Chest Radiology: A Systematic Approach. Objectives. Basic Principles 10/2/2014

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1 Chest Radiology: A Systematic Approach Brian Wetzel ACNP Senior Instructor OHSU School of Medicine Department of Emergency Medicine Objectives A systematic approach to evaluating CXRs Identifying common pathology Accurately identifying several can t miss findings Basic Principles Plain film radiographs Depends on differences in radiographic density Air fat Tissue (water) Metal (bone) Border sharp & well defined 1

2 CXR: why get one? CXR is helpful in selected patients Dyspnea Cough Hemoptysis Fever Chest pain Thoracic trauma CXR: why get one? Clinical decision rules developed to predict positive predictors Absence of fever, tachycardia, tachypnea, adventitious breath sounds decrease the likelihood of infiltrate to <1% Use clinical judgment (Gennis, et al. Clinical criteria for the detection of pneumonia in adults: Guidelines for ordering CXR in the emergency dept. J Emerg Med. 1989). 2

3 Chest X ray Standard view is Posterior anterior (PA) view and LEFT lateral view Anterior posterior (AP) view used if pt too sick to stand Heart is further away (distorted) Systematic Approach Generally least to most interesting 1.Adequacy of the film 2. Upper abdomen 3.Thoracic cage (soft tissue and bones) 4.Mediastinal structures 5. Lungs a. each individually b. comparison of both 3

4 X ray Quality 1. Penetration thoracic spine is just visible 2. Alignment clavicles should be equal 3. Nothing is cut off entire chest visualized 4. Sufficient Inspiration 9 or 10 ribs seen Upper abdomen 1. Right hemi diaphragm slightly elevated 2. Gastric bubble 3. No free sub diaphragmatic air 4

5 Subdiaphramatic air Thoracic Cage Scapula Humerus Shoulder joint Clavicle Ribs Sternum Thoracic spine 5

6 Mediastinal Structures Mediastinum & heart Trachea (including carina) Mediastinal widening (> 8cm = pathology) Cardiac borders Cardiothoracic ratio (> ½ the width of the thorax = cardiomegaly) Hila Aortic knob Right atrium Left ventricle 6

7 Cardiothoracic ratio Lungs Right lung lobes Upper Middle Lower Left lung Upper Lingula (lower portion of upper lobe) Lower Lungs Lung markings well defined Compare for symmetry Various shades of Opacities Alveolar or interstitial process Volume loss Hyperinflation Pleural surfaces Effusion, pneumothorax 7

8 Aortic knob Right atrium Left ventricle Normal Chest X Ray 8

9 Case #1 53 y/o female c/o fever, productive cough, DOE, right sided pleuritic chest pain. No Pmhx, Soc. Hx smokes 38.5, 102, 20, 94%, 120/71 Scattered rales heard on the right 9

10 Case #2 60 y/o male c/o fevers, productive cough (no blood), pleuritic chest pain for 2 weeks. Alcohol binge; 14 pound weight loss Soc Hx: alcoholic, homeless PMHx: HIV not on ART VS 112/78 HR 110 RR 20 T 38 O2 sat 93% 10

11 Case #3 72 y/o male right sided CP worse over last several months, new onset dry, hacking cough, sputum blood streaked, (+) malaise Denies SOB, fever, recent URI symptoms 2 pack cigarettes per day for 40 years VS 37.2, HR 72, R 12, 135/85 92% Crackles right upper lung 11

12 Case #4 62 y/o female presents to clinic with c/o SOB at rest x 1 week. Productive cough. No hemoptysis. Recent URI. No fevers. Long smoking hx Exam: T 37, HR 105, BP 150/85, RR 24, O2 89% Expiratory wheezes with poor air movement 12

13 Case #5 29 y/o male left sided CP worse over last several days, no known trauma or overuse injury Denies SOB, fever, fatigue 1 pack cigarettes per day for 15 years VS 37.2, HR 105, R 12, 135/85 92% Diminished breath sounds left upper lung 13

14 Case #6 66 y/o female c/o progressively worsening SOB and cough over last several days with DOE, PND, and bilateral lower leg swelling Denies fever or recent illness Pmhx: MI 2 yrs ago VS 37.2, HR 105, R 18, 135/85 92% Bibasilar rales 14

15 Plain abdominal radiography Suspected perforation Obstruction Foreign body Plain abdominal radiography Abdominal series Supine & upright abdominal films Air fluid levels Dilated loops of bowel Upright chest Free air under the diaphragm Abdominal pain may have intrathoracic disorder Case Study Mrs. Obstruction 72 y/o female c/o 3 day hx of constipation, diffuse abdominal discomfort, bloating, and nausea Pmhx: recently tx d with vicodin s/p fall with foot fx VS 37.2, HR 90, R 18, 135/85 99% Mildly distended, diffusely tender abdomen 15

16 Extremity Films Trauma Fractures and dislocations Foreign Bodies Metal easily seen Glass +/ visualized Wood rarely seen Standard and Supplementary Views Shoulder Elbow Wrist Finger Standard View AP views: Internal & Ext rotation AP Lateral PA; Lateral Oblique Supplement View Y view of scapula Axillary view Oblique views (2) Olecranon view Scaphoid PA; Lateral Oblique Thumb PA; Lateral True AP 16

17 Upper Extremity Films Wrist and hand 1. Colles (distal radius) 2. Scaphoid 3. Boxer s (5 th metacarpal) Colles Fracture Scaphoid Fracture Common wrist injury Fall onto outstretched hand (typical) If missed, high risk of avascular necrosis 17

18 Boxer s Fracture Fracture of the 5 th metacarpal Maximal acceptable angulation is 40 degrees Suspect fight bite with any break in skin 18

19 Lower Extremity Fractures Ankle or Foot fractures 1. Jones fracture (transverse 5 th metatarsal) 2. Pseudojones (avulsion of 5 th MT) 3. Distal tibia/fibula fx s 4. Maisonneuve fractures 5. Lisfranc fractures Standard and Supplementary Views Standard View Supplement View Pelvis AP Judet Inlet & outlet Hip Knee Ankle Foot AP (pelvis) frog leg AP Lateral AP; Lateral Mortise AP; Lateral Oblique Cross-table lateral Oblique view Sunrise Notch view Oblique Calcaneal views Ottawa Knee Rules Patient s age 55 years or older Tenderness at head of the fibula Tenderness of the patella Inability to flex to 90 degrees Inability to bear weight for four steps both immediately and in the ED (Stiell IG, et al., Prospective validation of a decision rule for the use of radiography in acute knee injuries. JAMA, 1996) 19

20 Ottawa Ankle Rules Bone tenderness Posterior edge of either lateral or medial malleolus Tenderness at the anterior aspect of the distal fibula common in ankle sprains Midfoot Navicular Base of 5 th metatarsal Inability to bear weight Both immediately or in the ED Defined as ability to take 4 steps (even w/ limp) (Stiell, IG, et al., Decision rules for use of radiography in acute ankle injuries: Refinement and prospective validation. JAMA, 1993). Evaluating Ankle Films 1. AP View 2. Lateral View 3. Mortis 4. +/ Oblique 20

21 Metaphyseal Diaphyseal Junction (Jones) Fracture Fracture extends across 5 th metatarsal Mechanism: side to side motion (i.e. soccer/basketball players) High risk of nonunion due to blood supply 21

22 22

23 Salter Harris Classification How to present your case Describing a fracture 1. Clinical descriptors: age, gender, mechanism of injury, anatomic location, soft tissue involvement 2. Key physical exam findings: radiologic descriptors, type of imaging, anatomic location 3. Fracture pattern: relationship of fragments, physeal involvement, apophyseal disruption, joint involvement, soft tissue involvement 23

24 References Goodman, L.R. Felson s Principles of Chest Roentgenology. (2007) Third ed. W. B. Saunders Co. Google images Disseminated bronchioloalveolar cell carcinoma Cardiomyopathy 24

25 Pulmonary edema Community Acquired PNA 25

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