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![Page 1: 1 Pharos university faculty of Allied medical sciences Clinical Practice I (RSCP-201) Department of Radiological Sciences and Medical Imaging Technology.](https://reader030.fdocuments.in/reader030/viewer/2022032707/56649e4f5503460f94b46e98/html5/thumbnails/1.jpg)
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Pharos universityfaculty of Allied medical sciences
Clinical Practice I (RSCP-201) Department of Radiological Sciences and Medical
Imaging Technology
Prof. Dr. Hesham BadawyDr.Mohamed El Safwany
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Intended Learning Outcomes
The student should be able to learn how to perform adequate chest radiograph at the end of this lecture.
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Chest Radiography
• All chest views are taken at 72” SID to minimize magnification.
• All chest view are taken using high kVp to obtain a broad scale of contrast.
• Routine: P-A & Lateral
• Supplemental: Apical Lordotic, Anterior Oblique Views
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P-A Chest
• Measure: P-A at mid chest
• Protection: Half Apron• SID: 72” Bucky• No Tube Angle• Film: 14” x 17” regular
I.D. up Portrait unless wider than 35 cm.
• Marker: Pronated
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P-A Chest
• Patient stand P-A, facing Bucky with hands on hips. Shoulders rolled forward to get scapulae clear of lungs.
• Film placed two inches above the shoulders.
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P-A Chest
• Horizontal central ray: centered to film
• Vertical central ray: mid-sagittal
• Collimation: slightly less than film size.
• Breathing Instructions: “Take a deep breath in and hold it .” Inspiration
• Make exposure and let patient relax.
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P-A Chest Film
• The scapulae should be clear of the lung fields.
• The thoracic spine can be made out through the heart.
• Respiratory effort should be to the 10 ribs.
• No rotation: S.C. joints equal distance from spine.
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P-A Chest Film
• Note that this is a large patient.
• For large patients, the film may be turned 17” x 14” with the I.D. up.
• If the lateral measurement is greater than 35 cm turn film 17” x 14” Landscape.
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Lateral Chest
• Routine lateral is the left lateral.
• If pathology is suspected in the right lung, take a right lateral.
• Important to have arms over head for view of apices.
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Lateral Chest
• Measure: Lateral mid-chest
• Protection: Half apron• SID: 72” Bucky• Film: 14” x 17” regular
I.D. up Portrait• Top of film two inches
above shoulder.• Center horizontal
central ray to film
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Lateral Chest
• Instruct patient to interlock fingers with arm over head. May place arm behind head.
• Make sure patient is as close as possible to the Bucky.
• Vertical central ray: mid coronal plane.
• Push film into Bucky.
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Lateral Chest
• Collimation top to bottom: slightly less than film size.
• Collimation side to side: skin of chest
• Breathing instructions: “Take a deep breathe and hold it.” Inspiration
• Make exposure and have patient breathe and relax.
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Lateral Chest Film
• Should see apical area of chest.
• Respiratory effort down to tenth ribs.
• No rotation: ribs superimposed.
• Evidence of collimation
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Chest Supplemental Views
• Chest oblique views should be taken as anterior obliques.
• The RAO will show the left lung field. The LAO will show the right lung field. The heart should be clear of the t-spine.
• The Apical Lordotic View will demonstrate the apices clear of the clavicles and ribs.
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Apical Lordotic Chest
• Measure: A-P at mid chest
• Protection: Half Apron• SID: 72” Bucky• Tube Angle: 10 to 20
degrees cephalad• Film: 14” x 17” Portrait or
12” x 10” regular I.D. up Landscape Preferred
• Marker: Anatomical
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Apical Lordotic Chest
• Patient stands facing tube about 12 inches from Bucky.
• Patient asked to extend backwards until their back touches Bucky.
• Assist patient if necessary.
• Tube angle is dependent upon how well the patient can extend.
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Apical Lordotic Chest
• Horizontal Central Ray: mid way between xiphoid and manubrium
• Vertical Central Ray: mid sagittal
• Center film to horizontal central ray.
• Instruct patient to put hand on hips and roll shoulders forward.
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Apical Lordotic Chest
• Collimation: slightly less than film size.
• Breathing Instructions: “Take a deep breathe and hold it” Inspiration.
• Make exposure • Assist patient out of
position.
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Apical Lordotic Chest Film
• View taken to achieve a clear view of the lung apices.
• Clavicles should be clear of the lung apices.
• Views used to rule out pathologies in the lung apices such as tuberculosis.
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Right Anterior Oblique Chest
• Measure: P-A at mid chest
• Protection: Half Apron• SID: 72” Bucky• No Tube Angle• Film: 14” x 17” regular
I.D. up Portrait unless wider than 35 cm
• Marker: Pronated
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Right Anterior Oblique Chest
• Patient stands facing Bucky.Body is rotated to a 45 degree anterior oblique with the right shoulder touching the Bucky.
• Top of film placed two inches above the shoulder.
• Horizontal Central ray centered to film.
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Right Anterior Oblique Chest
• Center sternum to center line of Bucky or set collimation.
• Collimation is set slightly less than film size.
• Using the collimator light field, make sure that all of left lung field is within the lighted field.
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Right Anterior Oblique Chest
• If possible make sure that all of the chest is within the light field.
• Have patient put right hand on hip. The left arm is raised and rests on the Bucky.
• Breathing Instructions: “Take a deep breathe and hold it.
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Right Anterior Oblique Chest
• Make exposure.• Have patient breathe
and relax.
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Right Anterior Oblique Chest Film
• The heart borders should be clear of the thoracic spine.
• You will be able to evaluate the left bronchial tree and hilar area and the lung fields.
• Oblique views can help locate a pulmonary lesion seen on the P-A or Lateral chest but not seen on both.
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Left Anterior Oblique Chest
• Measure: P-A at mid chest
• Protection: Half Apron• SID: 72” Bucky• No Tube Angle• Film: 14” x 17” regular
I.D. up Portrait unless wider than 35 cm
• Marker: Pronated
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Left Anterior Oblique Chest
• Patient stands facing Bucky.Body is rotated to a 60 degree anterior oblique with the left shoulder touching the Bucky.
• Top of film placed two inches above the shoulder.
• Horizontal Central ray centered to film.
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Left Anterior Oblique Chest
• Center sternum to center line of Bucky or set collimation.
• Collimation is set slightly less than film size.
• Using the collimator light field, make sure that all of right lung field is within the lighted field.
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Left Anterior Oblique Chest
• If possible make sure that all of the chest is within the light field.
• Have patient put left hand on hip. The right arm is raised and rests on the Bucky.
• Breathing Instructions: “Take a deep breathe and hold it.
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Left Anterior Oblique Chest
• Make exposure.• Have patient breathe
and relax.
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Left Anterior Oblique Chest Film
• The heart borders should be clear of the thoracic spine.
• You will be able to evaluate the right bronchial tree and hilar area and the lung fields.
• Oblique views can help locate a pulmonary lesion seen on the P-A or Lateral chest but not seen on both.
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Locating an Abnormality
• An abnormality was seen on the A-P thoracic spine.
• The P-A and Lateral Chest were requested.
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Locating an Abnormality
• If was felt that the abnormality was cardiac so oblique views were ordered to confirm location of nodule.
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Chest & Thoracic Spine Review
• Film is centered to anatomy and central ray set to the film.– Two inches above C-7 for thoracic spine– Two inches above shoulders for the chest
• Thoracic Spine taken with 40” SID
• kVp 70 to 80 kVp for thoracic spine
• Short scale of contrast for spine.
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Chest & Thoracic Spine Review
• Chest views taken with 72” SID
• kVp is from 100 to 115 kVp for chest.
• Broad Scale of contrast for soft tissue visualization..
• All views except swimmers projection taken on full inspiration.
• I.D. is up whenever 14” x 17” is used.
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Why Do I Need This Class?
• Radiography is a key diagnostic tool.
• Proper interpretation is easier when the films are of good quality.
• When taking films , you are exposing the patient to radiation. Do it right the first time.
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Clinical History
• Age and sex of the patient– Over 50 years old -determine extent of
degeneration. No recent films.
– Menopause and hormone therapy; bone loss or osteoporosis
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Clinical History
• Trauma that may have resulted in a fracture, dislocation or significant soft tissue injury.
• Mode of injury may help determine views needed.
• Chest pain with cardiopulmonary disease history.
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Clinical History
• Malignancy that may metastasize to osseous structures. i.e. prostate cancer
• Unexplained weight loss, prolonged hormonal therapy or corticosteriod therapy or abuse.
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Physical Examination
• Clinical indications of active or aggressive bone or joint pathology:– chronic nocturnal pain
– fever ,warm and swollen joints
– bony or soft tissue masses
– Severe restriction of active range of motion
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Physical Examination
• Active or progressive neurologic or neuromotor deficits
• Suspicion of possible peripheral joint or spinal instability
• A significant or progressing scoliosis
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Risk Vs Benefits of the Examination
• Will x-rays affect the certainty of my differential diagnosis? How much?
• Will the information expected from the x-ray change my treatment plan?
• What test would be most sensitive in detecting or excluding the disease process?
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Other factors to be considered
• Your ability to interpret your films should also be considered. Are you sending them to a radiologist?– You must be able to detect gross
pathologies or fracture on the films that may require immediate attention and referral.
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What is a complete study?
• We must have right angle views to have a complete exam in most cases. There are exceptions:– A P-A chest could be considered a
complete exam.
– A single Waters view of the sinuses cane be a complete exam.
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What is a complete study?
• Generally we will need a A-P or P-A view and lateral view.
• Oblique view are done when indicated.– Most extremity studies will include a
oblique view.
• Stress views or flexion and extension views are done when indicated.
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Assignment
One student will be selected for assignment.
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Suggested Readings
Clark’s radiographic positioning and techniques.
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Question
What are the technical aspects for optimal chest PA radiograph?.
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Thank You