TIPS AND PITFALLS IN PLAIN FILM INTERPRETATION

Transcription

1 TIPS AND PITFALLS IN PLAIN FILM INTERPRETATION Dr Philip Touska MBBS, BMedSci(Hons), MRCS, DO-HNS, FRCR Radiology Fellow Guy s & St Thomas Hospitals

2 LEARNING OBJECTIVES Where do we go wrong? Common pitfalls Brief recap of basics Technique, adequacy and anatomy Cases Interactive session

3 Errare humanum est Seneca WHERE CAN WE GO WRONG? Technical E.g. Rotation, limits of technique Perceptive Missed finding, distraction by obvious abnormalities Interpretative Misdiagnosis

4 SYSTEMATIC APPROACH AABCDEF Adequacy (technical quality) Airways Breathing (lungs) Circulation (heart and vessels & hila) Densities (bones/prostheses/surgical clips) Edges (incl. skin/breasts) Fundus of stomach (gastric bubble/under the diaphragm)

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6 PA radiograph = outpatients and some inpatients AP radiograph = most inpatients Magnification ~22% Sources: Fundamentals of radiography. (1) (2) Young-Cheol J et al. IJST 2015.

7 Leftward rotation = slightly enlarged cardiac silhouette

8 CHEST RADIOGRAPH

9 Airway Bronchi

10 Lungs and fissure

11 Left subclavian a. SVC Azygous vein Pulmonary veins Pulmonary arteries Thoracic aorta RA, LAA, LV

12 Scapula Ribs Vertebrae Gastric bubble

13 SYSTEMATIC APPROACH ABDO X Air (in right place) Bowel (wall thickness) Dense structures (bones/calcification) Organs external object/artefacts

14 Gastric bubble Caecum Ascending colon Transverse colon Descending colon Sigmoid colon & rectum Liver L kidney R psoas muscle

15 INTERACTIVE CASES Fingers on buzzers please

16 43 year old SOB

17 WHAT IS THE DIAGNOSIS? 1. Left upper lobe collapse 2. Upper mediastinal mass 3. Aortic rupture 4. Lymphadenopathy

18 37 year old chest pain & pyrexia

19 WHAT IS THE MAIN DIAGNOSIS? 1. Right lower lobe consolidation 2. Middle lobe consolidation 3. Primary lung malignancy

20 51 year old SOB and cough

21 WHERE IS THE MAIN ABNORMALITY? 1. Right upper zone 2. Left upper zone 3. Right middle zone 4. Left middle zone 5. Right lower zone 6. Left lower zone

22 48 year old chest pain

23 WHERE IS THE MAIN ABNORMALITY? 1. Right upper zone 2. Left upper zone 3. Right middle zone 4. Left middle zone 5. Right lower zone 6. Left lower zone

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26 65 year old SOB and cough

27 WHAT IS THE DIAGNOSIS? 1. Normal study 2. Tuberculosis 3. Primary lung cancer 4. Upper lobe collapse

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29 53 year old SOB and cough

30 WHAT IS THE NATURE OF THE ABNORMALITY? 1. Pulmonary arterial hypertension 2. Lymphadenopathy 3. Primary lung cancer

31 38 year old acute chest pain

32 WHAT IS THE DIAGNOSIS? 1. Normal study 2. Pneumomediastinum/pneumopericardium

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35 78 year old confused NG tube check

36 WHERE IS THE ABNORMALITY? 1. Airway 2. Lung parenchyma 3. Hila 4. Below the diaphragm

37 82 year old cough and SOB

38 WHAT IS THE DIAGNOSIS? 1. Left upper lobe collapse 2. Left lower lobe pneumonia 3. Left lower lobe collapse

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40 56 year old - chest pain

41 HOW MANY ABNORMALITIES? 1. One 2. Two 3. Three

42 34 year old acute chest pain & cough

43 WHAT IS THE DIAGNOSIS? 1. Pneumonia 2. Acute cardiac failure 3. Sickle crisis 4. Hyperparathyroidism

44 47 year old SOB

45 WHAT IS THE DIAGNOSIS? 1. Acute pulmonary oedema 2. Incidental lung cancer 3. Combination of above

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47 21 year old chest pain and SOB

48 WHAT IS THE DIAGNOSIS? 1. Lymphoma 2. Pneumonia 3. Tuberculosis

49 60 year old chest pain

50 WHERE IS THE ABNORMALITY? 1. Airway 2. Lungs 3. Mediastinum 4. Bones

51 19 year old chest pain and SOB

52 WHERE IS THE ABNORMALITY? 1. Right upper zone 2. Left upper zone 3. Right middle zone 4. Left middle zone

53 84 year old abdominal pain

54 IS THERE AN ACUTE ABNORMALITY ON THIS FILM? 1. Yes 2. No

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57 WHAT IS THE DIAGNOSIS? 1. Small bowel obstruction 2. Sigmoid volvulus 3. Caecal volvulus 4. Perforation

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61 45 year old abdominal pain & PR bleeding

62 WHAT IS THE DIAGNOSIS? 1. Infective colitis 2. Ischaemia 3. Inflammatory bowel disease 4. Any of the above

63 56 year old abdominal pain

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65 57 year old abdominal pain

66 SUMMARY AVOIDING PITFALLS Poor/limited technique Rotation, limited inspiration, AP projection, limitations of the technique Perceptive errors Missed finding, distraction by obvious abnormalities Interpretative errors Misdiagnosis Solution: Know the limitations of the study/technique consider other e.g. CT tekn Solution: Use a systematic approach; avoid satisfaction of search Solution: Consider alternatives, phone a friend!

67 THANK YOU

68 SILHOUETTES

69 WHAT TO LOOK FOR? 1. Bowel Is it small bowel or large bowel? Is it dilated? 3, 6, 9 cm rule Does it look normal? 2. Is there air where it shouldn t be? - Perforation 3. Densities (stones/surgical clips/foreign bodies) 4. Anything else? Bones/soft tissues/organs/masses

70 SMALL BOWEL Characteristics Often invisible under normal circumstances Position: central Size: small (max 3cm diameter) Valvulae conniventes (uninterupted lines)

71 LARGE BOWEL Characteristics Usually visible under normal circumstances faecal shadowing Position: peripheral (note: sigmoid & transverse colons are floppy may be central) Size: large (max diameters: 6cm transverse colon, 9cm caecum) Haustra (interrupted lines)

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80 39 year old SOB and cough

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