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Practical Problem-based CHEST RADIOLOGY: Conventional Film. Ronald E. Pust, MD Dept. of Family & Community Medicine College of Medicine University of Arizona Copyright 2004 Ronald E. Pust all rights reserved. 1. Objectives:

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practical problem based chest radiology conventional film

Practical Problem-basedCHEST RADIOLOGY:Conventional Film

Ronald E. Pust, MD

Dept. of

Family & Community Medicine

College of Medicine

University of Arizona

Copyright 2004 Ronald E. Pust

all rights reserved

1

slide2

Objectives:

Upon completion of this series, the participant should be able to:

1. Systematically “read” any chest roentgenogram, beginning with assessment of the film for radiographic quality.

2. Recognize normal and abnormal pulmonary anatomy on the chest film.

3. Delineate normal and abnormal cardiac anatomy on the chest film.

4. Discuss the chest film in terms of problem-solving: indications, sensitivity and specificity, cost-effectiveness in screening and other diagnostic situations.

5. Synthesize clinical case information with basic skills in chest film interpretation to arrive at a problem assessment or “differential diagnosis.”

slide3

Texts you may find useful on the basic chest film (old editions are as good as new editions):

1. Corne J, Carroll M, Brown, I, Delany, D. Chest X-ray Made Easy. London: Churchill Livingstone, 2000. 2nd edition. ($19.95 in AHSC Bookstore, pocket-sized, 127 pp.) (Excerpts are included in this manual.)

2. Felson B. Chest roentgenology. Philadelphia: W.B. Saunders Co., 1973.

3. Felson B. Principles of chest roentgenology, a programmed text. Philadelphia: W.B. Saunders Co., 1965. 2nd edition, 1999.

4. Forrest and Feigin. Essentials of Chest Radiology, W.B. Saunders Co., 1982.

(Good basic text)

5. Lillington and Jamplis. A Diagnostic Approach to Chest Diseases: Differential Diagnoses Based on Roentgenographic Patterns. Baltimore: Williams and Wilkins Co., 3rd edition, 1987.

6. Mettler F. Essentials of Radiology, W.B. Saunders Co., 1996.

7. Squire, LF. Fundamentals of roentgenology (3rd ed.). (general principles). Cambridge: Harvard University Press, 1982

8. Squire, Colaice, and Strutynsky. Exercises in Diagnostic Radiology, Vol. 1:

The Chest, 1972. (Paperback, problem oriented.)

9. Műller N,Fraser R, Colman N, Paré P.. Radiologic Diagnosis of Diseases of the Chest, W.B. Saunders Co., 2001.

slide4

Chest Radiology: Interpretation of Conventional Films

Plunge in…

I. Basics

4 Radiologic Densities

Technique

Normal film

PA

Left lateral

Normal lung fields

Normal heart & mediastinum

II. Heart---Abnormal

III. Lungs---Abnormal

Lobar infiltrates

Effusions

Masses

Cavities

IV. Tuberculosis

(Optional)

slide5

28 yo male,

Sharp trauma left lateral thorax, BP 104/60, p=120, r=24, t=normal

Using whatever background you may have, describe this film . . .

slide6

Abnormalities: severe com- pression of the left lung (white → ) and “air musculogram” of L. pectoralis major (black →) caused by sub-q emphysema.

What is the emergency “first aid” treatment?

slide9

Classic Rx for tension (or any) pneumo-thorax is chest tube inserted over 3rd anterior rib in mid-clavicular line

But, what appears in right chest 1-day post chest tube?

slide10

Partial right pneumothorax (non-tension)

Now to review some basics and some normal films . . .

slide11

Basics: Assessing the film before “reading” it

  • Use the previous 2 and the following 2 films to review:
  • The 4 radiologic (and physical) densities:
      • Air, fat, water (soft tissue), bone (calcium)
  • The 2 orientation directions:
        • Patient: Identify the left side, name and number.
  • Beam direction: Posterior-to-anterior (PA) vs AP
  • The 3 technical quality indicators (“built in”)
  • Inspiration: Posteriorly, 9 or more ribs visible
  • Rotation: Spinous process centered between
  • medial ends of clavicles
  • Penetration (correctly exposed?): Use the PA
  • heart shadow, which increases in density from
  • cephalad to caudad, as an “exposure indicator.”
  • The intervertebral spaces should be visible
  • through the top half of the heart shadow,
  • but invisible in the lower half.
slide12

The next 5 frames provide normal PA and lateral radiographic chest anatomy

35 yo asymptomatic male, taken for a visa application. With the aid of the next film, describe the anatomy . . .

slide13

1. Trachea

2. R main bronchus

3. L main bronchus

4. L pulm artery

5. RUL pulm vein

6. R (desc) pulm artery

7. RLL and RML veins

8. Aortic arch

9. S. vena cava

10. Azygous vein

slide14

Left lateral view of same (asymptomatic) 35 yo man. The left lateral is the standard lateral, because it distorts the heart shadow the least.

Review the anatomy with the aid of frame 16.

slide15

Because the textbook anatomy view in #16 (for some reason !?) shows the right lateral, this frame is a mirror image of the previous frame. This should aid in anatomical interpretation from the next frame - #16)

slide16

1. Trachea

  • 2. R main bronchus
  • 3. LUL bronchus
  • 4. RUL bronchus
  • 5. L pulmonary artery
  • 6. R pulmonary artery
  • 7. Pulmonary vein
  • 8. Aortic arch
  • 9. Brachiocephalic vessels
  • Note: Vascular details are variable from film to film
slide17

Same pt. as #12 and #14, 20 years later, now 55 yo.

Is this a good example of a normal PA for a 55 yo?

slide18

55 yo with four recently fractured ribs (L 2, 3, 4, 5), otherwise it’s a good normal

48 yo Tucson female, with chronic dyspnea. Describe and interpret film . . .

slide19

Prior frame shows high clavicles, low diaphragms and the changes of bronchiectasis and emphysema. The symmetric small masses in lower lung fields are nipple shadows.

13 yo boy with chronic low-grade fever. Can the likely cause be diagnosed from this film?

slide20

Heart: Normal vs. Abnormal

  • Identifying the 4 chambers
  • PA view: right atrium &
  • left ventricle
  • Lateral view: left atrium &
  • right ventricle
slide21

22 yo Sonoran woman

Complaint: dyspnea upon exertion after 1/2 block, chronic. Describe the film. Concentrate on mediastinal/ heart shadows.

slide23

46 yo Tucson male, admits to alcohol problem, complains of swelling of the legs over 6 weeks. BP 95/60, P 112, R 22, Temp normal, 4+ edema/anasarca.

EKG normal, except for low voltage and rate of 112.

Heart exam normal except S3 gallop with distant heart sounds, PMI @ AAL. Describe. . .

slide24

III. Lungs---Abnormal

Lobar infiltrates

Effusions

Masses

Cavities

slide25

24 yo male. T=103, cough, rusty sputum. Describe the abnormal elements in radiological and anatomical terms. . .

slide26

Prior film: Classic RUL consolidation with air bronchogram.

Classic film of pneumococcal pneumonia.

Review lobar and segmental anatomy radiologically . . .

slide28

Prior film: Posterior segment RUL pneumonia, (w/some apical segment involvement). Anterior segment clear (bounded inferiorly by the visible normal/horizontal minor fissure.)

Chronic cough, acute fever in 45 yo male. Describe the abnormality radiologically and locate it anatomically. Describe the heart shadow . . .

slide30

13 yo boy with mild chronic cough for 2 months. Admitted with T=103°.

Describe the abnormality radiologically and anatomically. . .

slide32

This R lateral is classic confirmation of “RML syndrome.” It shows both partial RML atelectasis and partial RML (mainly lateral segment) consolidation.

slide33

The diagnosis is given for this 55 yo man with acute temperature of 103°. Work backwards to describe the abnormalities of heart and lungs on the PA chest film. . .

slide34

52 yo male with weight loss and shortness of breath, both mild and of gradual onset.

Describe radiologically and anatomically . . .

slide35

Prior film shows classic meniscus sign of right pleural fluid

93 yo Tohono O’odham female rancher who fell on right chest. Now sharp chest wall pain, some shortness of breath. Vital signs normal.

Describe this PA and the next lateral film . . .

slide36

Lateral of same 93 yo great-grandmother

How would you prove that this is mobile fluid and not old, stable pleural changes?

slide38

2-1/2 yo boy in Papua New Guinea (PNG), T=100°, other vitals normal. Dull left chest percussion. Describe the two abnormalities . . .

slide39

Film 38 shows loculated L empyema, causing R mediastinal shift.

This film is of PNG male, 30 yo, with fever, weight loss x 3 months.

Describe . . .

slide40

Prior film shows: Rightward shift of heart and media-

stinum, severe chronic left pleural thickening, and an

air/fluid level without a meniscus.

This is a chronic bacterial empyema with a left broncho-

pleural fistula.

The next film is of a Tohono O’odham non-smoking

man of 55. Referred because of PPD of 18 mm.

Denies symptoms. Exam normal except T = 100.4°

What is the differential of this pleural-based infiltrate?

slide42

The wedge-shaped shadow could be : infectious, neoplastic, vascular (pulmonary infarct), or uncommonly another cause .

Note the air in the transvere colon, overlying the liver.

68 yo male UMC patient. Where is the mass?

slide43

Film 42 – the apical mass appears to widen the mediastinum. It was a lung carcinoma in the apical segment of the R U L.

45 yo male in UMC. No chest symptoms. Describe . . .

slide44

Film 43: “coin lesion” overlies posterior 9th rib.

Coin lesion differential is very broad.

Dx: coccidioidomycosis

Nodule (on biopsy)

73 yo female, St. E’s Clinic patient, smoker w/chronic cough.

Describe 2 abnormalities: one is general/obvious and other is specific/small. Also use lateral (next frame) . . .

slide46

1. PA showed flat, low diaphragm to 11th rib

2. Lateral (and PA !) shows calcified azygous lymph node.

This is the most subtle example in this series of chest “masses.”

slide47

50 yo Navajo diabetic woman with cough,

PPD = 22 mm

Describe . . .

slide48

Film 47: one cavity, thin walled, over ribs 5, 6.

Broad differential of cavities includes… ?

56 yo Hispanic man with 3 months of cough, 6 lb. weight loss, smoker.

Describe . . . .

slide49

Film 48: Fibronodular infiltrate, RUL > LUL.

Dx: Active TB , no cavity.

Woman from PNG, 37.

Where is the cavity?

What is wrong in the right upper lobe?

Is the mediastinum normal?

slide51

IV. Tuberculosis

(Optional)

This final third of the series goes into more detail on the radiographic variability in pulmonary tuberculosis.

slide53

Hispanic, 39 yo, father of two, with cough, fever, weight loss, see also lateral (next frame).

Describe . . .

slide56

Film 53/54: giant URL cavity with fluid level; loculated effusion.

Dx: active TB

His daughter; no symptoms.

Describe . . .

slide57

Film 56: Primary TB, right lung; incidental thymic shadow and left air bronchogram.

Son, 3 years-10 months old, of the 39 yo man; also see lateral (next frame).

Describe PA and lateral . . .

slide60

Film 59: “Progressive primary” TB with TB pneumonia, left lung.

Note minor fissure on R.

PNG male, 35 yo, T=100°.

Describe . . .

slide61

Film 60: TB pleural effusion in HIV negative man; resolved with TB Rx.

Navajo male, 20 yo, with acute cough, T=103°.

Describe . . .

slide62

Film 61: R lung volume loss from healed TB; acute pneumonia and fluid level in damaged RUL.

Same patient; after Rx of pneumonia.

slide63

Tohono O’odham cowboy 84 yo, who had LUL resection in 1962 for TB. Describe residual abnormalities and predict physical findings . . .

slide66

Navajo teacher, 60 yo female. Surgery for TB at age 13. Describe radiologically and anatomically . . .

slide67

Thoracoplasty for TB: note resected and “bent” ribs.

Horizontal arrow points to linear pleural calcification; vertical arrow points to air/fluid level.

Patient has no acute symptoms: in what organ is the fluid?

slide68

Lateral of this Navajo teacher:

Fluid is in colon – prolapsed through a hiatal hernia in the diaphragm.

slide69

Now, see how

simple it is to

interpret this

chest film….

See the syllabus

and next slide

for further texts

and reading.

Best wishes…

from Family &

Community Medicine,

University of

Arizona

slide70

Texts you may find useful on the basic chest film (old editions are as good as new editions):

1. Corne J, Carroll M, Brown, I, Delany, D. Chest X-ray Made Easy. London: Churchill Livingstone, 2000. 2nd edition. ($19.95 in AHSC Bookstore, pocket-sized, 127 pp.) (Excerpts are included in this manual.)

2. Felson B. Chest roentgenology. Philadelphia: W.B. Saunders Co., 1973.

3. Felson B. Principles of chest roentgenology, a programmed text. Philadelphia: W.B. Saunders Co., 1965. 2nd edition, 1999.

4. Forrest and Feigin. Essentials of Chest Radiology, W.B. Saunders Co., 1982.

(Good basic text)

5. Lillington and Jamplis. A Diagnostic Approach to Chest Diseases: Differential Diagnoses Based on Roentgenographic Patterns. Baltimore: Williams and Wilkins Co., 3rd edition, 1987.

6. Mettler F. Essentials of Radiology, W.B. Saunders Co., 1996.

7. Squire, LF. Fundamentals of roentgenology (3rd ed.). (general principles). Cambridge: Harvard University Press, 1982

8. Squire, Colaice, and Strutynsky. Exercises in Diagnostic Radiology, Vol. 1:

The Chest, 1972. (Paperback, problem oriented.)

9. Műller N,Fraser R, Colman N, Paré P.. Radiologic Diagnosis of Diseases of the Chest, W.B. Saunders Co., 2001.