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What do you look for in a chest x ray

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The standard chest radiograph is acquired with the patient standing up, and with the X-ray beam passing through the patient from Posterior to Anterior PA. The chest X-ray image produced is viewed as if looking at the patient from the front, face-to-face. The heart is on the right side of the image as you look at it. Sometimes it is not possible for radiographers to acquire a PA chest X-ray.

SEE VIDEO BY TOPIC: An EASY way to read the Chest X Ray!

SEE VIDEO BY TOPIC: How to Interpret a Chest X-Ray (Lesson 7 - Diffuse Lung Processes)

Chest X-ray (CXR) Interpretation

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On the PA chest-film it is important to examine all the areas where the lung borders the diaphragm, the heart and other mediastinal structures. These lines and silhouettes are useful localizers of disease, because they can be displaced or obscured with loss of the normal silhouette.

This is called the silhouette sign , which we will discuss later. The paraspinal line may be displaced by a paravertebral abscess, hemorrhage due to a fracture or extravertebral extension of a neoplasm. Displacement of the para-aortic line can be due to elongation of the aorta, aneurysm, dissection and rupture.

The anterior and posterior junction lines are formed where the upper lobes join anteriorly and posteriorly. These are usely not well seen and we will not discuss them. An important mediastinal-lung interface to look for is the azygoesophageal line or recess arrow.

The azygoesophageal recess is the region inferior to the level of the azygos vein arch in which the right lung forms an interface with the mediastinum between the heart anteriorly and vertebral column posteriorly. It is bordered on the left by the esophagus. The azygos lobe is created when a laterally displaced azygos vein makes a deep fissure in the upper part of the lung.

Here another patient with an azygos lobe. The azygos vein is seen as a thick structure within the azygos fissure. In some patients an extra joint is seen in the anterior part of the first rib at the point where the bone meets the calcified cartilageneous part arrow. In patients with a pectus excavatum the right heart border can be ill-defined, but this is normal. It produces a silhouette sign and thus simulating a consolidation or atelectasis of the right middle lobe.

Pectus excavatum is a congenital deformity of the ribs and the sternum producing a concave appearance of the anterior chest wall. On a normal lateral view the contours of the heart are visible and the IVC is seen entering the right atrium. The retrosternal space should be radiolucent, since it only contains air. Any radiopacity in this area is suspective of a proces in the anterior mediastinum or upper lobes of the lung.

As you go from superior to inferior over the vertebral bodies they should get darker, because usually there will be less soft tissue and more radiolucent lung tissue red arrow. If this is not the case, look carefully for pathology in the lower lobes. The right diaphragm should be visible all the way to the anterior chest wall red arrow. Actually we see the interface between the air in the lungs and the soft tissue structures in the abdomen.

The left diaphragm can only be seen to a point where it borders the heart blue arrow. Here the interface is lost, since the heart has the same density as the structures below the diaphragm. The left main pulmonary artery in purple passes over the left main bronchus and is higher than the right pulmonary artery in blue which passes in front of the right main bronchus.

Once you know how the normal hilar structures look like on a lateral view, it is easier to detect abnormalities. In this case on the PA-view there is hilar enlargement. On the PA-view it is not clear whether this is due to dilated vessels or enlarged lymph nodes.

On the lateral view there are round structures in areas where you don't expect any vessels. So we can conclude that we are dealing with enlarged lymph nodes. This patient has sarcoidosis. Notice also the widening of the paratracheal line or stripe as a result of enlarged lymph nodes. Any density in the area of the vertebral bodies should lead you to the PA-film to look for spondylosis, which is usually located on the right side arrows.

On the left side the formation of osteophytes is hampered by the pulsations of the aorta. On the PA-view the superior mediastinum is widened. The lateral view is helpful in this case because it demonstrates a density in the retrosternal space. Now the differential diagnosis is limited to a mass in the anterior mediastinum 4 T's. A common incidental finding in adults is a Bochdalek hernia, which is due to a congenital defect in the posterior diaphragm arrows.

In most cases it only contains retroperitoneal fat and is asymptomatic, but occasionally it may contain abdominal organs. A hernia of Morgagni is also a congenital diaphragmatic hernia, but is less common.

It is located anteriorly. Whenever you review a chest x-ray, always use a systematic approach. We use an inside-out approach from central to peripheral. First the heart figure is evaluated, followed by mediastinum and hili. Subsequently the lungs, lungborders and finally the chest wall and abdomen are examined. You have to know the normal anatomy and variants. Find subtle abnormalities by using the sihouette sign and mediastinal lines.

Once you see an abnormality use a pattern approach to come up with the most likely diagnosis and differential diagnosis. It is extremely important to always compare with old films, as we will demonstrate in this case. Actually someone said that the most important radiograph is the old film, since it gives you so much information.

For instance a lung mass, which hasn't changed in many years is not a lung cancer. Based on the CXR that you just saw, you could have made the diagnosis of congestive heart failure, but the findings are very subtle. However once you compare it to the old film, things become more obvious and you will be much more confident in your diagnosis:.

This is a very important sign. It enables us to find subtle pathology and to locate it within the chest. The loss of the normal silhouette of a structure is called the silhouette sign. Here an example to explain the silhouette sign: The heart is located anteriorly in the chest and it is bordered by the lingula of the left lung. The difference in density between the heart and the air in the lung enables us to see the silhouette of the left ventricle.

When there is something in the lingula with the same 'water density' as the heart, the normal silhouette will be lost blue arrow. When there is a pneumonia in the left lower lobe, which is located more posteriorly in the chest, the left ventricle will still be bordered by air in the lingula and we will still see the silhouette of the heart red arrow.

The PA-film shows a silhouette sign of the left heart border. Even without looking at the lateral film, we know, that the pathology must be located anteriorly in the left lung. This was a consolidation due to a pneumonia caused by Sterptococcus pneumoniae. Here we see a consolidation which is located in the left lower lobe. There is a normal silhouette of the left heart border. By only looking at the interfaces of the left and right diaphragm on the lateral film, it is possible to tell on which side the pathology is located.

On a normal lateral chest film the silhouette of the left diaphragm 2- can be seen from posterior up to where it is bordered by the heart, which has the same density blue arrow. One should be able to follow the contour of the right diaphragm from posterior all the way to anterior, because it is only bordered by the lung. Here we cannot follow the contour of the right diaphragm all the way to posterior, which indicates that there is something of water-density in the right lower lobe red arrow.

On the PA-film there is a normal silhouette of the heart border, so the pathology is not in the anterior part of the chest, which we already suspected by studying the lateral view. What we see is actually the highest point of the right diaphragm, which is anterior to the pneumonia in the right lower lobe.

The pneumonia does not border the highest point of the diaphragm. There are some areas that need special attention, because pathology in these areas can easily be overlooked:. Notice that there is quite some lung volume below the dome of the diaphragm, which will need your attention arrow. Here an example of a large lesion in the right lower lobe, which is difficult to detect on the PA-film, unless when you give special attention to the hidden areas.

Here a pneumonia which was hidden in the right lower lobe mainly below the level of the dome of the diaphragm red arrow. Notice the subtle increased density in the area behind the heart that needs special attention blue arrow.

This was a lower lobe pneumonia. We know that in some cases there is an extra joint in the anterior part of the first rib which may simulate a mass. However this is also a hidden area where it can be difficult to detect a mass. In this case a small lung cancer is seen behind the left first rib. Notice that is is also seen on the lateral view in the retrosternal area. The diagnosis was made by a biopsy of an osteeolytic metastasis in the iliac bone. There is a subtle consolidation in the left lower lobe in the hidden area behind the heart.

Again there is increased density over the lower vertrebral region. On a chest film only the outer contours of the heart are seen. In many cases we can only tell whether the heart figure is normal or enlarged and it will be difficult to say anything about the different heart compartments. However it can be helpful to know where the different compartments are situated.

Left Atrium enlargement This is a patient with longstanding mitral valve disease and mitral valve replacement. Extreme dilatation of the left atrium has resulted in bulging of the contours blue and black arrows.

Right ventricle enlargement First study the PA and lateral chest film and then continue reading. On these chest films the heart is extremely dilated. Notice that it is especially the right ventricle that is dilated. This is well seen on the lateral film yellow arrow. There is a small aortic knob blue arrow , while the pulmonary trunk and the right lower pulmonary artery are dilated. All these findings are probably the result of a left-to-right shunt with subsequent development of pulmonary hypertension.

The location of the cardiac valves is best determined on the lateral radiograph.

How to read chest x-rays

Basic interpretation of the chest X-ray is easy. It is simply a black and white film and any abnormalities can be classified into:. To gain the most information from an X-ray, and avoid inevitable panic when you see an abnormality, adopt the following procedure:.

On the PA chest-film it is important to examine all the areas where the lung borders the diaphragm, the heart and other mediastinal structures. These lines and silhouettes are useful localizers of disease, because they can be displaced or obscured with loss of the normal silhouette. This is called the silhouette sign , which we will discuss later.

Chest X-ray interpretation is one of the fundamental skills of every doctor. Emergency physicians are particularly exposed to various chest x-rays during a regular shift. Therefore, knowing the basics and pathologies in the ED setting is very important. This chapter will summarize the basics of chest x-ray interpretation and give some pathologic examples. The ideal timing can be defined as the end of inspiration , and the patient should hold his breath at that time.

Chest X-Ray

This article is an attempt to give the reader guidance how to read a chest Xray and below are two methods. There is no perfect way to read an x-ray. However, the important message I would like to give is, to adopt one or the other approach, and to use the chosen approach consistently. I would like to close with a clarification of two important radiological findings, whose understanding is very useful for a correct interpretation of chest x-ray findings. The first is the silhouette sign , which can localise abnormalities on a pa-film without need for a lateral view. The loss of clarity of a structure, such as the hemidiaphragm or heart border, suggests that there is adjacent soft tissue shadowing, such as consolidated lung, even when the abnormality itself is not clearly visualised. The reason is, that borders, outlines and edges seen on plain radiographs depend on the presence of two adjacent areas of different density, Roughly speaking, only four different densities are detectable on plain films; air, fat, soft tissue and calcium five if you include contrast such as barium. If two soft tissue densities lie adjacent, then they will not be visible separately eg the left and right ventricles. If, however, they are separated by air, the boundaries of both will be seen. The second important x-ray finding is the lung collapse.


Governor Hogan announced that health care institutions in Maryland can start performing elective surgical cases in guidance with the State Department of Health. Learn what Johns Hopkins is doing. A chest X-ray is an imaging test that uses X-rays to look at the structures and organs in your chest. It can help your healthcare provider see how well your lungs and heart are working. Certain heart problems can cause changes in your lungs.

A comprehensive collection of clinical examination OSCE guides that include step-by-step images of key steps, video demonstrations and PDF mark schemes.

An X-ray is an imaging test that uses small amounts of radiation to produce pictures of the organs, tissues, and bones of the body. When focused on the chest, it can help spot abnormalities or diseases of the airways, blood vessels, bones, heart, and lungs. Chest X-rays can also determine if you have fluid in your lungs, or fluid or air surrounding your lungs.

What Can a Chest X-Ray Diagnose?

Chest x-rays CXR are a scan used to evaluate the lungs, heart and chest wall and can detect medical conditions such as:. Chest x-rays are also used to disgnose lung issues, bone problems of the chest wall, and some heart problems. Find GPs in Australia.

A chest X-ray helps detect problems with your heart and lungs. The chest X-ray on the left is normal. The image on the right shows a mass in the right lung. Chest X-rays produce images of your heart, lungs, blood vessels, airways, and the bones of your chest and spine. Chest X-rays can also reveal fluid in or around your lungs or air surrounding a lung. If you go to your doctor or the emergency room with chest pain, a chest injury or shortness of breath, you will typically get a chest X-ray.

How to Read a Chest X-ray – A Step By Step Approach

Chest x-ray uses a very small dose of ionizing radiation to produce pictures of the inside of the chest. It is used to evaluate the lungs, heart and chest wall and may be used to help diagnose shortness of breath, persistent cough, fever, chest pain or injury. It also may be used to help diagnose and monitor treatment for a variety of lung conditions such as pneumonia, emphysema and cancer. Because chest x-ray is fast and easy, it is particularly useful in emergency diagnosis and treatment. This exam requires little to no special preparation.

Chest x-rays (CXR) are a frequently performed radiological investigation that you'll be You should (as with the trachea) look for any evidence of the hilar being.








Comments: 2
  1. Akinogis

    And other variant is?

  2. Meztizil

    It is a pity, that now I can not express - I hurry up on job. But I will return - I will necessarily write that I think.

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