Clinical I ~ Chest & Abdomen ~ Image Review

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Clinical I~~~

Chest & Abdomen~~~~~

Image Review

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The following information is only a personal suggested guideline to follow when positioning for Chest and

Abdomen radiologic exams.

For additional information on positioning of these

exams, please reference your Radiographic

Positioning and Related Anatomy Textbook.

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ChestImages

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Hypersthenic- IR is crosswise Asthenic-IR is lengthwise

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Chest*Good

positioning Images will

always be on the right.

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Trachea

Apex

Aortic knob

Hilum

Heart

Breast

CostophrenicAngle

Diaphragm

Lung base

Mediastinum

Scapula

Clavicles equal

3 ribs above clavicle

Posterior rib

Air in stomach

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PA Uprt Chest• CR to IR• SID 72”• Anterior body against Uprt Bucky• Direct CR horizontally to T7• Collimate/place marker• Shield• Suspend Respiration on 2nd Inspiration• Visualize apices to costophrenic angles. and at least 10 ribs

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◄Bra Bra ►

◄ necklace &nipple piercings PLUS poor centering!

ASK… Do you have any metal on under your gown?

Artifacts? Internal

or ? External

Glasses ►

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◄Back brace

Dreads ►

◄Cough drops

More Artifacts

Wet hair ►

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Idiot▲

More artifacts

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Exposure errors – Double exposures - Make sure you keep track of which IR plates have already been exposed!

Repeatable error?

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Repeatable error? Positioning - Chin is in the way of anatomy and clipped apex

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More double exposures!

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Repeatable error? Positioning - Chin is in the way of anatomy

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Repeatable error?

Positioning - Chin is in the way of anatomy

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Repeatable error? Positioning - Clipped anatomy

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Repeatable error?

Positioning –Clipped anatomy and artifact

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Repeatable error? w/ Pathology Positioning - Clipped anatomy Pathology - Tumor left lung

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Repeatable error? Positioning - Rotation

*Clavicles should be equal distance away from the spine!

See above.

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Repeatable error?

Positioning - Rotation

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Repeatable error?


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Repeatable error? Rotation and too many wires in the way

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Repeatable errors? Collimation/CR - Incorrect CR.Positioning - chin in anatomy and rotation.

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For AP Chest imaging, the correct CR angle will produce the visualization of 3 ribs above the clavicles. Anything more or less than that could be because of poor CR angle.

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Repeatable errors -

Positioning - Incorrect patient contact with the IR

Collimation/CR - Incorrect CR to IR. This will cause an apical lordotic image and/or possible grid cut-off

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Repeatable error?

Collimation/CR - Incorrect CR angle

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Repeatable errors? Collimation/CR - Incorrect CR anglePositioning - Clipped anatomy

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Repeatable error? Collimation/CR - Incorrect CR angle

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Pathology -

Pulmonary Edema (“Bat Wings”)

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Pathology - Pleural Effusion

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Pathology - Large amount of Pleural Effusion

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Most common AP/PA Chest Errors

1.Artifacts - accidental2.Clipped anatomy3.Chin in the way4.Rotation5.Marker misuse6.Poor CR angle

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AP or PA Decubitus Chest• CR horizontal and to IR

• SID 56-72”• Body is recumbent & against IR or Uprt

Bucky, ensure arms are out of the way of chest anatomy

• Direct CR horizontally to T7• Collimate/place marker• Shield• Suspend Respiration on 2nd Inspiration• Visualize apices to costophrenic angles. and at least 10 ribs

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Repeatable error?

Positioning - Arm is obscuring lung anatomy

Left side down Decubitus

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Repeatable error?

Positioning - Both Breasts are Obscuring lung anatomy

Right side down Decubitus Chest

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Decubitus Pathology – Pleural Effusion

Right side down Decubitus Chest

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Most common Decubitus Chest Positioning Errors

1. Rotation2. Marker misuse3. Clipped anatomy

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Protocols for Decubitus Chest X-rays

*Remember:Air goes UP

AndFluid goes DOWN

(Abdomen Decubitus ALWAYS goes Left side down! WHY?)

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Pathology -

Pneumonia

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Pathology -

Cardiomegaly w/ pacemaker.

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Pathology -

SUPER Cardiomegaly

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Pathology -

Situs Inverses**Markers are only proof!

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Pathology - Scoliosis

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Pathology - Tortious Aorta

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Pathology - Left Lobectomy/Pneumonectomy

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Pathology - Pneumothorax

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Pathology - Pneumothorax with lung collapse.

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Pathology - Pneumothorax with lung collapse.

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Pathology - Pneumothorax with bilateral lung collapse.

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Pathology - Lung mass

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Pathology - Lung mass in an Infant

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Pathology - Subcutaneous Emphysema

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Pathology - Breast Implants - saline

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Pathology - Breast Implants - silicone

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Pathology -

Pt. is missing an arm and clavicle

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Pathology -

Congenital abnormality

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Pathology - Colon is in the chest cavity.

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Pathology - Colon is in the chest cavity.

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Pathology -

Gun shot

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Pathology - Gun shot/bullet….but where? The Heart?

63Pathology - Gun shot/bullet in the back muscle

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Pathology -

Gun shot/bullet….in the spine. With Plural Effusion

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Pathology -

Calcified lung

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Pathology – Cystic fibrous

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Pathology & Positioning error & Artifact

Lung Abscess – clipped anatomy – pen in pocket

68Pathology – Meth use

43yo female ~ Aug 2007 43yo female ~ Aug 2006

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Pathology – Lung cancer

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Pathology – MAC InfectionMycobacterium Avium-intracellular

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Pathology – Metastases

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Pathology –

External Artificial Heart

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Pathology –

Internal Artificial Heart

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Pathology – Previous Surgery to the thorax

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Pathology – Free Air/Pneumoperitoneum

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Pathology – Free Air/Pneumoperitoneum

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Uprt Lateral Chest• CR to IR• SID 72”• Left side of patient is against the Uprt

Bucky• Direct CR horizontally to T7• Collimate/place marker• Shield• Suspend Respiration on 2nd Inspiration• Visualize apices to costophrenic angles. and at least 10 ribs

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Apex

Hilum

Thoracic Spine

Intervertebral Disc space

Costophrenic Angle

Lung base

Heart

Scapulae

Arm shadow Aorta

Treachea

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Repeatable error? Positioning - Know where your IR is & make sure the CR is centered to it.

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Repeatable error? Positioning – ArtifactHeart monitor wires are in the anatomy

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Repeatable error? Positioning – Rotation with clipped anatomy

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Repeatable error?Positioning - Anatomy is obscured by the wheelchair. Need to use a sponge behind the patient’s back.

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Repeatable errors? Collimation/CR – CR is centered too high. Artifact – Wheelchair arm

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Repeatable errors? Collimation/CR – poor CenteringCausing clipped anatomy

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Repeatable error?

Collimation/CR – poor centeringCausing clipped anatomy

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Repeatable error? Collimation/CR – centering too lowCausing clipped anatomy

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Repeatable error? Collimation/CR – poor centeringCausing clipped anatomy & tumor

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Repeatable error? Collimation/CR – poor centeringCausing clipped anatomy

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Repeatable error? Collimation/CR – poor centeringCausing clipped anatomy

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Repeatable errors?

Collimation/CR – poor centeringCausing clipped anatomyExposure - motion

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Most common Lateral Chest Errors

1.Clipped anatomy2.Rotation3.Marker misuse

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Supine & Uprt Abdomen

• CR to IR• SID 40”• supine on table or uprt• Direct CR to crest for supine or 2”

above the crest for the uprt• Collimate/place marker• Shield (only when doing 2 crosswise)• Suspend Respiration on Expiration

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Repeatable errors?

ASK- Do you have any metal on under your gown??Anatomy Demonstrated – Artifacts in the way of anatomy

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Repeatable errors?

ASK- Do you have any metal on under your blankets??

Anatomy Demonstrated – Artifacts in the way of anatomy

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Repeatable error? Not always… Anatomy demonstrated - Artifact vs. Foreign Body – Patient swallowed a coin

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Repeatable error? Not always… Anatomy demonstrated - Artifact vs. Foreign Body – Patient swallowed stuff (chains)

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Repeatable error? Not always…Anatomy demonstrated - Artifact vs. Foreign Body – Patient swallowed an earring.

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Repeatable error? Not always… Anatomy demonstrated - Artifact vs. Foreign Body – Patient swallowed a battery.

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Repeatable error? Not always… Anatomy demonstrated - Artifact vs. Foreign Body – Patient swallowed a lot of stuff!

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Repeatable error?Anatomy demonstrated – Artifact vs. Foreign Body???

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Foreign Body - Hx of previous Abd surgery with post surgical Abd Pain

Oops… Forceps left in patient after surgery.

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Repeatable error? Not always…

Patient did not swallow?

Anatomy demonstrated – Artifact vs. Foreign Body???

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Repeatable errors?Anatomy Demonstrated - patienthand in anatomy.Exposure – too light

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Repeatable errors?Anatomy Demonstrated – Patient hand in anatomy.Markers - Poor annotation placement, should have used markers.

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Repeatable error? Collimation/CR – CR not centered to IRKnow where the IR plate is.

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Repeatable error?Collimation/CR – CR not centered to IRKnow where the IR plate is.

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Repeatable error? Positioning – Rotation &Clipped anatomy

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Repeatable error? Markers – are obscuring anatomy

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It is extremely important to shield those who are of child bearing years.

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Pathology -

Scoliosis

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Pathology - Gallbladder stones

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Pathology -

Gun Shot

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Pathology - Gun Shot

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Pathology - Aorta Aneurysm coiling/repair

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Pathology - myeloma

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Pathology - Surgery to back with hardware

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Pathology -

Free air/Pneumoperitoneum

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Pathology -

Free Air/Pneumoperitoneum

Left Lateral Decub

Supine

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Pathology - Free Air/Pneumoperitoneum

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Pathology -


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Most common Supine & Uprt Abdomen Errors

1.Artifacts accidental and intentional

2.CR not centered to IR3.Rotation4.Marker misuse

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AP or PA Decubitus Abdomen

• CR horizontal and to IR• SID 40”• Body is LEFT side down recumbent,

ensure the back or abdomen is ǁ with IR & arms are out of the way of anatomy

• Direct CR horizontally to 2” above crest• Collimate/place marker• Shield• Suspend Respiration on expiration

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Repeatable error ?


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Pathology -

Small bowel obstruction with free air

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Pathology -


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Pathology - Free Air/Pneumoperitoneum

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Most common Decubitus Abdomen Errors

1. Rotation2. Marker misuse3. Clipped anatomy

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~ The End ~

Clinical I ~ Chest & Abdomen ~ Image Review

Education

Transcript of Clinical I ~ Chest & Abdomen ~ Image Review