edema blurring of pulmonary vasculatureH perihilar ha#eH may appear rapidly after

sudden AR failure or it may be superimposed on the more gradual %D" findings of %2.


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ulmonary edema can also occur in noncardiac conditions such as fluid overload, renal failure, heroin overdose, and inhalation inMury or burns.

%D" findings can lag behind hemodynamic s but the following patterns can predict pulmonary artery wedge pressure7

&rade +7 normal / O 3G mm 2g.

&rade 37 pulmonary venous 2T8, pulmonary vascular redistribution to the apices (venous markings into the upper lobes), and loss of the right

hilar angle / 3G-34 mm 2g.

&rade G7 interstitial edema (UerleyJs lines), hilar ha#e or blurriness, peribronchial vascular thickening / G+-G6 mm 2g.

&rade ?7 generali#ed or perihilar alveolar edema / W G6 mm 2g.


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&istinguishing Between Cardiac 2ypertrophy" &ilatation" and Pericardial

3ffusion:

lain films may show ventricular enlargement but do not differentiate between hypertrophy and dilatation.

!f heart is decompensating, it will tend to shapelessness and extend to both the " and A in the view, suggesting either failure or pericardial effusion.

review of the patientJs old films is probably the best way to assess development of cardiac enlargement, in and out of failure.

1udden shapeless_in si#e should suggest pericardial effusion.

ack to 2ome age
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Section ,hree

Chamber Enlargement

The echocardiogram is much more specific for identifying structural abnormalities and chamber enlargement. The echocardiogram also is very

important for distinguishing hypertrophy from dilation and recogni#ing pericardial effusions.

AP 5iewateral 5iew

o Eil ortic Eilatation Eil ulmonary rtery Eilatation

sc o scending orta 2T8-Eil ulmonary rtery ulging due to

AC Aeft trial Cnlargement ulmonary 2ypertension

ARC Aeft Rentricular Cnlargement "RC "ight Rentricular Cnlargement

3nlargement of the eft Atrium

%D" studies are most accurate in detecting enlargement of the A compared to the other ? chambers.

A most posterior of the cardiac chambers and lies in the midline below the carina of the trachea and the mainstem bronchus.

A has G distinct components a body and an appendage.

The body of the A is centrally placed and does not form a border on the frontal view.

The A atrial appendage is to the left of the body, immediately beneath the pulmonary artery segment, and above the AR.

The most common findings are a double density of the right cardiac shadow, bulging the atrial appendage along the middle of the left cardiac border

on the frontal view, and a posterior bulge of the upper cardiac border on the lateral view.


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A enlargement may eventually extend it to the right so that its margin is visible along the rightheart border, above the profile of the " and

overlapping it the Kdouble shadowK fre$uently referred to as a classic sign of A enlargement.

1traightening of the A heart border may be a normal findingH does not always signify increased A si#e.

illing in of the normally concave waistline may be due to fullness that is either posterior (as in A dilatation) or anterior (as in any condition such as

poststenotic dilatation in pulmonic stenosis, or dilatation due to E).

A enlargement in mitral disease cardiac enlargement elevation of the A main bronchus Must above the A *th rib, double shadow along the " heart

border, P straightening of A heart border (P due to slight fullness of main pulmonary artery).

3nlargement of the eft 5entricle

AR forms the apex of the heart on the frontal view.

/ith dilation, the cardiac apex is displaced downward toward the diaphragm and to the leftH shadow of aortic arch may be flattened.

/ith hypertrophy, the apex becomes rounded.


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AR enlargement often a'w aortic stenosis and chronic 2T8 both of which may cause enlargement of the aorta.

Aateral film rounded posterior proMection of ARH border of heart is extended posteriorly and low against the diaphragm.

3nlargement of the #ight Side more difficult to recogni#e.

" forms the right lateral cardiac border. The "R is normally an anterior midline chamber located directly behind the sternum.

" enlargement fills in the space behind the sternum.

"R enlargement enlarges in cor pulmonale and in pulmonic stenosisH %D" () may be deceptively normal or show displacement of normal AR

to the left.

ulmonary artery often enlarged concomitantly.

=ay also see AR and A enlargement if Aateral film filling in of the lower part of the anterior clear space Q flat posterior surface of the heart. 2eart

is notextended posteriorly.

Chest X-#ay /indings with !yocardial &ysfunction

large heart on %D" films supports the dx. of systolic myocardial dysfunction.

lateral view is often helpful to check for right-sided failure. !f the space behind the sternum is filled in, right-sided heart failure and "R dilation are

possible.

Cchocardiography is most useful for identifying enlargement of a specific chamber and separating dilation from hypertrophy.

_vascular markings in the upper lobes are GL tincreased filling pressure of N 3?-3* mm 2g.

!nterstitial edema (UerleyJs lines) suggests a AR end-diastolic pressure of 34-G6 mm 2g.

lveolar infiltrates (pulmonary edema) are consistent with a ARCE W G6 mm 2g.

lunting of the margins is due to effusion.


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%D" can help rule in or out other causes of dyspnea such as pulmonary fibrosis or %>E.

Chest X-#ay /indings with !yocardial Ischemia

1pecial x-ray imaging (fluoroscopy or %T) can demonstrate coronary artery calcification, but this is an uncertain marker. !t has not had the test

characteristics that were originally anticipated because calcification of the arterial walls is not necessarily a'w luminal occlusion, particularly in older

individuals.

Chest X-#ay /indings with 5alvular &ysfunction

1igns of %2 and chamber enlargement can be detected using chest x-ray studies.

Ralvular calcification can sometimes be seen.

Chest X-#ay /indings with Poor 3ercise Capacity

1igns of pulmonary disease can suggest a noncardiac limitation to exercise and a large heart could suggest cardiac disease.

1igns of %2 can offer the possibility of a cardiac cause for a change in exercise capacity.

Chest X-#ay /indings with Arrhythmias

ilms are of little use in the diagnosis of arrhythmias. 2owever, finding problems that are often a'w arrhythmias, such as cardiac enlargement and

lung disease, should alter one to the possibility of arrhythmias.

The straight back syndrome or pectus excavatum was thought to be a'w with mitral valve prolapse and arrhythmias.

#A&I''+IC SI+$S '/ P8!'$A#4 &IS3AS3

3. Trachea and carina and lateral

G. =aMor bronchi and lateral

?. leura

B. Aeft upper and lower lobe representation and lateral


27/42

6. "ight upper, middle, and lower lobe representation and lateral

5. Eifferences in density, upper and lower lung fields reason

9. eripheral vasculature in a film the peripheral vasculature is normally seen out to the lateral one inch of the films and is more clearly

delineated in the lower lobes than the apices

*. 1ilhouette sign

4. ir bronchogram sign

3+. Solitary Pulmonary $odules

/ell-circumscribed, approximately round lesion that is O B-5 cm. in diameter on %D".

y definition, it is completely surrounded by aerated lung.

U a Kcoin lesion.K

Pulmonary massesare W B-5 cm. in diameter.

%alcification of the lesion, absence of a history of tobacco use, and age O ?6 years are important factors that strongly correlate with benign nodules.

8oncalcified lesions can be benign or malignant.

Cven benign calcification does not exclude the presence of coincidental malignancy in adMacent tissue or the subse$uent degeneration of a previously

benign process into a malignant lesion.

%lose observation with serial %D"s every 5 mo. for at least G years is prudent.

%avitating lesions, lesions with multilobulated or spiculated contours, and lesions with shaggy or extremely irregular borders tend to be malignant.

enign nodules tend to grow at either very slow or very rapid rates.

!n contrast, malignant processes grow at steady, predictable, exponential rates.

The growth of a nodule is conventionally defined as the doubling time (time re$uired for its volumeto double) and corresponds to an increase in

diameter by a factor of 3.G5.

!n general, doubling times W 35 months or O 3 month are associated with benign processes.

!f a nodule has not increased in si#e over a G-year period, the probability that it is benign is W 44.


28/42

SIX C'!!'$ PA,,3#$S '/ CACI/ICA,I'$ I$ S'I,A#4 P8!'$A#4 $'&83S

dapted from7 /ebb, /. ". (344+). "adiologic evaluation of the solitary pulmonary nodule.

merican @ournal of "adiology, 36B, 9+3-9+*.

----------------------------------------A-----------------B ----------------C --------------& -----------------3 -------------------/----------------------------------

FFFFFFFFFFFFFFFFFFFFFFFEiffuseFFFFFFFFF %entralFFFFFFF opcornFFFF AaminarFFFFFF 1tippledFFFFFFF CccentricFFFFFFFFFFFFFFFFFF

%oncentric

The first four are almost always benignH the latter two may be benign or malignant.

#A&I''+IC SI+$S '/ A53'A# 8$+ &IS3AS3

2ypersensitivity Pneumonitis(Cxtrinsic llergic lveolitis)

erihilar ha#iness and peripheral alveolar infiltrates.

%hronic disease abnormalities indistinguishable from fibrosing alveolitis are commonly found reticulonodular parenchymal infiltrates, dense

fibrotic areas, and decreased lung volumes.

2ilar adenopathy is not found.

Signs>Symptoms of Acute 3posure fever, chills, anorexia, shortness of breath, dry coughH tachypnea, pyrexia, tachycardia, dry basilar inspiratory

rales without rhonchiH occasionally, cyanosis or restlessness indicating hypoxemia.


29/42

Signs>Symptoms of Chronic 3posure shortness of breath, mild fever, weight loss, fatigue, malaise, dry cough, dyspnea on exertion, tachypneaH

above signs Q P cor pulmonale (neck vein distention, hepatoMugular reflex, hepatomegaly, ankle edema, ascites, loud G, increased "R activity with a

parasternal lift and parasternal 1Bgallop).

C23S, X-#A4: S3C,I'$ /'8#

#A&I''+IC SI+$S '/ I$,3#S,I,IA 8$+ &IS3AS3

#eticular lung parenchyma replaced by many thin-walled cysts (lesions less than 3+ mm in diameter), hence the term KhoneycombK lung, these

microcysts may be barely perceptible, round or oval, giving the lung the radiologic appearance of a fine network.

1een in disseminated interstitial diseases such as eosinophilic granuloma of the lung, scleroderma, pneumoconiosis (diseases caused by inhalation of

organic or inorganic matter), idiopathic pulmonary fibrosis, sarcoidosis, and other, less common disorders.

!iliary" $odular numerous discrete, tiny (O 6 mm), uniform densitiesH evenly distributed throughout the lungsH $uite uniform in si#e.

1een in miliary tuberculosis, other fungal diseases (histoplasmosis), pneumoconiosis, histiocytosis D (early stage), pulmonary hemosiderosis (late

stage) and primary amyloidosis.

#eticulonodular mixture of the two previously described patterns.

=ay predominate in one or another portion of the lung in the diseases described.

E.


30/42

5iral Pneumonia

atchy alveolar consolidation usuallyH rarely a predominance of interstitial abnormalities.

&rug-Induced Pneumonia

8itrofurantoin-!nduced neumonia

!nterstitial lung changes, principally a basal reticular infiltrate.

resents acutely with chills, fever, $uite severe dyspnea, and nonproductive cough within hours or days of the initiation of nitrofurantoin therapy.

Aikely to have moderate peripheral eosinophilia.


31/42

Pulmonary 3dema

=ixed alveolar and interstitial edema.

pical redistribution of blood flow results in increased si#e of upper lung vasculature and background veiling of the pulmonary parenchyma

initially.

1ubpleural edema, peribronchial cuffing, bronchiolar cuffing, hilar ha#iness, ha#iness of vessel detail, reticular pattern, and basilar septal lines.

Uerley lines are present at the periphery of the lung bases and may be $uite prominent represent thickened interlobular septa.

;sually, enlargement of the heart (if cardiogenic in origin) and redistribution of the pulmonary vasculature (appears esp. engorged in the upper lung

#ones).

Idiopathic Pulmonary /i(rosis(2amman-"ich disease)"eticular pattern (honeycombing).

=ost common KetiologyK of disseminated pulmonary fibrosis.

&ifferential &iagnosis of Interstitial ung &isease


32/42

PneumoconiosisPrimary ung &iseases

1ilicosis

1arcoidosis

sbestosis

2istiocytosis D

%oal /orkerJs pneumoconiosis

Aymphangiomyomatosis

erylliosis

Aymphangitic carcinomatosis

>rganic dusts (pigeons, turkey, duck, chicken, humidifier) Aipoidosis

Cmphysema

&rugs

%ystic fibrosis

%hemotherapeutic agents (busulfan, bleomycin, methotrexate)

ntibiotics (nitrofurantoin, sulfonamides, !82)

Alveolar /illing &isease

Eiffuse alveolar bleeding (&oodpastureJsmiodarone syndrome, lupus, mitral stenosis, enicillamine idiopathic pulmonary hemosiderosis)

Aupus-like reactions (hydrala#ine, procainamide)

lveolar proteinosis

"adiation

lveolar cell carcinoma

Cosinophilic pneumonia

Connective ,issue &isease

Aipid pneumonia

1ystemic lupus erythematosus

"heumatoid arthritis

Infectious &iseases

1cleroderma

=iliary tuberculosis

olymyositis

1ome fungal and viral infections


33/42

'therCardiovascular &iseases

!diopathic pulmonary fibrosis

!nterstitial pulmonary edema

ronchiolitis obliterans organi#ing

ulmonary hemosiderosis GL to mitral pneumonia stenosis

Aymphocytic interstitial pneumonia

myloidosis

Pulmonary Sarcoidosis lymphadenopathy always precedes or presents concurrently with pulmonary changes of the disease.

X 2ilar and paratracheal adenopathy.

!ntrathoracic lymphadenopathy (96)

Eiffuse parenchymal disease (6+)

Cxclusively hilar lymphadenopathy initially (??)

ulmonary disease without hilar lymph node enlargement (G6)

Aung involvement varies from a miliary nodular pattern, to a reticulonodular pattern, to a purely reticular pattern (honeycombing).

>ccasionally patients exhibit mx. large granulomas simulating metastatic neoplasm.

Aikely that a miliary nodular form precedes the reticular pattern.

rogression to marked pulmonary fibrosis of bullous emphysema with disabling functional impairment, development of cor pulmonale, and death

occurs in a small of cases.

=aMority of patients remain relatively asymptomatic.

Scleroderma

&reat maMority of patients with abnormal pulmonary function studies do not exhibit radiologically

discernible pulmonary changes.

PP "elatively fine network of reticular infiltrates (honeycombing)H generally restricted to the lower lung #ones.

"adiologic demonstration of abnormalities of esophagus, duodenum, small bowel, or terminal phalanges more likely to be seen.

"ecurrent or chronic aspiration of ingested material may be underlying cause of pulmonary fibrosis.

2istiocytosis X includes Aetterer-1iwe disease, 2and-1chYller-%hristian disease, and eosinophilic granuloma. >nly eosinophilic granuloma

occurs in adults.

%oarse, reticular interstitial pattern.

!ndividual cysts comprising the coarse reticular or honeycomb pattern are generally less than 6 mm in greatest dimension, although large cysts of up to

5 cm in diameter have been reported.

neumothorax relatively fre$uent complication.

G'? deny dyspneaH G'? have dry coughH systemic symptoms lassitude, weight loss, and less

commonly, fever may predominate in 3'?.


34/42

Eiabetes insipidus may be and associated disorder.

1ystemic form P involvement of bone, liver, %81, kidneys, and alimentary tract.

Pneumonia


35/42

IA,#'+3$IC #A&I''+IC SI+$S

. C%& leads

. Cndotracheal tube positioning

%. %R and lines

+'SSA#4

Air (ronchogram 1urrounding consolidation will sometimes allow more peripheral bronchi to be seen as tubular or branching lucencies. 8ormally

only the trachea, mainstem bronchi, and occasionally the origins of the lobar bronchi, are visible on %D"s as air-filled tubular structures. Risuali#ation

of the more peripheral bronchi with air in them is usually not possible.

Alveolar 0consolidative1 densities n abnormal density caused by the collapse or, more often, the filling of air spaces with abnormal material

(blood, pus, water, protein, or cells). lveolar densities characteristically have irregular, ha#y margins except where they are bounded by a pleural

surface. (lso referred to as Kacinar patternK.) 1egmental distribution and air bronchograms are also characteristic of this pattern.

Atelectasis %ollapse and volume loss are synonymous terms. Rery small areas of atelectasis often produce a linear shadow, which is often, but not

always, hori#ontal. This is referred to as Kplate-likeK, KlinearK, or KsubsegmentalK atelectasis. Aobar and total lung atelectasis also occur. These larger


36/42

varieties of atelectasis are usually associated with increased density in the involved portion of lung so that there is, in fact, consolidation present as

well. To diagnose atelectasis, there must be a specific evidence of volume loss such as displacement of a fissure, the mediastinum, or a hilum.

Clevation of the hemidiaphragm and decreased space between ribs can also be signs of atelectasis.

Ble( small, thin-walled, air-containing structure. This term is fre$uently reserved for such small areas which are fre$uently intrapleural. This

term may be used synonymously with KbullaK but often is reserved for smaller air spaces.

Bronchiectasis Eilatation of a bronchus or bronchi, usually secreting large amounts of offensive pus. Eilatation may be in an isolated segment orspread throughout the bronchi.

Bulla 1ee KblebK or Kcavity.K These abnormal air spaces may or may not be associated with diffuse pulmonary emphysema.

Caseous cheese-like.

Cavity nother form of air space in the lung. This term is usually reserved for those which are the result of tissue necrosis, unlike bullae. Thickness

and irregularity of the walls often the distinguishing feature separating cavities from bullae or blebs.

Consolidation illing of pulmonary air space with some abnormal material. =ay also be referred to as Kalveolar disease.K

&ensity nonspecific term that can be used to describe any area of whiteness on the chest film. 8ormal structures such as the heart as well as

abnormalities in the lungs may be called densities. This term is often used when the nature or cause of an abnormal shadow is not known. !t is a useful

term in that situation, since other terms (e.g., KmassK or KinfiltrateK) fre$uently imply more specific entities which may or may not be present.

3tra-pleural nything that is outside both the parietal and the visceral pleura but that impinges on the lungs. The heart is the most obvious

example. 1ince normal or abnormal structures in this location are separated by two layers of pleura from the lung, the margins of these densities are

characteristically sharp and smoothly tapering.

2ilum(pleural hila.) Klung rootHK medusa-like tangle of arteries and veins on either side of the heart shadow. !rregular medial shadow in each

lung where the bronchi and pulmonary arteries enter. >ther structures in these areas, particularly lymph nodes, are normally so small as to be

inapparent. The normal hilar shadow is almost entirely composed of the central pulmonary arteries. " hilar vessels seem to extend out farther than

those on the A because a part of the A hilum is obscured by the shadow of the more prominent A side of the heart. The A hilum on a normal %D" is a

little higher than the " one because of the slightly higher take-off of the A pulmonary artery.

Interminate or mied lung disease This category of diffuse lung disease is fre$uently used when the radiographic criteria to designate a specific

pattern (consolidative, interstitial, etc.) may not be present, or when there may be elements of several types of diffuse lung disease in the same patient.

Infiltrate poorly defined abnormal pulmonary density or any such density sharply bounded by pleura and fissures. This is a confusing term, sinceit may be used to indicate any abnormal lung density or, by others, as a synonym for consolidation. 1ynonymous with Kfluid density.K

Interstitial The portion of the pulmonary parenchyma that consists of the actual lung tissue as opposed to the air spaces. !ncludes alveolar walls,

septa, bronchovascular structures, and pleura. !nvolvement of this tissue is a fre$uent form of diffuse lung disease.

E.

seconds 0mAs1 This is the amount of current through the radiographic tube. The amount of current and the length of time during

which the current flows control the $uantity of x-rays generated. !ncreasing the m causes an increase in patient exposure to ioni#ing radiation and

produces more x-rays to create an image on the film.

!ass solid-appearing, reasonably well-defined soft tissue density usually larger than ? or B cm in diameter.


37/42

!ediastinal "eferring to the structures or a lesion between the lungs. ;nless the lungs are actually invaded by a mediastinal lesion, the lesionJs x-

ray shadow will be extra-pleural and, therefore, usually will have sharp demarcation from the lung.

!iliary form of diffuse lung disease consisting of countless very tiny nodular densities.

$odule well-defined, more or less round density in the lungH smaller than a mass. 8o rigid si#e distinction between a KmassK and KnoduleK is

possible.

'pacity 1ynonym for Kdensity.K

Pleural "efers to an abnormality arising in the pleura or pleural space. =ost commonly this is free of loculated fluid.

Pneumothora ree air in the pleural spaceH may be modified by the following descriptive termsK hydro-, pyo-, hemo-, chylo-, tension.

Pulmonary edema defined radiographically as diffuse, bilateral consolidation by fluidJ other materials can fill air spaces bilaterally and give the

same radiographic pattern.

#eticular fine branching pattern with lines radiating in all directionsH one of the signs of the interstitial pattern.

Segmental Aimited to specific bronchopulmonary segments or lobes. 1egmental distribution of disease usually indicated bronchial or vascular

involvement and is most common in consolidation.

Septal lines see Uerley lines.

Silhouette sign 8ormally an interface is seen between areas of different density as between shadows of the heart and lung. Aoss of air on the

pulmonary side, usually because of consolidation, may cause obliteration or KsilhouettingK of this normal interface. This sign is useful in locali#ing an

abnormality or confirming the presence of abnormality. >ccasionally the silhouette sign will be the only definite indication of consolidation next to the

heart or diaphragm.

C23S, #A&I''+4 A#,IC3S

aumstark, ., 1wensson, ". &., 2essel, 1. @., et al. (34*B). Cvaluating the radiographic assessment of pulmonary venous hypertension in chronic

heart disease."merican #ournal of !adiology, $%&,*99.

%hakko, 1., /oska, E., =artine#, 2., et al. (3443). %linical, radiographic, hemodynamic correlations in chronic congestive heart failure7 %onflicting

results may lead to inappropriate care."merican #ournal of 'edicine, (),?6?.

%hen, @. T. T., eliar, R. 1., =orris, @. @., et al. (345*). %orrelation of roentgen findings with hemodynamic data in pure mitral stenosis. "merican

#ournal of !oentgenology, $)&,G*+.

%igarroa, @. C., !sselbacher, C. =., Ee1anctis, ". /., 0 Cagle, U. . (344?). Eiagnostic imaging in the evaluation of suspected aortic dissection7 >ld

standard and new directions.*ew +ngland #ournal of 'edicine, &,?6-B?.

%rystal, ". &., itterman, . ., "ennard, 1. !., et al. (34*B). !nterstitial lung disease of unknown cause. Eisorders characteri#ed by chronic

inflammation of the lower respiratory tract7 arts 3 and G.*ew +ngland #ournal of 'edicine, $), 36B.

riedman, . @., et al. (34*6). %omparison of magnetic resonance imaging and echocardiography in determination of cardiac dimensions in normal

subMects.#ournal of the "merican ollege of ardiology, /,3?54.

&oodman, A. ". "adiology of asbestos disease. (34*?).#ournal of the "merican 'edical "ssociation, &0(,B56.

&yssenhoven, C. @., et al. (34*5). Transesophageal two-dimensional echocardiography7 !ts role in solving clinical problems.#ournal of the "merican

ollege of ardiology, ,496.

2aupt, =., =oore, &. /., 0 2utchins, &. =. The lung in systemic lupus erythematosus. (34*3)."merican #ournal of 'edicine, 1$,943.

2unninghake, &. /., 0 auci, . 1. (3494). ulmonary involvement in the collagen vascular diseases."merican !eview of !espiratory 2isease,

$$(,B93.

@ay, 1. @., @ohannson, /. &., 0 ierce, . U. (3496). The radiographic resolution of 3treptococcus pneumoniaepneumonia.*ew +ngland 'edicine

&(,94*.

Uhouri, 8. ., =e#iane, =. .,


38/42

=eaney, @. . =., /eg, @. &., %henevert, T. A., et al. (3449). Eiagnosis of pulmonary embolus with magnetic resonance angiography.*ew +ngland

#ournal of 'edicine, 0,(G+), 3BGG-3BG9

=ehlman, E. @. , 0 "esnekov, A. (349*). guide to the radiographic identification of prosthetic heart valves. irculation, /1,53?.

8ienaber, %. ., von Uodolistch, V., 8icolas, R., et al. (344?). The diagnosis of thoracic aortic dissection by noninvasive imaging procedures. *ew

+ngland #ournal of 'edicine, &,3-4.

>JUeefe, =. C., &ood, %. ., 0 =cEonald, @. ". %alcification in solitary nodules of the lung."merican #ournal of !adiology, 11,3+G?-3+??.

ratt, . %. (34*9). "ole of conventional chest radiography in diagnosis and exclusion of emphysema."merican #ournal of 'edicine, &,44*.

"itchie, @. !., et al. (3446). &uidelines for clinical use of cardiac radionuclide imaging. report of the merican 2eart ssociation'merican %ollege

of %ardiology Task orce. irculation, ($(B), 3G9*-3?+?.

"osenow !!!, C. %. (344*). !nterpreting chest films7 Tricks of the trade. onsultant, (?), 66?-659.

1chapiro, ". A., 0 =usallam, @. @. (3499). radiologic approach to disorders involving the interstitium of the lung.4eart 5 ung, 0 (B), 5?6-5B?.

1eward, @. . (344G). Transesophageal echocardiography7 %% osition 1tatement.#ournal of the "merican ollege of ardiology, &),6+5.

1huford, /. 2. (344G). Eetection of cardiac chamber enlargement with the chest roentgenogram.4eart 2isease and 3troke, &,?B3-?B9.

1tein, . E., et al. (344G). "elation of plain chest radiographic findings to pulmonary arterial pressure and arterial blood oxygen levels in patients

with acute pulmonary embolism."merican #ournal of ardiology, 0(,?4B.

TaMik, . @., et al. (349*). Two-dimensional real-time ultrasonic imaging of the heart and great vessels. 'ayo linic Proceedings, /,G93.

Tapson, R. ". (3449). ulmonary embolus - 8ew diagnostic approaches.*ew +ngland #ournal of 'edicine, 0(G+), 3BB4-3B63.

? Theodore, @., 0 "obin, C. E. (3496). athogenesis of neurogenic pulmonary edema. ancet, &,9B4.

?/ebb, /. ". (344+). "adiologic evaluation of the solitary pulmonary nodule."merican #ournal of !adiology, $/%,9+3-9+*.

/interhauer, ". 2., elic, 8., 0 =oores, U. E. (349?). %linical interpretation of bilateral hilar adenopathy."nnals of 6nternal 'edicine, 1,56.

/oodring, @. 2. (344+). Aung cancer.!adiology linics of *orth "merica, &,B*4.

ctober ?+, ??-?5.

C23S, X-#A4: S3C,I'$ /I53

S8!!A#4 '/ C23S, X-#A4 /I$&I$+S>I$,3#P#3,A,I'$

PneumoniaPulmonary

InfarctA#&S

Pneumo-

,hora

Pulmonary

3dema

Interstitial

&isease

Cystic

/i(rosis

3mphysema BronchitisPl

3

,rachea


39/42

Shifted

Air visi(le

Air occluded

!asses near(y

Intercostal Spaces

$arrow

.ide

&iaphragm

Shape

/lat

Curved

Placement

3levated

$onsymmetrical

5isi(ility

&iffuse

Increased density (etween

gastric (u((le and

diaphragm (oarder

ungs 0consolidation1

/luid changes

,ype

Interstitial

Alveolar

2omogeneous density

Patchy infiltration

0heterogeneous1

Complete density


40/42

S8!!A#4 '/ C23S, X-#A4 /I$&I$+S>I$,3#P#3,A,I'$ 0Continued1

Pneumonia

Pulmonary

Infarct A#&S

Pneumo-

,hora

Pulmonary

3dema

Interstitial

&isease

Cystic

/i(rosis3mphysema Bronchitis

Pl

3

Area involved

Alveolus

Segment

o(e

8nilateral

Bilateral

&iagnostic Changes

Air (ronchogram


41/42

$oticea(le structures

Bul(s>(ulli

!asses

'ld scarring


PneumoniaPulmonary

Infarct A#&S

Pneumo-

,hora

Pulmonary

3dema

Interstitial

&isease

Cystic

/i(rosis


3

Bronchi

Increased density

!ediastinum

Silhouette Sign

&isappeared 0anterior1

2a7y 0posterior1

Increased Borders

Aortic kno(

Pulmonary artery

eft ventricular (order

#ight ventricular (order

,riangular shape

Signs of Shift

!asses

$onsymmetrical clavicles



42/42

PneumoniaPulmonary

InfarctA#&S

Pneumo-

,hora

Pulmonary

3dema

Interstitial

&isease

Cystic

/i(rosis


3

5essels

2ilar #egion

Butterfly effect

&ilated

$onsymmetrical

Symmetrical - elevated

Symmetrical - depressed

Periphery

>ver-dilated

8ot visible

2a#iness

Pleura

Angles

Sharp

&iffuse

/issures

5isi(ility

/luid density 0white1

Air density 0(lack1

Position

................................... %@% 8p

% &own

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