Interpreting Chest X-Rays

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Presentation transcript:

Interpreting Chest X-Rays iCollaborative Presentation Flint Wang, MD Assistant Professor of Clinical Medicine Section of Hospital Medicine University of Pennsylvania

Objectives Develop a framework for reading chest X-rays Identify anatomic landmarks Recognize and describe common findings Recognize and describe “Can’t Miss” diagnoses Small group practice

Agenda Anatomy of CXRs Framework for Reading Lines/Tubes/Drains PIR ABCD Lung Parenchyma Can’t Miss Diagnoses Small Group Practice

ANATOMY OF CHEST X-RAYS FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ANATOMY OF CHEST X-RAYS FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ANATOMY OF CHEST X-RAYS 1. Trachea ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ANATOMY OF CHEST X-RAYS 1. Trachea ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ANATOMY OF CHEST X-RAYS Trachea Hilum/Hila ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ANATOMY OF CHEST X-RAYS Trachea Hilum/Hila ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ANATOMY OF CHEST X-RAYS Trachea Hilum/Hila Lungs ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ANATOMY OF CHEST X-RAYS Trachea Hilum/Hila Lungs ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ANATOMY OF CHEST X-RAYS Trachea Hilum/Hila Lungs Diaphragm ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ANATOMY OF CHEST X-RAYS Trachea Hilum/Hila Lungs Diaphragm ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ANATOMY OF CHEST X-RAYS Trachea Hilum/Hila Lungs Diaphragm Heart ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ANATOMY OF CHEST X-RAYS Trachea Hilum/Hila Lungs Diaphragm Heart ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ANATOMY OF CHEST X-RAYS Trachea Hilum/Hila Lungs Diaphragm Heart ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ANATOMY OF CHEST X-RAYS Trachea Hilum/Hila Lungs Diaphragm Heart Aortic notch ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ANATOMY OF CHEST X-RAYS Trachea Hilum/Hila Lungs Diaphragm Heart Aortic notch ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ANATOMY OF CHEST X-RAYS Trachea Hilum/Hila Lungs Diaphragm Heart Aortic notch Ribs ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ANATOMY OF CHEST X-RAYS Trachea Hilum/Hila Lungs Diaphragm Heart Aortic notch Ribs ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ANATOMY OF CHEST X-RAYS Trachea Hilum/Hila Lungs Diaphragm Heart Aortic notch Ribs Scapula ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ANATOMY OF CHEST X-RAYS Trachea Hilum/Hila Lungs Diaphragm Heart Aortic notch Ribs Scapula ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ANATOMY OF CHEST X-RAYS Trachea Hilum/Hila Lungs Diaphragm Heart Aortic notch Ribs Scapula Breasts ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ANATOMY OF CHEST X-RAYS Trachea Hilum/Hila Lungs Diaphragm Heart Aortic notch Ribs Scapula Breasts ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ANATOMY OF CHEST X-RAYS Trachea Hilum/Hila Lungs Diaphragm Heart Aortic notch Ribs Scapula Breasts Bowel gas ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

LET’S REVIEW ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ANATOMY OF CHEST X-RAYS 1. Trachea ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ANATOMY OF CHEST X-RAYS Trachea Hilum/Hila ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ANATOMY OF CHEST X-RAYS Trachea Hilum/Hila Lungs ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ANATOMY OF CHEST X-RAYS Trachea Hilum/Hila Lungs Diaphragm ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ANATOMY OF CHEST X-RAYS Trachea Hilum/Hila Lungs Diaphragm Heart ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ANATOMY OF CHEST X-RAYS Trachea Hilum/Hila Lungs Diaphragm Heart Aortic notch ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ANATOMY OF CHEST X-RAYS Trachea Hilum/Hila Lungs Diaphragm Heart Aortic notch Ribs ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ANATOMY OF CHEST X-RAYS Trachea Hilum/Hila Lungs Diaphragm Heart Aortic notch Ribs Scapula ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ANATOMY OF CHEST X-RAYS Trachea Hilum/Hila Lungs Diaphragm Heart Aortic notch Ribs Scapula Breasts ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ANATOMY OF CHEST X-RAYS Trachea Hilum/Hila Lungs Diaphragm Heart Aortic notch Ribs Scapula Breasts Bowel gas ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ONE MORE TIME, NO LINES ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ONE MORE TIME, NO LINES ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ONE MORE TIME, NO LINES ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ONE MORE TIME, NO LINES ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ONE MORE TIME, NO LINES ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ONE MORE TIME, NO LINES ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ONE MORE TIME, NO LINES ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ONE MORE TIME, NO LINES ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ONE MORE TIME, NO LINES ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ONE MORE TIME, NO LINES ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ONE MORE TIME, NO LINES ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

FRAMEWORK FOR READING CXRs Type of Film AP vs PA vs Lateral, Upright vs Decubitus Lines/Tubes/Drains PICC, Port, IJ, Subclavian lines, Cordis, Swan-Ganz Pacemaker, ICD, transvenous pacing leads, pacer pads ET/tracheostomy tube, chest tube, Dobhoff, NG tube Telemetry wires, gown buttons PIR: penetration, inspiration, rotation ABCDs: airway, bones, cardiac, diaphragm Lung parenchyma: Upper/upper, middle/lingula, lower/lower ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

FRAMEWORK FOR READING CXRs Type of Film AP vs PA vs Lateral, Upright vs Decubitus Lines/Tubes/Drains PICC, Port, IJ, Subclavian lines, Cordis, Swan-Ganz Pacemaker, ICD, transvenous pacing leads, pacer pads ET/tracheostomy tube, chest tube, Dobhoff, NG tube Telemetry wires, gown buttons PIR: penetration, inspiration, rotation ABCDs: airway, bones, cardiac, diaphragm Lung parenchyma: Upper/upper, middle/lingula, lower/lower ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

FRAMEWORK FOR READING CXRs Type of Film AP vs PA vs Lateral, Upright vs Decubitus Lines/Tubes/Drains PICC, Port, IJ, Subclavian lines, Cordis, Swan-Ganz Pacemaker, ICD, transvenous pacing leads, pacer pads ET/tracheostomy tube, chest tube, Dobhoff, NG tube Telemetry wires, gown buttons PIR: penetration, inspiration, rotation ABCDs: airway, bones, cardiac, diaphragm Lung parenchyma: Upper/upper, middle/lingula, lower/lower ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

FRAMEWORK FOR READING CXRs Type of Film AP vs PA vs Lateral, Upright vs Decubitus Lines/Tubes/Drains PICC, Port, IJ, Subclavian lines, Cordis, Swan-Ganz Pacemaker, ICD, transvenous pacing leads, pacer pads ET/tracheostomy tube, chest tube, Dobhoff, NG tube Telemetry wires, gown buttons PIR: penetration, inspiration, rotation ABCDs: airway, bones, cardiac, diaphragm Lung parenchyma: Upper/upper, middle/lingula, lower/lower ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

FRAMEWORK FOR READING CXRs Type of Film AP vs PA vs Lateral, Upright vs Decubitus Lines/Tubes/Drains PICC, Port, IJ, Subclavian lines, Cordis, Swan-Ganz Pacemaker, ICD, transvenous pacing leads, pacer pads ET/tracheostomy tube, chest tube, Dobhoff, NG tube Telemetry wires, gown buttons PIR: penetration, inspiration, rotation ABCDs: airway, bones, cardiac, diaphragm Lung parenchyma: Upper/upper, middle/lingula, lower/lower ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

FRAMEWORK FOR READING CXRs Type of Film AP vs PA vs Lateral, Upright vs Decubitus Lines/Tubes/Drains PICC, Port, IJ, Subclavian lines, Cordis, Swan-Ganz Pacemaker, ICD, transvenous pacing leads, pacer pads ET/tracheostomy tube, chest tube, Dobhoff, NG tube Telemetry wires, gown buttons PIR: penetration, inspiration, rotation ABCDs: airway, bones, cardiac, diaphragm Lung parenchyma: Upper/upper, middle/lingula, lower/lower ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

LET’S REVIEW Type of Film Lines/Tubes/Drains AP vs PA vs Lateral, Upright vs Decubitus Lines/Tubes/Drains PICC, Port, IJ, Subclavian lines, Cordis, Swan-Ganz Pacemaker, ICD, transvenous pacing leads, pacer pads ET/tracheostomy tube, chest tube, Dobhoff, NG tube Telemetry wires, gown buttons PIR: penetration, inspiration, rotation ABCDs: airway, bones, cardiac, diaphragm Lung parenchyma: Upper/upper, middle/lingula, lower/lower ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

LET’S REVIEW Type of Film Lines/Tubes/Drains AP vs PA vs Lateral, Upright vs Decubitus Lines/Tubes/Drains PICC, Port, IJ, Subclavian lines, Cordis, Swan-Ganz Pacemaker, ICD, transvenous pacing leads, pacer pads ET/tracheostomy tube, chest tube, Dobhoff, NG tube Telemetry wires, gown buttons PIR: penetration, inspiration, rotation ABCDs: airway, bones, cardiac, diaphragm Lung parenchyma: Upper/upper, middle/lingula, lower/lower ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

LET’S REVIEW Type of Film Lines/Tubes/Drains AP vs PA vs Lateral, Upright vs Decubitus Lines/Tubes/Drains PICC, Port, IJ, Subclavian lines, Cordis, Swan-Ganz Pacemaker, ICD, transvenous pacing leads, pacer pads ET/tracheostomy tube, chest tube, Dobhoff, NG tube Telemetry wires, gown buttons PIR: penetration, inspiration, rotation ABCDs: airway, bones, cardiac, diaphragm Lung parenchyma: Upper/upper, middle/lingula, lower/lower ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

LET’S REVIEW Type of Film Lines/Tubes/Drains AP vs PA vs Lateral, Upright vs Decubitus Lines/Tubes/Drains PICC, Port, IJ, Subclavian lines, Cordis, Swan-Ganz Pacemaker, ICD, transvenous pacing leads, pacer pads ET/tracheostomy tube, chest tube, Dobhoff, NG tube Telemetry wires, gown buttons PIR: penetration, inspiration, rotation ABCDs: airway, bones, cardiac, diaphragm Lung parenchyma: Upper/upper, middle/lingula, lower/lower ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

LET’S REVIEW Type of Film Lines/Tubes/Drains AP vs PA vs Lateral, Upright vs Decubitus Lines/Tubes/Drains PICC, Port, IJ, Subclavian lines, Cordis, Swan-Ganz Pacemaker, ICD, transvenous pacing leads, pacer pads ET/tracheostomy tube, chest tube, Dobhoff, NG tube Telemetry wires, gown buttons PIR: penetration, inspiration, rotation ABCDs: airway, bones, cardiac, diaphragm Lung parenchyma: Upper/upper, middle/lingula, lower/lower ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

LET’S REVIEW Type of Film Lines/Tubes/Drains AP vs PA vs Lateral, Upright vs Decubitus Lines/Tubes/Drains PICC, Port, IJ, Subclavian lines, Cordis, Swan-Ganz Pacemaker, ICD, transvenous pacing leads, pacer pads ET/tracheostomy tube, chest tube, Dobhoff, NG tube Telemetry wires, gown buttons PIR: penetration, inspiration, rotation ABCDs: airway, bones, cardiac, diaphragm Lung parenchyma: Upper/upper, middle/lingula, lower/lower ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

TYPE OF FILM Type of Film AP vs PA vs Lateral, Upright vs Decubitus ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP Type of Film AP film Says “mobile” or “portable” Beam goes anterior to posterior Heart and mediastinum look larger

TYPE OF FILM Type of Film AP vs PA vs Lateral, Upright vs Decubitus ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP Type of Film PA film Doesn’t say “mobile” or “portable” Beam goes posterior to anterior Heart and mediastinum look smaller

TYPE OF FILM Type of Film AP vs PA vs Lateral, Upright vs Decubitus ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP Type of Film Lateral film Beam goes laterally Can see retrocardiac opacity, pleural effusions, middle/inferior lobes

LINES, TUBES, AND DRAINS Lines/Tubes/Drains PICC, Port, IJ, Subclavian lines, Cordis, Swan-Ganz ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

LINES, TUBES, AND DRAINS Lines/Tubes/Drains PICC: mid-distal SVC or cavo-atrial junction (if RA or proximal SVC or upward to IJ then is malpositioned) ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

LINES, TUBES, AND DRAINS Lines/Tubes/Drains Port: reservoir and catheter ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

LINES, TUBES, AND DRAINS Lines/Tubes/Drains Internal Jugular: starts halfway between PICC and IJ insertion sites in chest wall ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

LINES, TUBES, AND DRAINS Lines/Tubes/Drains Internal Jugular: starts halfway between PICC and IJ insertion sites in chest wall ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

LINES, TUBES, AND DRAINS Lines/Tubes/Drains Subclavian: starts halfway between PICC and IJ insertion sites in chest wall ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

LINES, TUBES, AND DRAINS Lines/Tubes/Drains Cordis with Swan-Ganz: comes down like IJ line but extends to RA/RV then pulmonary artery ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

LINES, TUBES, AND DRAINS Lines/Tubes/Drains Pacemaker, ICD, transvenous pacing leads, pacer pads ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

LINES, TUBES, AND DRAINS Lines/Tubes/Drains Pacemaker: can be single or dual chamber, leads are thinner ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

LINES, TUBES, AND DRAINS Lines/Tubes/Drains ICD (implantable cardiac defibrillator): larger chest wall device, thick coils instead of thinner pacing leads ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

LINES, TUBES, AND DRAINS Lines/Tubes/Drains Transvenous pacing wires: same as pacemaker but no device and comes through IJ ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

LINES, TUBES, AND DRAINS Lines/Tubes/Drains Pacer pads: two locations in shape of a fly swatter ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

LINES, TUBES, AND DRAINS Lines/Tubes/Drains Endotracheal tube, tracheostomy, chest tube, Dobhoff, NG tube ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

LINES, TUBES, AND DRAINS Lines/Tubes/Drains Endotracheal tube: goal is 2-3cm above carina (upside down V shape where splits into left/right bronchus) ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP BAD

LINES, TUBES, AND DRAINS Lines/Tubes/Drains Tracheostomy: goal is 2-3cm above carina (upside down V shape where splits into left/right bronchus) ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

LINES, TUBES, AND DRAINS Lines/Tubes/Drains Chest tube: just like ET tube can see both sides ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

LINES, TUBES, AND DRAINS Lines/Tubes/Drains Dobhoff/NG tube: should end in stomach, if malpositioned can end up in lungs and cause PTX ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP BAD

LINES, TUBES, AND DRAINS Lines/Tubes/Drains Telemetry wires, gown buttons ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

LINES, TUBES, AND DRAINS Lines/Tubes/Drains Telemetry wires ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

LINES, TUBES, AND DRAINS Lines/Tubes/Drains Gown buttons: shape of button near shoulders ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

PENETRATION, INSPIRATION, ROTATION Should be able to see thoracic spine over heart If underpenetrated, then obscures diaphragms and pulmonary vasculature appears more pronounced ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP UNDERPENETRATED

PENETRATION, INSPIRATION, ROTATION Want to see 9-10 ribs, if less then pulm vasculature more prominent ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

PENETRATION, INSPIRATION, ROTATION Are the medial ends of the clavicles equidistant from the midline spinous processes? ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ABCDs ABCDs: Airway: trachea midline? Bones: obvious fractures? Cardiac: can you see the heart borders clearly? Especially the right (pt’s right, image left) heart border where the right middle lobe is? Diaphragm: can you see them or is there an effusion? Hyperinflated lungs? ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ABCDs ABCDs: Airway: trachea midline? ANATOMY FRAMEWORK LINES PIR LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ABCDs ABCDs: Bones: humerus/clavicle/rib fracture? Lytic lesions? ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ABCDs ABCDs: Bones: humerus/clavicle/rib fracture? Lytic lesions? ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ABCDs ABCDs: Cardiac: can you see the borders esp pt’s right heart border? (location of RML pneumonias) ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ABCDs ABCDs: Cardiac: RML is closest to right heart border (rather than inferior lobe), this suggests a RML pneumonia ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ABCDs ABCDs: Diaphragm: look for pleural effusion and hyperinflation (COPD) ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

ABCDs ABCDs: Diaphragm: look for pleural effusion and hyperinflation (COPD) ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

COMMON LUNG DIAGNOSES Pneumonia: lobar Infiltrate/haziness localized to one lobe 1st image: RUL PNA, 2nd image: RML PNA ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

COMMON LUNG DIAGNOSES Pneumonia: lobar Infiltrate/haziness localized to one lobe 1st image: RLL PNA, 2nd image: LUL PNA ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

COMMON LUNG DIAGNOSES Pneumonia: lobar Infiltrate/haziness localized to one lobe 1st image: LLL PNA ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

COMMON LUNG DIAGNOSES Atelectasis Looks similar to pneumonia but trachea pulled toward the infiltrate ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

COMMON LUNG DIAGNOSES Pneumonia: multifocal Infiltrate/haziness/opacities in multiple lobes ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

COMMON LUNG DIAGNOSES ARDS Looks like multifocal pneumonia but with other ARDS criteria: non-cardiogenic, low PaO2/FiO2 ratio ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

COMMON LUNG DIAGNOSES COPD Hyperinflation: many ribs, flattened diaphragms ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

COMMON LUNG DIAGNOSES Pleural effusion Obscured diaphragm, can do lateral or decubitus film ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

COMMON LUNG DIAGNOSES Note that an infiltrate can be pneumonia, atelectasis, or a pleural effusion Atelectasis is collapsed lung so pulls the trachea toward it Pneumonia and pleural effusion are space-occupying lesions so trachea is either midline or moves away from it ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

COMMON LUNG DIAGNOSES Pulmonary edema Kerley B lines (lines perpendicular to chest wall extending past 2/3 of way outward), prominence of pulmonary vasculature ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

COMMON LUNG DIAGNOSES Pulmonary edema Kerley B lines (lines perpendicular to chest wall extending past 2/3 of way outward), prominence of pulmonary vasculature ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

COMMON LUNG DIAGNOSES Interstitial Pulmonary Fibrosis Reticular (lines) opacities throughout ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

COMMON LUNG DIAGNOSES Cystic fibrosis Bronchiectasis (looks like holes with white rim) and hyperinflation ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

COMMON LUNG DIAGNOSES Lung Masses Starts as nodules that need to be followed up ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

CAN’T MISS DIAGNOSES Don’t miss these (surgical emergencies): Pneumothorax (air in pleural space) Pneumomediastinum (air in mediastinum) Pneumoperitoneum (air in peritoneum) Aortic dissection ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

CAN’T MISS DIAGNOSES Pneumothorax: Absence of lung markings ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

CAN’T MISS DIAGNOSES Pneumothorax: Absence of lung markings ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

CAN’T MISS DIAGNOSES Pneumo-mediastinum: See border with air underneath it surrounding heart ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

CAN’T MISS DIAGNOSES Pneumo-peritoneum: See in upright CXR below diaphragm ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

CAN’T MISS DIAGNOSES Aortic Dissection: See in upright CXR below diaphragm ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

QUICK REVIEW ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

QUICK REVIEW ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

QUICK REVIEW Type of Film Lines/Tubes/Drains AP vs PA vs Lateral, Upright vs Decubitus Lines/Tubes/Drains PICC, Port, IJ, Subclavian lines, Cordis, Swan-Ganz Pacemaker, ICD, transvenous pacing leads, pacer pads ET/tracheostomy tube, chest tube, Dobhoff, NG tube Telemetry wires, gown buttons PIR: penetration, inspiration, rotation ABCDs: airway, bones, cardiac, diaphragm Lung parenchyma: Upper/upper, middle/lingula, lower/lower ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

QUICK REVIEW Penetration Should be able to see thoracic spine over heart If underpenetrated, then obscures diaphragms and pulmonary vasculature appears more pronounced ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

QUICK REVIEW Inspiration Want to see 9-10 ribs, if less then pulm vasculature more prominent ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

QUICK REVIEW Rotation Are the medial ends of the clavicles equidistant from the midline spinous processes? ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

QUICK REVIEW ABCDs: Airway: trachea midline? Bones: obvious fractures? Cardiac: can you see the heart borders clearly? Especially the right (pt’s right, image left) heart border where the right middle lobe is? Diaphragm: can you see them or is there an effusion? Hyperinflated lungs? ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

QUICK REVIEW ABCDs: Airway: trachea midline? ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

QUICK REVIEW ABCDs: Bones: humerus/clavicle/rib fracture? Lytic lesions? ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

QUICK REVIEW ABCDs: Cardiac: can you see the borders esp pt’s right heart border? (location of RML pneumonias) ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

QUICK REVIEW ABCDs: Cardiac: RML is closest to right heart border (rather than inferior lobe), this suggests a RML pneumonia ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

QUICK REVIEW ABCDs: Diaphragm: look for pleural effusion and hyperinflation (COPD) ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

QUICK REVIEW ABCDs: Diaphragm: look for pleural effusion and hyperinflation (COPD) ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP QUICK REVIEW QUICK REVIEW

COMMON LUNG DIAGNOSES Pneumonia: lobar Infiltrate/haziness localized to one lobe 1st image: RUL PNA, 2nd image: RML PNA ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

COMMON LUNG DIAGNOSES Pneumonia: lobar Infiltrate/haziness localized to one lobe 1st image: RLL PNA, 2nd image: LUL PNA ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

COMMON LUNG DIAGNOSES Pneumonia: lobar Infiltrate/haziness localized to one lobe 1st image: LLL PNA ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

COMMON LUNG DIAGNOSES Atelectasis Looks similar to pneumonia but trachea pulled toward the infiltrate ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

COMMON LUNG DIAGNOSES Pneumonia: multifocal Infiltrate/haziness/opacities in multiple lobes ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

COMMON LUNG DIAGNOSES ARDS Looks like multifocal pneumonia but with other ARDS criteria: non-cardiogenic, low PaO2/FiO2 ratio ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

COMMON LUNG DIAGNOSES COPD Hyperinflation: many ribs, flattened diaphragms ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

COMMON LUNG DIAGNOSES Pleural effusion Obscured diaphragm, can do lateral or decubitus film ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

COMMON LUNG DIAGNOSES Note that an infiltrate can be pneumonia, atelectasis, or a pleural effusion Atelectasis is collapsed lung so pulls the trachea toward it Pneumonia and pleural effusion are space-occupying lesions so trachea is either midline or moves away from it ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

COMMON LUNG DIAGNOSES Pulmonary edema Kerley B lines (lines perpendicular to chest wall extending past 2/3 of way outward), prominence of pulmonary vasculature ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

COMMON LUNG DIAGNOSES Pulmonary edema Kerley B lines (lines perpendicular to chest wall extending past 2/3 of way outward), prominence of pulmonary vasculature ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

COMMON LUNG DIAGNOSES Interstitial Pulmonary Fibrosis Reticular (lines) opacities throughout ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

COMMON LUNG DIAGNOSES Cystic fibrosis Bronchiectasis (looks like holes with white rim) and hyperinflation ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

COMMON LUNG DIAGNOSES Lung Masses Starts as nodules that need to be followed up ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

CAN’T MISS DIAGNOSES Pneumothorax: Absence of lung markings ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

CAN’T MISS DIAGNOSES Pneumothorax: Absence of lung markings ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

CAN’T MISS DIAGNOSES Pneumo-mediastinum: See border with air underneath it surrounding heart ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

CAN’T MISS DIAGNOSES Pneumo-peritoneum: See in upright CXR below diaphragm ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

CAN’T MISS DIAGNOSES Aortic Dissection: See in upright CXR below diaphragm ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP

IN GROUPS ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP Type of film: PA upright (heart is small) Lines/tubes/drains: telemetry wires PIR: underpenetrated (can’t see thoracic spine clearly through heart), can see 10 ribs so good inspiration (needs 9-10), slightly rotated (clavicular heads not equidistant from spinous process in midline) ABCD: trachea midline, no rib/clavicular/scapular fractures seen here, cardiac: hard to see right heart border, diaphragm: can see both costophrenic angles Lungs: upper/upper: roughly equal, middle/lingula: hazy opacity (without clear borders) in right middle lobe area, lower/lower: slightly increased opacities in right base but moreso in the RML area Diagnosis: RML pneumonia, concern for aspiration

IN GROUPS ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP Type of film: AP upright (heart is larger) Lines/tubes/drains: sternotomy wires PIR: adequate penetration (can see thoracic spine through heart), can see 10 ribs so good inspiration (needs 9-10), slightly rotated (clavicular heads not equidistant from spinous process in midline) ABCD: trachea midline, no rib/clavicular/scapular fractures seen here, cardiac: can see all heart borders (pulmonary vasculature overlies right heart border), diaphragm: costophrenic/costodiaphragmatic angles are blunted Lungs: upper/upper: roughly equal, middle/lingula: roughly equal, lower/lower: opacities in both lower lobes just above diaphragm with blunting of costophrenic/costodiaphragmatic angles Diagnosis: bilateral small pleural effusions in a patient who has had a prior sternotomy

IN GROUPS ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP Type of film: PA upright (heart is smaller) Lines/tubes/drains: none PIR: adequate penetration (can see thoracic spine through heart), can see 10 ribs so good inspiration (needs 9-10), minimal rotation (clavicular heads roughly equidistant from spinous process in midline) ABCD: trachea midline, no rib/clavicular/scapular fractures seen here, cardiac: can see all heart borders, diaphragm: below diaphragm there is radio-lucency (black space) between the diaphragm and the organs underneath Lungs: upper/upper: roughly equal, middle/lingula: roughly equal, lower/lower: roughly equal Diagnosis: pneumoperitoneum, possibility of perforated gastric/duodenal ulcer, bowel perforation, air from bowel ischemia, post-PEG placement, post-laparotomy with air insufflation

IN GROUPS ANATOMY FRAMEWORK LINES PIR ABCDs LUNG DIAGNOSES CAN’T MISS DX SMALL GROUP Type of film: AP upright (heart is larger) Lines/tubes/drains: tracheostomy tube, telemetry wires, R IJ central line, left IJ catheter likely dialysis catheter because thicker PIR: underpenetrated (cannot see thoracic spine through heart), can see 9 ribs so good inspiration (needs 9-10), minimally rotated (clavicular heads not equidistant from spinous process in midline) ABCD: trachea midline, no rib/clavicular/scapular fractures seen here, cardiac: right heart border especially obscured, left heart border slightly obscured, cardiomegaly (extends laterally to the patient’s left moreso than would be expected), diaphragm: costophrenic/costodiaphragmatic angles are blunted or difficult to make out on both sides Lungs: upper/upper: interstitial opacities/”fluffiness” like splotches of paint on both sides moreso on the left side, middle/lingula: same as upper lobes but also with prominent vasculature over right heart border, lower/lower: same as upper lobes but with blunting of both costophrenic angles Diagnosis: congestive heart failure with pulmonary edema and pleural effusions

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