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ReadCXR
Diff Diagnosis, Test 2
| Question | Answer |
|---|---|
| Hilum | pulmonary vessels (Left hilum slightly higher than right) |
| What is an abn cardiothoracic ratio for adults & children? | adult: > 50% nenoate: > 66% |
| Normal cardiac diameter in an adult? | males < 15.5 cm female < 14.5cm |
| What is a significant change in cardiac diameter change btw 2 x-rays? | > 1.5 cm |
| Radiolocent | blackest, least dense tissue; maximum xray transmission ex: air |
| Radiopaque | whitest, densest tissue; maximum xray absorption ex:bone |
| What 4 factors do you evaluate for an optimal CXR? | 1. magnification, 2. angulation, 3. penetration & depth of inspiration, 4. rotation & centering |
| What x-ray view is the heart closer to the film? PA or AP | PA (film is in front of the pt) |
| What is the standard chest x-ray? | PA |
| what type of xray is usually taken in ICU or as a portable? | AP (film is behind the pt) |
| How does a PA xray change the image seen? | heart is farther away and more magnified (looks bigger than it is) |
| Which diaphram is expected to be higher and why? | Right diaphram is higher due to liver |
| What is a prominent feature of CXR in children under 2? | heart is bigger; thymus gland is prominent (creates a sailshadow) |
| What indicates a good inspiration? | 10 ribs visible |
| apical lordotic | xray angled toward the head (pt in semi-recumbent position) clavicles will be higher than posterior structures |
| How does an apical lordotic position change the view of the CXR? | unusual shape to heart, border of left diaphram will be absent, but can see upper lobes more clearly if suspect ca or TB |
| How do you evaluate an xray for good penetration? | you should be able to see the thoracic spine through the heart |
| What affects the magnification of the CXR? | position of film to pt...AP vs. PA |
| What is the result of underpenetration? | xray too white |
| What is the result of overpenetration | xray too dark (black) |
| What is an adequate inspiration for hospitalized pts? | view of 9 posterior ribs. |
| How do you distiguish the posterior ribs on an xray? | horizontal, easier to view |
| What are the pitfalls due to poor inspiration? | crowding of lung landmarks, creating an appearance of airspace dx |
| What do you evaluate to make sure xray isn't rotated? | determine equal distance of spinous process to clavicles (Clavicle over 3rd rib) |
| If spine is closer to the R clavicle, which way is the pt rotated? | pt is rotated to their left side |
| What points do you evaluate to check quality of xray? | 1. magnification=PA vs. AP (PA xray taken from pt's back) 2. angulation=clavicle over 3rd rib 3. penetration=spinous process visible through heart 4. inspiration=8-9 posterior ribs 5. center/rotation=clavicle over 3rd rib,centered |
| What is the importance of a lateral chest film? | find abn hidden in frontal film shows depth of abd |
| When would you order a lateral decubitus? | to see mobile pleural effusion |
| How much fluid is require to see a plueral effusion on frontal film? | 200-400 cc |
| How much fluid before it is visible on lateral film? | 50-75cc |
| Where do you look for pleural effusions? | in the fissures |
| What soft tissue do you evaluate? | neck, shoulders, breast & SQ fat |
| What are Amerosa's 8 step approach to evaluate CXR? | 1.paperwork 2. outside of chest 3. soft tissue 4. bones 5. pleura 6. mediastinum 7. lungs 8. conclusion |
| What do you evaluate in the trachea? | visible above clavicles and can see bifurcation at the carina |
| What characteristics do you evaluate in the diaphram? | dome shape R hemidiaphram is 1-3cm higher than L costophrenic angle symmetric and sharply defined |
| Kerley's B lines | perpendicular lines in pleua seen in CHF, indicate excessive fluid |
| Air Bronchogram | visible when bronchi fill with fluid density ex: pulmonary edema fluid, blood, aspiration, inflammatory exudate |
| Define silhouette sign | edges disappear when objects of same density touch each other (water density obliterates existering interface) |
| Example of silhouette sign: RML, Lingula, RLL, LLL | RML-right heart border Lingula-left heart border RLL-right hemidiaphram LLL-left hemidiaphram |
| If the right heart border is obliterated, what process is likely possible? | Pneumonia of RML |
| Alveolar infiltrates | fluffy white clouds - indistinct (fluid in alveoli) air bronchograms confluent & homongenous segmental or lobular distinctions present in airspace disease |
| Instertitial infiltrates | small, well-defined, reticular (net-like), nodular or reticulonodular opacities due to fibrosis, fluid or inflammatory by-product (honeycombing)inhomogenous, NO air bronchograms |
| Examples of interstitial disease | cancer, sarcoidosis, cystif fibrosis, asbestosis |
| Examples of alveolar disease | pneumonia, pulmonary edema, pulmonary hemorrhage, aspiration |
| What is the difference between pneumonia and atelectasis? | atelectasis is volume loss-draws things in, has ipsilateral shift, linear, wedge shape to apex & hilum. Pneumonia has nml or > volume, no shift, consolidation, air space process, not contered at hilum. Both have air bronchograms |
| Pulmonary edema | alveolar disease, fluffy indistinct white clouds |
| Pneumonia | air bronchograms, alveolar disease of lung segment |
| TB | consolidation, adenopathy, pleural effusion (focal patchy airspace dx, cotton wool shadows, cavitation, fibrosis, calcification, flecks of caseous material) |
| Where is TB found | posterior upper lobe or superior lower lobe |
| What type of cavities can be found on CXR? | carcinoma, TB, abscess |
| Characteristics of cancerous cavity? | thick walled, nodular inner margin, air-fluid level may or may not be present |
| TB | thin walled, smooth inner margin, no air-fluid level |
| Abcess | thick cell wall, smooth inner margin, air-fluid level present |
| Examples benign cysts in lung | PCP pneumatocele, cryptocccus maximum wall thickness <=4mm |
| Pulmonary Embolism | usually normal CXR Westermark's sign, > size of hilum, atelectasis (w/elevated hemidiaphram), pleural effusion, consolidation, Hamptom's Hump |
| What are some common causes for pleural effusion | CHF, Infection, trauma, PE, tumor, autoimmune dx, renal failure |
| What best demonstrates a pneumothorax on xray | Expiratory Film |
| How is pneumothorax shown on xray | air without lung markings in least dependent part of chest,, air in apices |
| Hypothorax | air and fluid in pleural space |
| Difference between Simple vs Tension pneumothorax | simple-no mediastinal shift tension-mediastinal sheft away from pneumothorax |
| Intersitial Fibrosis | hazy ground glass opacification-early volume loss w/linear opacification bilat & honecombing-late stages (idiopathic, collagen vascular dx, cytotoxic agents, nitrofurantoin, pneumoconiosis, radiation, sarcoidosis) |
| Emphysema | hyperinflation, flattened diaphram > retrosternal space, bullae > PA/RV, narrow trachea (Saber sheath), cylindrical heart (verticle heart) |
| opafication of what part of the lung will silhouette the left heart border? | Lingula |
| What clinical finding would you expect to find if a patient had Hampton's Hump on the CXR? | Hypoxia and dyspnea (with a PE) |
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