Tutorial Rc Torax

7/27/2019 Tutorial Rc Torax

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MRCS Chest X-ray (CXR) 1

Normal Chest Radiograph

There is a very easy system to remember when reporting chest x rays- RIPABCDE!

Firstly, is this radiograph (never say x-ray!) of good enough quality to comment on health

and disease from?

Film Adequacy

Rotation: Are the clavicular heads symmetrical either side of the manubrium? In this film the

right clavicular head is slightlly further away from the manubrium than the left (there is

minimal rotation to the right). Otherwise one can simply say, there is no significant

rotation.

Inspiration: There should be at least 5 anteriorribs (note the ribs labelled above are

posterior ribs) visible within each lung field. If not there is said to be inadequate

inspiration. NB patients with less or significantly more ribs anteriorly may be suffering from

restrictive and obstructive lung diseases respectively.

Penetration and Position: As shown in the above radiograph, one should just about be able

to make out the borders of the vertebral bodies behind the sternum. If this is just a white


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haze then the film is probably under-penetrated; if one can clearly see the whole of the

vertebral column descending all the way down into the abdomen then the film is over-

penetrated. Otherwise one simply says, There is appropriate penetration/exposure. Check

whether all the lung fields are included in the radiograph too, especially the apices

costophrenic margins. (editors note: apologies if some of the radiographs on this page are

inadequate!

At this point also mention any tubes/ pacemakers etc. in situ. Here are some examples

Nasogastric Tube in situ Chest Drain in situ

Central Line in situ Pacemaker in situ


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ABCDE System

Having commented on the films adequacy and anything remarkable in situ, move on tocomment on any pathology present. In order to be thorough consistently, it is useful to have

a recollectable system:

Airway: Is the airway (trachea) central? If anything, allow for some deviation to the rightbut the trachea, as seen in this radiograph, should be dead central. Common causes of a

deviated trachea: pulmonary collapse, tension pneumothorax, massive pleural effusion,

lung cancer, kyphoscliosis.

Breathing: Be clinical in checking the whole of the lung margin (purple) aswell as field(green) in a snake like pattern on both sides.

This should take up the bulk of your inspection as there are many things to watch out for.

PURPLE ROUTE

Firstly, as you follow the mediastinal lung margins consider whether the distance between

each side is wider than normal.


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Knowledge of the underlying anatomy

is key to understanding why the

mediastinum may become wider.

Bounded laterally by the pleural

cavities, the mediastinum is a three-

dimensional space with four

compartments that are best

appreciated in sagittal section (see

above). The superior and inferior

parts are bounded by a horizontal

line passing backwards from the level

of the manubriosternal joint, which

passes between the 4th and 5th

thoracic vertebrae posteriorly. The

inferior mediastinum itself is broken

up into three compartments, the

anterior and posterior compartments being separated by the fibrous pericardium which

defines the middle compartment of the inferior mediastinum. From front to back the main

structures present in the superior mediastinum are: thymus gland, superior vena cava and

draining brachiocephalic veins, aortic arch, trachea and oesophagus. The anterior

mediastinum (in no particular direction) contains the internal thoracic arteries (from

subclavian arteries), inferior pole of thymus gland and lymphatics. Aforementioned, the

middle mediastinum contains the fibrous pericardium and heart contained within. Since the

aorta arches posteriorly, the arrangement of structures in the posterior mediastinum is

trachea (bifurcating at T4), oesophagus, aorta (from front to back). Common causes for

widened mediastinum are: hilar lymphadenopathy (sarcoidosis, lymphoma, metastases,

TB), Aortic Aneurysm or rupture, pericardial cyst and oesophageal dilatation (achalasia,

hiatus hernia).

Moving down from the mediastinum down the left heart border, there are four moguls

corresponding to: aortic knuckle, pulmonary artery, left atrium and left ventricle:

Normal Left Heart Border

You will commonly see an exaggeratedleft atrial mogul, caused by conditions in

which there is sustained increase in

chamber pressure: Hypertension, Mitral

Valve disease, Atrial Fibrillation,


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Left Atrial Dilatation

Right Atrial Dilatation

NB, if either heart border is obliterated/ blurred, then this is likely to be due to pulmonary

consolidation rather than cardiac pathology. The same rule of thumb applies to the hemi-

diaphragms


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SAILS SIGN- Left Hemi-Diaphragmatic Obliteration (Left Lower Lobar

Pneumonia:

Right Middle Lobe Pneumonia (no clear RHB)


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Superior Segment of RLL Pneumonia (no clear RHB)

Following our purple route further, landmarks NOT to forget are the costophrenic angles.

Nearly all the chest radiographs so far have sharp and obvious angles to show the

diaphragmatic pleura meeting the pleura of the chest wall. If more than about 250 mls of

fluid accumulates within the pleural space, there is often blunting of these radiographicangles:

Left Sided Pleural Effusion (Blunting of left Costophrenic Angle)

Causes for pleural effusion can be

categorised into exudative (where the

protein content exceeds 35 g/L) and

transudative (less than 25 g/L of

protein). If 25-35 g/l of protein and

serum protein content is greater than

0.5 then the effusion is exudative.

Exudative Causes: Pneumonia,

Malignancy (metastatic/lung primary,

PE, Rheumatoid Arthritis. Transudative

causes: cardiac failure, fluid overload,

hypoproteinaemia (liver disease/

nephrotic syndrome), Meigs syndrome.

Always look for clues elsewhere on the

radiograph as to what the cause could

be (paraoneumoinc effusion? Enlarge

Heart? Hilar Lymphadenopathy?).


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Finally on purple route, you must check for pneumothorax (air in the pleural space). When

following the pleural line, make sure there are lung markings reaching it, and not stopping

short (at the parietal pleura the other side of a pneumothorax!).

Left sided Pneumothorax


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A TENSION PNEUMOTHORAX is characterised by mediastinal shift and is diagnosed clinically,

not through the radiology department. The radiograph below represents a clinical

emergency, requiring immediate decompression through the insertion of a cannula in the

2nd intercostal space in the mid-clavicular line

Tension Pneumothorax

GREEN ROUTE

There are different types of shadowing within the lung, each associated with different

pathologies.

Noduar Shadowing

Neoplastic Causes: Carcinoma,

Adenoma, Hamartoma,

Metastases (NB the majority of

malignant lung disease ismetastatic). Infectious Causes:

Varicella Pneumonia, Septic

Emboli. Granulomas: Miliary TB,

Sarcoidosis, Wegeners

Granulomatosis,

Histoplasmosis.Pneumoconioses:

e.g. Caplans Syndrome.


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Alveolar Shadowing- ARDS

Note the fluffy cloud-like appearance of the shadowing. This is a non-cardiogenic cause of

pulmonary oedema- note the normal heart size and no pleural effusion (see Cardiac section

for heart failure radiographs) associated. Usually alveolar shadowing is secondary to left

ventricular failure (causing pulmonary oedema)- common causes: Pneumonia,Haemorrhage, Drugs (heroin, cytotoxics), renal and/or liver failure.

Reticular Shadowing- Post Primary TB

Note the predilection for

upper lobes in

Tuberculous parenchymal

fibrosis. Reticular

shadowing is usually

due to acute interstitial

changes: Sarcoidosis,

asbestosis, silicosis,

Wegeners

Granulomatosis,

Fibrosing Alveolitis.


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Be specific with what you see when reporting. Do not only mention the type of shadowing.

Comment on the location of the shadowing present- upper zones? (sarcoidosis, TB,

silicosis), lower zones? (asbestosis, drug reactions), central zones? (Pulmonary oedema,

lymphoma) together with any associated lung volume abnormality- increased?(emphysema,

cystic fibrosis) or decreased? (fibrotic lung disease, sarcoidosis).

NBIt is seldom possible to reach a diagnosis on the basis of the chest radiograph alone. If

there is unexpected diffuse shadowing of the lung field or a suspicious isolated lesion a CT

chest is usually the investigation of choice. Chest X rays are a better screening tool than

diagnostic tool.

Cardiac:Most importantly look at the size of the heart, which should be no wider thanhalf the transthoracic width (usually


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The right side is usually higher (liver in right upper quadrant of abdomen pushing from

underneath) but not by too much! The right hemidiaphragm is usually situated at the level

of the 6th anterior rib +/- 1 rib so if in doubt count. The most common cause for an

elevated hemidiaphragm is eventration of the higher hemidiaphragm. Eventration is

membraneous replacement of the diagphragmatic muscular tendon, which is weaker and

allows abdominal viscera to move upwards (colon, spleen, stomach, greater omentum etc.).

If elevation of the hemidiaphragm is a new finding then phrenic nerve paralysis MUST be

ruled out (the most common pathology for unilateral phrenic nerve paralysis is malignancy

in the mediastinum).

Elevated Hemidiaphragm- Mucous Plug with Left Lung Collapse

Another common pulmonary cause for elevation of the hemidiarphragm is lung collapse.


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The other important area to assess is whether there is any air visible UNDER the diaphragm-

a sign of pneumoperitoneum.

Pneumoperitoneum- Bowel Perforation

Although a perforated abdominal viscus is the most common cause (usually perforated

peptic ulcer), air may come from many other places within the abdominal cavity: post

lapartomy/laparoscopy, gall bladder or a subphrenic abscess.

Everything Else!:Apparently normal chest x-ray? Check common neglect areas: lungapices? (TB), bones? (clavicular fracture, glenohumeral dislocation, humeral fracture,

vertebral crush fracture), soft tissue mass? (axillary mass/ breast shadow mass).


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Further Radiology

HIstoplasmosis- calcified nodes; clumpy calcification; calcified nodules in lungs

Splenic Rupture- pleural effusion after blunt trauma


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Squamous Cell Cancer- Mass Density in anterior segment of LUL; thick calcification

Pancoast Tumour- Apical Density with 2nd Rib Destruction


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Canon Ball Metastases- multiple; bilateral; round opacities

Wedge Shaped Opacity-Vascular (infarct, Aspergillosis) or Bronchial (consolidation.

Atelectasis)

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