THE CHEST X-RAYBy

Dr. Mehmet KaphouryResidence of radio-diagnosis, ASU

Preliminary checklist

Dose Centralization Patient’s data (name, age, sex, smoking,

occupation, residence) Clinical history in brief

Centralized film

Mr. J is a 65-year-old male presents to the OPC complaining of cough & expectoration of bloody sputum 2 weeks ago. His smoking index is 1 pack/40 years. Past history is unremarkable except for frequent morning coughs with whitish sputum all through past 25 years almost everyday..

What is the best initial step in diagnosis?

The answer is: a plain CXR

Bit-by-bit checklist Trachea Mediastinum Heart Cardio-phrenic

angles Diaphragm Costo-phrenic

angles Lungs Bony cage Lateral film, if

present Other findings

Trachea

Central at its upper part Deviates slightly to the right at its lower part Its lucency decreases caudally

Comment on: Displacement Caliber Intraluminal ‘things’ Paratracheal stripe Carina

Mediastinum Central with aortic knuckle to the left and

SVC to the right Smooth with no irregularities or festooning Thymus in children

Comment on: Displacement Widening Fluid level, Air Spine

Thymus

Mediastinum

Heart One third to the right, 2 thirds to the left Learn normal configuration Borders can be well defined Cardio-thoracic ratio is no more than 50%

Comment on:

Size & configuration Borders (well defined or not) Chambers size and effects of their enlargement Retro-cardiac shadows Pericardial calcification, cysts

Aortic knuckle

Pulmonary trunk

Left atrium

Left ventricle

apex

SVC

Right atrium

Cardio-phrenic angles

Acute angles Mostly filled with fat pad Abnormalities known by blunting of these

anglesComment on:

Blunting of the angles Learn D.D of cardio-phrenic angles opacity

Diaphragm Dom shaped, right higher than left, left

may be higher but not more than 3 cm than the right

Can be traced all through Diaphragmatic hump may be normal Cut by the 6th or 7th rib in the mid-calv.

line Comment on:

Level (normal, depressed, elevated) Trace the contour Air under

Costo-phrenic angles

Acute angles Lucent

Comment on:

Blunted angles

Lungs

Airways Vessels Interstitium (fluid, fibrosis) Opacities (total, lobar, segmental,

focal, miliary// homogenous, heterogenous)

Cavity Pleura (line, calcification) Apices

Compare both sides for:

Bony Cage Cervical ribs Fractures Osteolytic lesions Inter-costal spaces