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2. Check List(1)
1.
2.
Check patient data, position, technical quality and normal anatomy.
Review systematically
o
o
o
Initial survey
Review skeletal structures of shoulder girdles and chest wall
Review mediastinum:
•
•
•
•
•
o
overall size and shape
trachea: position
margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch,
main pulmonary artery, left ventricle
lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal),
paraaortic
retrosternal clear space
Review hila:
•
•
normal relationships
size
www.indiandentalacademy.com
3. Check List(2)
o
Review lungs and pleura:
•
•
•
•
o
compare lung sizes
evaluate pulmonary vascular pattern: compare upper to lower lobe, right to
left, normal tapering to periphery
pulmonary parenchyma
pleural surfaces
– fissures - major and minor - if seen
– compare hemidiaphragms
– follow pleura around rib cage
Soft tissue including breast, companion shadow .
•
•
•
Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc.
Review soft tissues and spine of neck.
Review spine and rib cage: check alignment, disc space narrowing, lytic or
blastic regions, etc.
www.indiandentalacademy.com
4. Check List
1.
Check patient data, position, technical quality and normal
anatomy.
Review systematically
2.
o
o
o
o
o
o
Initial survey
Review skeletal structures of shoulder girdles and chest wall
Review mediastinum
Review hila
Review lungs and pleura
Soft tissue including breast, companion shadow
www.indiandentalacademy.com
5. 1. Data base
1. Name
2. Date
- important for comparing prior exams
- Serial image
3. Position markers
- right(R) vs. left(L)
4. Type of film
5. Patients position
–
supine, upright, lateral, etc.
6. Technical quality
www.indiandentalacademy.com
7. Introduction
• Serial image: Doubling time
– Point of disease(location/size)
– Make diagnosis easily
• Pneumonia
• Edema
• Tumor
www.indiandentalacademy.com
13. Technical quality
• Ideal KV exposure
– Key points
•
•
•
•
•
Apex
Retrocardiac lung marking
Trachea position
Spine
Scapula
– You can't find a subtle pneumothorax if there is patient
motion or the film is overexposed.
• 4 basic radiographic densities
www.indiandentalacademy.com
32. Normal Anatomy
• Anatomy & projection
• The sihouette sign
– Define
• Interface is invisible when two areas of similar
radiodensity touch.
– Position
www.indiandentalacademy.com
43. Check List
1.
Check patient data, position, technical quality and normal
anatomy.
Review systematically
2.
o
o
o
o
o
o
Initial survey
Review skeletal structures of shoulder girdles and chest wall
Review mediastinum
Review hila
Review lungs and pleura
Soft tissue including breast, companion shadow
www.indiandentalacademy.com
44. Systematic review
• A-B-C-D-E-F-G-H or
• Try interpret and understand what you see:
– D.D. normal v.s. abnormal?
www.indiandentalacademy.com
46. Systematic review
o
o
o
o
o
o
Initial survey
Review skeletal structures of shoulder girdles and
chest wall
Review mediastinum
Review hila
Review lungs and pleura:
Soft tissue including breast, companion shadow. .
www.indiandentalacademy.com
47. Check List
1.
Check patient data, position, technical quality and normal
anatomy.
Review systematically
2.
o
o
o
o
o
o
Initial survey
Review skeletal structures of shoulder girdles and chest wall
Review mediastinum
Review hila
Review lungs and pleura
Soft tissue including breast, companion shadow
www.indiandentalacademy.com
48. Initial survey
1. General Body Size, Shape, and Symmetry
2. Sex
3. Age(cartilage/aortic arch
/asending aorta/Pulmonary trunk)
•
Infant/ child/ young adult/ elderly person
1. Foreign objects
•
•
tubes, IV lines, EKG leads, surgical drains, prosthesis
non-medical objects, bullets, shrapnel, glass, etc
www.indiandentalacademy.com
49. Check List
1.
Check patient data, position, technical quality and normal
anatomy.
Review systematically
2.
o
o
o
o
o
o
Initial survey
Review skeletal structures of shoulder girdles and chest wall
Review mediastinum
Review hila
Review lungs and pleura
Soft tissue including breast, companion shadow
www.indiandentalacademy.com
50. Skeletal structures
•
Overall size, shape, contour of each bone.
–
–
–
Density( mineralization)
Compare cortical thickness to medullary cavity,
trabecular pattern,
Erosions, fractures, any lytic or blastic regions.
•
Joints
–
–
–
–
•
Articular relationships
Joint spaces narrowed, widened
Calcification in the cartilages
Air in the joint space, abnormal fat pads
Refresh gross anatomy radiology
www.indiandentalacademy.com
51. Neck and Cervical spines
•
Overall(soft tissue)
– amounts
– calcifications,
– subcutaneous emphysema
•
Trachea
– position
– size
•
Cervical spine,
– alignment
– note any major congenital
abnormalities.
•
•
Specific parts of the vertebra and
disc spaces
Checking
– erosions
– lytic or blastic lesions
– disc and synovial joint narrowing
www.indiandentalacademy.com
– Other abnormalities.
52. Thoracic spine and Rib cage
•
•
•
•
Overall alignment- spine
Symmetry - rib cage
Double check bone density
Two reminders at this
point:
– Principle of general
• More detailed review in each
section.
– concentrate on the skeletal
detail
• “Look through" the
mediastinum and lungs.
www.indiandentalacademy.com
53. Thoracic spine
• Specific parts(Each)
– Vertebra
– Disc spaces
•
•
•
•
height
integrity of cortical margins/pedicles/lamina
presence of any lytic or sclerotic areas
synovial joints(normal /narrowing /sclerosis spacing )
• Compare frontal & lateral projections
www.indiandentalacademy.com
58. Check List
1.
Check patient data, position, technical quality and normal
anatomy.
Review systematically
2.
o
o
o
o
o
o
Initial survey
Review skeletal structures of shoulder girdles and chest wall
Review mediastinum
Review hila
Review lungs and pleura
Soft tissue including breast, companion shadow
www.indiandentalacademy.com
59. Mediastinum
• Define
– Area between the lung
– Water density
• Surrounded two air filled lungs and
• Intersected by the air filled trachea and major bronchi.
• Key is knowledge of anatomical relationships and
how structures project on a radiograph.
• CT and MRI is helpful.
• Interfaces of air-soft tissue margins may be distorted by
pathological lesion
– Masses
– otherwise
www.indiandentalacademy.com
60. Mediastinum
• Define
– Area between the lung
– Water density
• Surrounded two air filled lungs and
• Intersected by the air filled trachea and major bronchi.
• Key is knowledge of anatomical relationships and
how structures project on a radiograph.
• CT and MRI is helpful.
• Interfaces of air-soft tissue margins may be distorted by
pathological lesion
– Masses
– otherwise
www.indiandentalacademy.com
62. Mediastinum
• Define
– Area between the lung
– Water density
• Surrounded two air filled lungs and
• Intersected by the air filled trachea and major bronchi.
• Key is knowledge of anatomical relationships and
how structures project on a radiograph.
• CT and MRI is helpful.
• Interfaces of air-soft tissue margins may be distorted by
pathological lesion
– Masses
– otherwise
www.indiandentalacademy.com
68. MEDIASTINUM
• Anatomy dividing region
– SUPERIOR MEDIASTINUM
• Begins - root of the neck and
• Ends - line drawn T-4 vertebrae --- sternomandible junction.
– line skims the top of the aortic arch. T
– Mediastinum
• Begins - this line
• End- diaphragm
• Further divided into three regions
– Anterior
– Middle
– Posterior.
www.indiandentalacademy.com
71. Mediastinum
•
•
•
Overall size and shape
Trachea- position
Margins
•
•
•
•
•
•
•
•
SVC- Ascending aorta
Right atrium
Left subclavian artery- Aortic arch
Main pulmonary artery
Left antrium
Left ventricle
Lines and stripes
Retrosternal clear space
www.indiandentalacademy.com
75. Axial plan of computer
tomography
1. Right Brachiocepahlic
Artery
2. Superior Vena Cava
3. Right Paratracheal Stripe
4. Esophagus
5. Left Subclavian Artery
6. Left Common Carotid
Artery
7. Left Brachiocephalic Vein
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77. Mediastinum
•
•
•
•
Overall size and shape
Trachea: position
Margins
Lines and stripes
•
•
•
•
•
Paratracheal
Paraspinal
Paraesophageal (azygoesophageal)
Paraaortic
Retrosternal clear space
www.indiandentalacademy.com
78. Edge of Superior vena cave (SVC)
• Seen PA(AP) view only
• Often only a portion
• Never bulge into the lung
with a convex border.
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80. Right Pratracheal stripe
• Normal- < 5 mm,
usually 2-3 mm.
– Important marker for subtle adenopathy.
• Distal end - formed by azygous vein
– Distended vein, stripe > 1 cm.
• Medial margin -soft tissue interface /right mucosal surface of trachea.
• Outer margin -begins medial end of clavicle/formed by plural surface of
right upper lobe (RUL).
• Normal structures in soft tissue density between air trachea and the RUL
–
–
–
–
–
Right wall of the trachea
Nerves
Fat
Lymph nodes
Pleura of the RUL.
• Azygous vein - anteriorly to empty into the posterior surface of the SVC.
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83. Left Subclavian stripe
• Width- normal 1.0-1.5 cm.
• Inner marginAir mucosal interface
-mucosal surface of the
trachea,
• Outer margin interface Medial aspect of left upper
lobe
• Upper- outer edge
Level of the clavicle and will
be able to follow it
• EndBulge of the aortic arch.
www.indiandentalacademy.com
85. • Sometimes(+) on the frontal view
• Plural edge parallel to the lateral margins of the
vertebral bodies.
• Edge > millimeters beyond the vertebral bodies
• Should not be lumpy or bulging.
www.indiandentalacademy.com
86. Pleural mediastinal interface
1. Superior Vena Cava
2. Right Paratracheal
Stripe
3. Left Subclavian Stripe
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88. • On the forntal view only
• Formed by the right lower lobe & Mediastinum,
containing
– Esophagus
– Azygous vein.
• Overlies the thoracic spine
– Near the midline
– Fairly straight, vertically.
• Bulges convex to lung
– S/p mediastinal mass, eg.
• subcarinal lymph nodes
• Enlarged left atrium.
www.indiandentalacademy.com
89. CT of the Azygoesophageal line
• 1. Esophagus
• 2. Azygous Vein
• 3. Descending Aorta
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92. MEDIASTINUM
• Overall size/ shape on PA & lateral views
– Decide if it is normal & age.
• Look for
– Obvious masses
– Calcifications
– Double check for foreign projects
•
•
•
•
Tubes
Electrical leads
Pacemaker
Artificial valves
www.indiandentalacademy.com
93. MEDIASTINUM
• Evidence of
– Mediastinal shift
• Entire or
• Section of it.
• Look trachea/major bronchus
– Size
– Position
– Intraluminal masses
www.indiandentalacademy.com
94. SUPERIOR MEDIASTINUM PA• Overall width for normal size,
• Look for
– Masses
– Calcifications
– Free air.
• Detailed search for subtle
distortion of
– several major pleural mediastinal
interfaces.
• Not all of the following
structures are seen on every
film
– Try to find them
www.indiandentalacademy.com
95. Mediastinum
• Define
– Area between the lung
– Water density
• Surrounded two air filled lungs and
• Intersected by the air filled trachea and major bronchi.
• Key is knowledge of anatomical relationships and
how structures project on a radiograph.
• CT and MRI is helpful.
• Interfaces of air-soft tissue margins may be distorted by
pathological lesion
– Masses
– otherwise
www.indiandentalacademy.com
96. HEART
1 Edge of superior
vena cava
2. Right atrium
3. Aortic arch
4. Edge of main
pulmonary artery
5. Left atrial
appendage
6. Left ventricle
www.indiandentalacademy.com
97. •
•
•
•
•
Superimposed on the frontal view.
The major structure is the heart.
Pericardium and heart is inseparable on plain film views.
Review the heart for overall size and shape.
Rough yardstick - cardiac-thoracic ratio
– Widest diameter of the heart /widest width of the thoracic cage( inner aspect
of rib to rib).
– > 50%
•
Check
–
–
–
–
–
•
Calcifications
Pneumopericardium
Pneumomediastinum
Sutures
Prosthetic valves etc.,
You may have overlooked on the general survey of the entire
mediastinum.
www.indiandentalacademy.com
103. • Try tracking
– Root
– Distal descending aorta.
• Young adult - hidden in the mediastinum
Older - swing to the right to cast a soft tissue bulge.
• Arch- always be seen
– make sure left to distal trachea
– Pushes trachea slightly to the right actually .
• Check aortic calcifications and size.
• Left lateral border of descending aorta
– abuts the left lung (column of dots on the pt's. left, on the
annotated image).
• Lateral view- aorta is usually not seen.
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104. Pulmonary artery
1. Carina
2. Left Main Stem
Bronchus
3. Descending Aorta
4. Main Pulmonary
Artery
5. Aorticopulmonary
Window
6. Arch of Aorta
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105. • Main pulmonary artery
– Straight or
– Convex (most commonly in young females).
• "middle mogul" - when convex
– Upper "mogul" - aortic knob
– Lower mogul - left ventricle.
• Left pulmonary artery- branching of main
pulmonary artery
• Right pulmonary artery– Proximal- not seen, ( buried in the mediastinum)
– Branches can see ( as the right hilum)
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107. Pulmonary arteries, Lateral view
6
1. Trachea
2. Right Ventricle
3. Left Ventricle
4. Region of left Atrium
5. Right Pulmonary
Artery
6. Left Pulmonary Artery
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108. Pulmonary artery
• Right pulmonary artery
– Ovoid branching structure- easily seen,
– Just anterior to the air column of the trachea and main
bronchi.
• Left pulmonary artery
–
–
–
–
Never seen as clearly as the right
Unless markedly enlarged.
Curved shadow, similar to the aorta
just behind the air column
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111. • Double check area - for subtle mediastinal
masses.
• Between
– Aortic arch
– Left pulmonary artery
– Residual portion
• Ligamentum arteriosum
• left recurrent laryngeal nerve
• Should concave or straight border.
– Mediastinal mass(+)
• Lung pushed laterally border becomes convex.
www.indiandentalacademy.com
112. MISCELLANEOUS
• Lateral view
– Adult
• anterior mediastinum cephalad
to the heart
• Lung-air density, not soft
tissue density.
– Infants and young children
• Thymus fills this area.
• Check posterior sternal
margin
– Small masses: internal thoracic
lymph node enlargement.
www.indiandentalacademy.com
113. Check List
8. Review hila:
–
–
normal relationships
size
8. Review lungs and pleura:
–
–
–
–
compare lung sizes
evaluate pulmonary vascular pattern: compare upper
to lower lobe, right to left, normal tapering to
periphery
pulmonary parenchyma
pleural surfaces
•
•
•
fissures - major and minor - if seen
compare hemidiaphragms
follow pleura around rib cage
www.indiandentalacademy.com
115. Frontal view of the hila
• Frontal view, hilar shadows most
– left pulmonary arteries.
– right pulmonary arteries.
• Bronchi(with the arteries)
– Radiolucent.
• Pulmonary veins
– Not clearly seen
• they are behind the widest parts of the heart, inferior to the hila,
where they converge into the left atrium.
• Left pulmonary artery always more superior >
right, left hilum higher.
• Calcified lymph nodes may be visible within the
hilar shadows. www.indiandentalacademy.com
116. Lateral view of the hila
1. Trachea
2. Lower lobe bronchi
(left and right
superimposed)
3. Right Pulmonary
Artery
www.indiandentalacademy.com
117. Check List
8. Review hila:
–
–
normal relationships
size
8. Review lungs and pleura:
–
–
compare lung sizes
evaluate pulmonary vascular pattern
•
–
–
compare upper to lower lobe, right to left, normal tapering to
periphery
pulmonary parenchyma
pleural surfaces
•
•
•
fissures - major and minor - if seen
compare hemidiaphragms
follow pleura around rib cage
www.indiandentalacademy.com
119. Lung
• Compare overall size of one lung bilateral,
• Also a double check on your earlier look at
the rib cage size.
• Look for major areas of abnormal lucency/or
density
• Train your eyes to look through the heart
and upper abdomen to lung posterior to these
areas.
www.indiandentalacademy.com
121. Blood vesseles in the lung
• Distribution- side to side
– Compare right/left upper lobes and lower lobes
for roughly equal.
• Distribution- upper to a lower
– Vessel in the same middle zone of the lung.
• Upright person- pressure differential
– lower lobe vessel wider (i.e., larger)
– If same size or reversed in size,
• Redistribution of flow has occurred.
• Phenomenon does not apply, if the person is
www.indiandentalacademy.com
semi-recumbent or supine.
124. PARENCHYMA
• Large abnormalities/small lesion
– Masses
– Infiltrates
– calcifications
• Compare- side to side at a time.
• Now ignore the bone but lung.
• 3 areas easily overlooked:
– Behind the calcified anterior first rib cartilage,
– Behind the heart
– Behind the diaphragm
www.indiandentalacademy.com
125. LATERAL VIEW OF THE LUNG
• Lateral view
– Help to look
• Posterior
costophrenic recess
• Anterior
mediastinum.
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126. Pleura
• PA view
– Minor fissue thickness and location
• Lateral view
– minor fissures
– major fissures
(even if you do not see them in their entirety which you rarely
will).
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127. AP VIEW OF THE PLEURA
•
Follow the pleural surface around
the lung periphery making the
following observations.
• On the frontal view, the apex of
the hemidiaphragms should be in
the mid third of each hemithorax
with the right hemidiaphragm
usually 2-2.5 cm higher than the
left.
• The costophrenic angles laterally
should be sharp.
• The lung should abut right up
against the inner margins of the
rib cage.
• If the pleural space is widened by
fluid or mass, the lung will be
pushed away by soft tissue
density.
• Also check for pleural
calcifications, and presence of
www.indiandentalacademy.com
pneumothorax.
128. LATERAL VIEW OF THE PLEURA
• Lateral view
– ,follow the pleura into the
posterior costophrenic
recess
– along the inner aspect of
the posterior ribs, if
possible.
• Recheck Posterior
sternal margin.
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129. Soft tissues
1. Overall
2. Following
–
–
–
Calcifications
Bony defect
Soft tissue companion shadow for the clavicle
•
Supraclavicular LAP
www.indiandentalacademy.com
131. BREAST TISSUE
• Symmetry
(Normal variation –
Standing(PA view) +
unequal pressure against the film holder)
• Notice lung density
changes
(lung area +/- soft tissue of
the breast )
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132. ABDOMEN
• Highly variable
• look for following
– Gastric and bowel gas
• Amount/ location( normal? )
– Organ size
• liver, spleen, kidneys
– Free peritoneal air
• Position will change location of
free air.
– Calcifications and masses
• can they be localized to a
specific structure.
www.indiandentalacademy.com
134. • This completes an introduction into the beginnings of chest
review.
• Be aware there are many more detailed observations to
learn in the future.
• Go through the sections until you understand the anatomy,
and then start practicing a continuous review looking at a
full frontal and lateral view.
• When you have developed a review system that works for
you (remember the order here is only a guide) go to the next
section that has the check off list type of review.
• Many people find it helpful to talk their way through the
film, the eye-brain-mouth loop does work.
• Finally look at films on a variety of normal people of all
ages, sizes, and both sexes to develop a data base of normal
references.
• Practice the review sequence that works best for you until it
is automatic, and then you can concentrate on the diagnostic
findings.
www.indiandentalacademy.com
135. Check List (1)
1.
2.
3.
Check patient name, position, technical quality.
Initial survey
Soft tissue including breast, chest wall, companion shadow.
•
•
•
•
1.
Review soft tissues and skeletal structures of shoulder girdles and chest
wall.
Review abdomen for bowel gas, organ size, abnormal calcifications, free
air, etc.
Review soft tissues and spine of neck.
Review spine and rib cage: check alignment, disc space narrowing, lytic or
blastic regions, etc.
Review mediastinum:
–
–
–
–
–
overall size and shape
trachea: position
margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic
arch, main pulmonary artery, left ventricle
lines and stripes: paratracheal, paraspinal, paraesophageal
(azygoesophageal), paraaortic
retrosternal clear space
www.indiandentalacademy.com
136. Check List (2)
8. Review hila:
–
–
normal relationships
size
8. Review lungs and pleura:
–
–
–
–
compare lung sizes
evaluate pulmonary vascular pattern: compare upper
to lower lobe, right to left, normal tapering to
periphery
pulmonary parenchyma
pleural surfaces
•
•
•
fissures - major and minor - if seen
compare hemidiaphragms
follow pleura around rib cage
www.indiandentalacademy.com
137. Thank you
For more details please visit
www.indiandentalacademy.com
www.indiandentalacademy.com
Notes de l'éditeur
Check patient name, position, technical quality.
Initial survey
Soft tissue including breast, chest wall, companion(同伴,伴侶;朋友) shadow.
4. Review soft tissues and skeletal structures of shoulder girdles and chest wall.
5. Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc.
6. Review soft tissues and spine of neck.
7. Review spine and rib cage: check alignment(隊列,一直線), disc space narrowing, lytic or blastic regions, etc.
8. Review mediastinum:
- overall size and shape
- trachea: position
- margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle
- lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic
- retrosternal clear space
Check patient name, position, technical quality.
Initial survey
Soft tissue including breast, chest wall, companion(同伴,伴侶;朋友) shadow.
4. Review soft tissues and skeletal structures of shoulder girdles and chest wall.
5. Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc.
6. Review soft tissues and spine of neck.
7. Review spine and rib cage: check alignment(隊列,一直線), disc space narrowing, lytic or blastic regions, etc.
8. Review mediastinum:
- overall size and shape
- trachea: position
- margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle
- lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic
- retrosternal clear space
Check patient name, position, technical quality.
Initial survey
Soft tissue including breast, chest wall, companion(同伴,伴侶;朋友) shadow.
4. Review soft tissues and skeletal structures of shoulder girdles and chest wall.
5. Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc.
6. Review soft tissues and spine of neck.
7. Review spine and rib cage: check alignment(隊列,一直線), disc space narrowing, lytic or blastic regions, etc.
8. Review mediastinum:
- overall size and shape
- trachea: position
- margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle
- lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic
- retrosternal clear space
1. Patient's name.
2. Date exam done (very important if comparing prior exams).
3. Check for position markers - right vs. left, upright
4. Type of film (although this is a chest program, practice noticing if it is a plain film, CT, angio, MRI, etc.)
5. Patients position
supine, upright, lateral, decubitus.
6. Technical quality of exam
learn what are the acceptable limits for the exam. You can't find a subtle pneumothorax if there is patient motion(動作,姿態;手勢,眼色) or the film is overexposed.
1. First, training your eyes to cover the film in a systematic way so all body parts and systems are examined
2. Second, being able to interpret and understand what you see: can you separate normal and its variants from abnormal?
Decubitus= lying down
Lordotic(脊柱前凸的)
3. Oblique(斜的;傾斜的)
- helpful localize lesions and eliminate superimposed structures.
-Right anterior oblique for left side lesion Far the light, move more laterally, and image more laterally as the point in stright when PA view.
Lt’ lesion with Rt’ ant. Oblique for increase difference distance.
Decubitus= lying down
Lordotic(脊柱前凸的)
3. Oblique(斜的;傾斜的)
- helpful localize lesions and eliminate(排除) superimposed structures.
-Right anterior oblique for left side lesion Far the light, move more laterally, and image more laterally as the point in stright when PA view.
Lt’ lesion with Rt’ ant. Oblique for increase difference distance.
PA
Lateral(left)
Right ant. oblique View
AP
AP supine
Rt’ Lat. decubitus
Lateral view of the same patient
Right lateral decubitus (right side down) view of the same patient, showing layering of the large effusion along the right chest wall.
1. First, training your eyes to cover the film in a systematic way so all body parts and systems are examined
2. Second, being able to interpret and understand what you see: can you separate normal and its variants from abnormal?
Motion: 移動
There is a small pneumothorax present on the radiograph to the left. It is located in the left pulmonary apex. If you compare the lucency of the lung fields in the first few intercostal spaces, you will notice that the left apex is slightly more lucent than the right. In the left third intercostal space, there is a thin white line (see magnified picture below) that represents the pleural surface of the lung. Increased lucency more peripheral to this line is the air trapped in the pleural
Def
A state characterized by the presence of gas within the pleural space.
CxR
The only direct sign is identification of a visceral pleural line. An air-fluid level in the hemithorax provides indirect evidence of a hydropneumothorax
1. First, training your eyes to cover the film in a systematic way so all body parts and systems are examined
2. Second, being able to interpret and understand what you see: can you separate normal and its variants from abnormal?
Motion: 移動
Diaphragm: 1.5-2 rib beadth(4 cm)
* Cardiothoracic ratio(N <0.5)- CTR
Type of film (although this is a chest program, practice noticing if it is a plain film, CT, angio, MRI, etc.)
Patients position - supine, upright, lateral, decubitus.
Technical quality of exam - learn what are the acceptable limits for the exam. You can't find a subtle pneumothorax if there is patient motion or the film is overexposed.
Type of film (although this is a chest program, practice noticing if it is a plain film, CT, angio, MRI, etc.)
Patients position - supine, upright, lateral, decubitus.
Technical quality of exam - learn what are the acceptable limits for the exam. You can't find a subtle pneumothorax if there is patient motion or the film is overexposed.
Check patient name, position, technical quality.
Initial survey
Soft tissue including breast, chest wall, companion(同伴,伴侶;朋友) shadow.
4. Review soft tissues and skeletal structures of shoulder girdles and chest wall.
5. Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc.
6. Review soft tissues and spine of neck.
7. Review spine and rib cage: check alignment(隊列,一直線), disc space narrowing, lytic or blastic regions, etc.
8. Review mediastinum:
- overall size and shape
- trachea: position
- margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle
- lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic
- retrosternal clear space
1. First, training your eyes to cover the film in a systematic way so all body parts and systems are examined
2. Second, being able to interpret and understand what you see: can you separate normal and its variants from abnormal?
1. First, training your eyes to cover the film in a systematic way so all body parts and systems are examined
2. Second, being able to interpret and understand what you see: can you separate normal and its variants from abnormal?
1. First, training your eyes to cover the film in a systematic way so all body parts and systems are examined
2. Second, being able to interpret and understand what you see: can you separate normal and its variants from abnormal?
Check patient name, position, technical quality.
Initial survey
Soft tissue including breast, chest wall, companion(同伴,伴侶;朋友) shadow.
4. Review soft tissues and skeletal structures of shoulder girdles and chest wall.
5. Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc.
6. Review soft tissues and spine of neck.
7. Review spine and rib cage: check alignment(隊列,一直線), disc space narrowing, lytic or blastic regions, etc.
8. Review mediastinum:
- overall size and shape
- trachea: position
- margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle
- lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic
- retrosternal clear space
1. General Body Size, Shape, and Symmetry
2. Male vs. Female
3. Is this an infant, child, young adult, elderly person?
4. Survey for foreign objects
- tubes, IV lines, EKG leads, surgical drains, prosthesis, etc., as well as
- non-medical objects, bullets, shrapnel(砲彈碎片), glass(玻璃), etc
Check patient name, position, technical quality.
Initial survey
Soft tissue including breast, chest wall, companion(同伴,伴侶;朋友) shadow.
4. Review soft tissues and skeletal structures of shoulder girdles and chest wall.
5. Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc.
6. Review soft tissues and spine of neck.
7. Review spine and rib cage: check alignment(隊列,一直線), disc space narrowing, lytic or blastic regions, etc.
8. Review mediastinum:
- overall size and shape
- trachea: position
- margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle
- lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic
- retrosternal clear space
1. Overall size, shape, and contour(輪廓;輪廓線) of each bone.
2. Density or mineralization.
3. Compare cortical thickness to medullary cavity, trabecular pattern, look for erosions, fractures, any lytic or blastic regions.
4. At joints, are articular(關節的) relationships normal, joint spaces narrowed, widened, any calcification in the cartilages, air in the joint space, abnormal fat pads, etc.
- Check overall amounts of soft tissue, presence of calcifications, subcutaneous emphysema, position and size of trachea.
- For the cervical spine, check alignment(隊列,一直線) and note any major congenital abnormalities.
- Then look at specific parts of the vertebra and disc spaces, checking for erosions, lytic or blastic lesions, disc and synovial joint narrowing or other abnormalities.
- Two reminders at this point:
>remember the principle of general to more detailed review in each section.
>concentrate on the skeletal detail -- "look through" the mediastinum and lungs.
- First check overall alignment of the spine and symmetry of the rib cage, double check bone density (this is a gross estimate).
Specific parts(Each)
Vertebra
Disc spaces
Compare frontal and lateral projections.
Some check list items to watch for are:
height of vertebral bodies and disc spaces,
integrity of cortical margins around the bodies, pedicles, and lamina,
presence of any lytic or sclerotic areas,
normal spacing of synovial joints, versus narrowing or sclerosis
Pedicle(根;肉莖;梗節)
Transverse process
Posterior process
Intervertebral disc
Intervertebral foramen
Anterior longitudinal ligament
Posterior longitudinal ligament
Ligamentum flavum
- Compare individual ribs side to side, check specific parts, cortical margins, trabecular patterns.
- Make a note if the anterior cartilages are calcified, frequently the first one does so irregularly and may obscure or mimic underlying lung lesions.
Check patient name, position, technical quality.
Initial survey
Soft tissue including breast, chest wall, companion(同伴,伴侶;朋友) shadow.
4. Review soft tissues and skeletal structures of shoulder girdles and chest wall.
5. Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc.
6. Review soft tissues and spine of neck.
7. Review spine and rib cage: check alignment(隊列,一直線), disc space narrowing, lytic or blastic regions, etc.
8. Review mediastinum:
- overall size and shape
- trachea: position
- margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle
- lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic
- retrosternal clear space
- An enormous amount of information about the mediastinum can be extracted from plain films; the key is a thorough knowledge of anatomical relationships and how structures are likely to project on a radiograph.
- Use of cross-sections from CT and MRI will supplement this section.
- Understand on plain films the mediastinum projects as a water density surrounded by the two air filled lungs and intersected(橫斷面)by the air filled trachea and major bronchi.
- The interfaces of these air-soft tissue margins may be distorted by pathological processes, usually masses, that otherwise would be hidden in the mediastinum.
- An enormous amount of information about the mediastinum can be extracted from plain films; the key is a thorough knowledge of anatomical relationships and how structures are likely to project on a radiograph.
- Use of cross-sections from CT and MRI will supplement this section.
- Understand on plain films the mediastinum projects as a water density surrounded by the two air filled lungs and intersected(橫斷面)by the air filled trachea and major bronchi.
- The interfaces of these air-soft tissue margins may be distorted by pathological processes, usually masses, that otherwise would be hidden in the mediastinum.
- An enormous amount of information about the mediastinum can be extracted from plain films; the key is a thorough knowledge of anatomical relationships and how structures are likely to project on a radiograph.
- Use of cross-sections from CT and MRI will supplement this section.
- Understand on plain films the mediastinum projects as a water density surrounded by the two air filled lungs and intersected(橫斷面)by the air filled trachea and major bronchi.
- The interfaces of these air-soft tissue margins may be distorted by pathological processes, usually masses, that otherwise would be hidden in the mediastinum.
* Aortopulmonary window
Lateral landmarks on chest radiographs
Although it is not uncommon to find the lateral chest film displayed with the body either looking left or right, depending on which side of the patient was closest to the film, it is most sensible to present the lateral the film always in some fixed manner to the viewer so that consistent visual pattern recognition can be achieved. A favored direction is as if the patient were being viewed through the left lateral chest wall, so that the image appears as if the patient is facing the viewer's left.
This film orientation provides an assessment of the overall heart size which should show a space anteriorly below the sternum if the
right cardiac chambers are not enlarged. The dome of the diaphragm will appear convex upward.
- The dome that can be seen to extend most anteriorly is identified as the right diaphragm.
- The left diaphragmatic dome merges with undersurface of the heart, a tissue of the same density, and therefore tends to disappear anteriorly. Another marker of the left diaphragm is the gastric air bubble which should most closely approach the boundary of the left diaphragm if the patient has normal cardiac situs.
The trachea should be readily visible to the carina.
Where there are slight amounts of fluid in the
- Although there are several methods of dividing the mediastinum into regions, this program will continue with the system taught in gross anatomy.
- The superior mediastinum begins at the root of the neck and ends caudally at a line drawn between T-4 vertebrae and the sternomanubrial junction. Usually that line skims(在...表面凝結) the top of the aortic arch. The area between this line and the diaphragm is further divided into three regions, anterior, middle, and posterior.
- Basically, the heart and pericardium form the middle section, everything anterior to the heart is the anterior region, and everything posterior to the heart back to the spine is the posterior mediastinum.
Check patient name, position, technical quality.
Initial survey
Soft tissue including breast, chest wall, companion(同伴,伴侶;朋友) shadow.
4. Review soft tissues and skeletal structures of shoulder girdles and chest wall.
5. Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc.
6. Review soft tissues and spine of neck.
7. Review spine and rib cage: check alignment(隊列,一直線), disc space narrowing, lytic or blastic regions, etc.
8. Review mediastinum:
- overall size and shape
- trachea: position
- margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle
- lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic
- retrosternal clear space
Check patient name, position, technical quality.
Initial survey
Soft tissue including breast, chest wall, companion(同伴,伴侶;朋友) shadow.
4. Review soft tissues and skeletal structures of shoulder girdles and chest wall.
5. Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc.
6. Review soft tissues and spine of neck.
7. Review spine and rib cage: check alignment(隊列,一直線), disc space narrowing, lytic or blastic regions, etc.
8. Review mediastinum:
- overall size and shape
- trachea: position
- margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle
- lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic
- retrosternal clear space
* Aortopulmonary window
* Aortopulmonary window
Strip(條,帶;細長片)
- Seen PA(AP) view only, and depending how laterally it projects, its right edge may cast a subtle line on the film.
- Sometimes the entire edge is seen, often only a portion, but it should not bulge into the lung with a convex border.
Normal- < 5 mm, usually 2-3 mm.
Important marker for subtle(精妙的) adenopathy.
3. The distal end of the stripe is formed by the azygous vein, and if the vein is distended, that portion of the stripe may normally be up to 1 cm wide.
4. The medial margin of the stripe is the air-soft tissue interface along the right mucosal surface of the trachea.
5. The outer margin of the stripe begins around the level of the medial end of the clavicle and is formed by the plural surface of the right upper lobe (RUL) against the mediastinum.
6. The only structures normally at that level to give soft tissue density between the air filled trachea and the RUL are the right wall of the trachea, nerves, some fat, lymph nodes, and pleura of the RUL.
7. The stripe ends where the RUL bronchus sweeps under the azygous vein as the latter arches anteriorly to empty into the posterior surface of the SVC.
Tomography-
Purpose: Body planes free of superimposition(重疊;添上).
ABC+ABC +ABC +ABC +ABC +ABC +ABCABBBBBBBC
The normal width is 1.0-1.5 cm. Its inner margin is the air mucosal interface along the left mucosal surface of the trachea, and its outer margin is the interface of the medial aspect of the left upper lobe against the lateral margin of the left subclavian artery.
You usually will pick up the outer edge of the stripe at the level of the clavicle and will be able to follow it down to the bulge of the aortic arch.
Sometimes(+) on the frontal view
Plural edge parallel to the lateral margins of the vertebral bodies.
Edge > millimeters beyond the vertebral bodies, and should not be lumpy or bulging. (The paraspinal edges are not visible on this image.)
- This is seen on the forntal view only and is formed by the right lower lobe where it meets the portion of the mediastinum containing the esophagus and the azygous vein.
- It usually overlies the thoracic spine, at or near the midline, and is usually fairly straight, vertically.
- If it bulges convex toward the lung, be suspicious of a mediastinal mass, usually subcarinal lymph nodes or an enlarged left atrium.
- An enormous amount of information about the mediastinum can be extracted from plain films; the key is a thorough knowledge of anatomical relationships and how structures are likely to project on a radiograph.
- Use of cross-sections from CT and MRI will supplement this section.
- Understand on plain films the mediastinum projects as a water density surrounded by the two air filled lungs and intersected(橫斷面)by the air filled trachea and major bronchi.
- The interfaces of these air-soft tissue margins may be distorted by pathological processes, usually masses, that otherwise would be hidden in the mediastinum.
1. Superimposed on the frontal view.
2. The major structure is the heart.
3. Pericardium and heart is inseparable on plain film views.
4. Review the heart for overall size and shape.
5. Rough yardstick(衡量標準,) for size on the frontal film is the ratio of the widest diameter of the heart to the widest width of the thoracic cage as measured from inner aspect of rib to rib.
6. This cardiac-thoracic ratio should be less than 50% (see inset for a graphic illustration of ratio measurements).
7. Look carefully for calcifications, pneumopericardium, pneumomediastinum, sutures, prosthetic valves etc., that you may have overlooked on the general survey of the entire mediastinum.
Gross anatomy - coronal section of the chest
1.Try tracking
Root
Distal descending aorta.
2. Young adult - hidden in the mediastinum
Older - swing to the right to cast a soft tissue bulge.
3. The arch should always be seen, make sure it is to the left of the distal trachea and actually pushes the distal trachea slightly to the right.
4. Check for aortic calcifications and size. The left lateral border of the descending aorta abuts(鄰接;毗連;緊靠) the left lung (column of dots on the pt's. left, on the annotated(有註釋的) image). [The other column of dots is not the right side of the aorta, but instead is the paraesophageal line - see below.]
5. On the lateral view the aorta is usually not seen.
- On the frontal view, the only part of the main pulmonary artery seen is the left lateral border where it meets the left lung. It can be relatively straight or convex (most commonly in young females).
- When convex(凸面的), it forms a "middle mogul(大人物)" just above the heart.
- The upper "mogul" is the aortic knob, the lower mogul is the left ventricle.
- The left pulmonary artery is directly behind the main pulmonary artery, and is visible on frontal films as a branching structure
Normal PA view of the chest. This is the most common presentation of an otherwise uncomplicated pulmonary embolus.
- Double check area This is another area radiologists for subtle mediastinal masses. It is seen on the frontal view (line of white dots) and is formed by a portion of the upper lobe sitting in the space immediately lateral to the area between the aortic arch and left pulmonary artery (remember ligamentum arteriosum and left recurrent laryngeal nerve?).
- The AP window should have a concave or straight border. If there is a mediastinal mass in the AP window region, the lung will be pushed laterally and the border becomes convex.
Lateral view is your great chance to look at the lung in the posterior costophrenic recess and anterior mediastinum.
1. Soft tissues
look again at overall amount, then check for the following: calcifications, obvious mass effect, abnormal air collections (called subcutaneous emphysema), and soft tissue companion shadow for the clavicle (this is a normal but variable finding).
2. Bones
look at each bone for the following items (notice again the progression from general to increasingly specific detail throughout the review).
If your anatomic memory is hazy, refresh with a review of the gross anatomy radiology review program.
- Look for overall thickness, subcutaneous emphysema, calcification.
- Look for sharp, distinct muscle fat planes as illustrated on the annotated image (dots).
- In males and females, some asymmetry can occur from standing with unequal pressure against the film holder.
- Notice how the apparent lung density changes from the lung area covered by the soft tissue of the breast to the lung area inferior to the breast.
- The visibility of structures is highly variable but look for the following even if you see very few on any one exam.
- Gastric and bowel gas - Is amount and location normal?
- Check for organ size of liver, spleen, and kidneys if visible.
- Check for free peritoneal air - Remember position of patient will change location of free air.
- Look for calcifications and masses - can they be localized to a specific structure.
Check patient name, position, technical quality.
Initial survey
Soft tissue including breast, chest wall, companion(同伴,伴侶;朋友) shadow.
4. Review soft tissues and skeletal structures of shoulder girdles and chest wall.
5. Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc.
6. Review soft tissues and spine of neck.
7. Review spine and rib cage: check alignment(隊列,一直線), disc space narrowing, lytic or blastic regions, etc.
8. Review mediastinum:
- overall size and shape
- trachea: position
- margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle
- lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic
- retrosternal clear space