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Jennifer Lim-Dunham, MD Arcot J. Chandrasekhar, M.D. December 10, 2014
CXR Review TCM2 Jennifer Lim-Dunham, MD Arcot J. Chandrasekhar, M.D. December 10, 2014 LOYOLA UNIVERSITY MEDICAL CENTER Loyola University Chicago LOYOLA UNIVERSITY MEDICAL CENTER Loyola University Chicago
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Is this a PA or AP film? PA film AP film
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AP Supine film Scapula (red arrow) projecting overlapping lung fields Clavicles projecting above the inlet of thorax. No air fluid levels in abdomen or chest Underpenetrated (too white, not enough xrays going through the body) PA Upright film Scapula does not overlap lung fields Clavicles projecting over upper chest Air fluid levels in abdomen or chest Penetration/exposure normal
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Is this film centered? Yes No
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Not centered. Patient rotated to his right
Draw a line along the central spinous process Draw a line along the medial end of clavicles Is the distance between medial end of clavicle and midline equal? Right ribs longer than left
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Image Characteristics
PA or AP Centered or rotated Degree of penetration Degree of inspiration
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What is your answer? Cavity Mass Consolidation Pneumothorax
Pleural effusion
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Consolidation Triangular density Air bronchogram (red arrows)
No loss of lung volume (midline). Distinguishes consolidation/pneumonia from atelectasis Unrecognizable vasculature R upper lobe (Silhouette sign) Know that these are the hallmarks of alveolar or airspace disease or consolidation, usually from pneumonia
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Roentgen Signs Silhouette Sign
Loss of silhouette indicates that there is airless (lung or mass or fluid) adjacent to that silhouette. Know the loss of which heart borders correspond to which lobes. (“Consolidation”)
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What is your assessment?
Consolidation Atelectasis Congestion Mass Pleural effusion
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Resorptive Atelectasis
Triangular density Loss of lung volume. Minor/horizontal fissure is elevated (arrows). Unrecognizable vasculature Right upper lobe (Silhouette sign) Compensatory hyperinflation Know types of atelectasis: resorptive, relaxation, adhesive. Know which fissures become elevated in atelectasis (“Atelectasis”)
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What is your choice? Mass Consolidation Congestion Cavity
Diffuse interstitial disease
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Cavitating Mass Hole in lung Wall characteristics
Lumen characteristics Contents Number Location Cavity signifies lung abscess or necrotic mass or tumor
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What is your diagnosis? Pneumothorax Pleural effusion Consolidation
Atelectasis Congestion
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Pleural Effusion Homogenous density Dependent position
Loss of diaphragm and costophrenic angle (Silhouette sign) Slanting meniscus Mediastinal shift to contralateral side
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Unilateral White Out Pleural Effusion
Mediastinal shift to contralateral side Larger hemithorax
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Your choice? Diffuse alveolar disease Diffuse interstitial disease
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Acute Diffuse Alveolar Disease
Soft fluffy densities Butterfly distribution Air bronchogram Diffuse white out Acute vs. chronic
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Acute diffuse alveolar disease You choice?
Pulmonary edema Pulmonary hemorrhage Influenza Adult respiratory distress syndrome
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Acute LV Failure: Pulmonary Edema
Diffuse white out Soft fluffy densities Butterfly distribution Air bronchogram (arrowheads) A: ET tube, B: NG tube, C: Central line
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Chronic Heart Failure Vascular Phase
First phase: Cephalization
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Congestive Heart Failure Interstitial Phase
Second phase. Kerley B lines
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Congestive Heart Failure Alveolar Phase
Third phase Basal densities Pleural effusions Hilar fullness Peribronchial edema
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What is your diagnosis? Diffuse alveolar disease
Diffuse interstitial disease
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Diffuse Interstitial Disease Miliary Tuberculosis
Reticulonodular Ground glass / dirty lungs Kerley lines Miliary nodules Honeycombing These terms are used to described specific types of intersititial disease Distinguish interstitial from airspace disease
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What is your impression?
Atelectasis Pneumothorax Consolidation Lung mass
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Pneumothorax Air in pleural cavity Visible lung margin
Relaxation atelectasis Mediastinal shift to contralateral side Enlarged hemithorax Deep costophrenic sulcus
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Mediastinal Widening Supracardiac Vessel / Anterior mediastinal Area
Mediastinal nodes Mediastinal mass Aortic aneurysms
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Tubes and Lines Learn to identify them.
Make sure that the tip is in the right place. There are no complications from their placement. ET tube NG tube Central line (PICC, subclavian) Swan Ganz catheter Aortic balloon pump IV tubing, oxygen tubing, EKG leads Artifacts Foreign bodies (“Tubes and lines”)
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COPD (chronic bronchitis and emphysema)
Hyperinflated lungs Flattened diaphragm (yellow arrow) Retrosternal air (red arrow) Hyperlucent lungs Blebs (white arrow) in emphysema only Avascular zones
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