Transcript X-Rays

X-Rays
Kunal D Patel
Research Fellow
IMM
The 12-Steps
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1: Name
Pre-read
2: Date
3: Old films
4: What type of view(s)
5: Penetration
6: Inspiration
Quality Control
7: Rotation
8: Angulation
9: Soft tissues / bony structures
10: Mediastinum
Findings
11: Diaphragms
12: Lung Fields
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Densities and Techniques?
Densities
The big two densities are:
(1) WHITE - Bone
(2) BLACK - Air
The others are:
(3) DARK GREY- Fat
(4) GREY- Soft tissue/water
And if anything Man-made is on the film, it is:
(5) BRIGHT WHITE - Man-made
Technique/ Orientation
• First determine is the film a PA or AP view.
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PA- the x-rays penetrate through the
back of the patient on to the film
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AP-the x-rays penetrate through the
front of the patient on to the film. (heart
larger)
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All x-rays in the PICU are portable
and are AP view
• P-A (relation of x-ray beam to patient)
• Lateral
• Lateral Decubitus
3 views: AP, oblique and lateral
Rotation
Quality
• Inspiration and penetration!
• Was film taken under full inspiration?
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2
• Should be able to count 910 posterior ribs
• Heart shadow should not
be hidden by the
diaphragm
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4
5
6
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10
• Under penetration?
•if under penetrated you will
not be able to see the thoracic
vertebrae.
Angulation
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2
• Clavicle should lay
over 3rd rib
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Sometimes handy to use PIER
Position: Typically, upright PA and lateral. Sick
patients will have the fuzzier supine AP (because the
film is slid under their chest as they are lying down).
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Inspiration: Count the visible ribs. Lung fields should
extend to about the 10th or 11th rib.
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Exposure: If the film is penetrated enough, you
should be able to make out the spinous processes
"inside" the vertebrae. If the film is underexposed/too
white, you won't be able to see them. If the film is
overexposed/too black, bony details will be lost.
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Rotation: Evaluate the clavicals. They should appear
symmetric and equal in length. Now systematically
work through the x-ray.
Findings!
• Start with soft tissues and bony structures
• Check for
• Symmetry
• Deformities
• Fractures
• Masses
• Calcifications
• Lytic lesions
Remember your lung anatomy!
The right upper lobe (RUL) occupies the
upper 1/3 of the right lung.
Posteriorly, the RUL is adjacent to the
first three to five ribs.
Anteriorly, the RUL extends inferiorly as
far as the 4th right anterior rib
The
right middle lobe is
typically the smallest of the
three, and appears triangular in
shape, being narrowest near
the hilum
The right lower lobe is the largest of all three lobes,
separated from the others by the major fissure.
Posteriorly, the RLL extend as far superiorly as the 6th
thoracic vertebral body, and extends inferiorly to the
diaphragm.
Review of the lateral plain film surprisingly shows the
superior extent of the RLL.
The Heart, mediastinum and
hilum
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Size
Shape
Silhouette-margins should be sharp
Evidence of stents, clips, wires and valves
Diameter (>1/2 thoracic diameter is
enlarged heart)
• Hilum: Size and shape of aorta, any
enlarged vessels?
Remember: AP views make heart appear larger than it
actually is.
1. R Atrium
2. R Ventricle
3. Apex of L Ventricle
4. Superior Vena Cava
5. Inferior Vena Cava
6. Tricuspid Valve
7. Pulmonary Valve
8. Pulmonary Trunk
9. R PA 10. L PA
Lung Fields
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Apices
Top to bottom: lobes, fissures etc
Diaphragm: right should be higher than left
Bottom: Costophrenic angles
Gastric bubble?
Lung Fields: Using Structures / Silhouettes
Upper right heart
border /
ascending aorta
(anterior RUL)
Right heart border
(medial RML)
Anterior
hemidiaphragms
(anterior
lower lobes)
Aortic knob
(Apical portion
of LUL )
Upper left
heart border
(anterior
LUL)
Left heart
border
(lingula;
anterior)
Reviewing these areas
Heart
• Size
• Shape
• Silhouette-margins should be sharp
• Evidence of stents, clips, wires and
valves
• Diameter (>1/2 thoracic diameter is
enlarged heart)
Mediastinum
•Width?
•Contour?
Lung fields
•Apices
•Lobes and fissures
•USE SILHOUETTES
•CP angles
•Diaphragm
•Gastric bubble
•NOTE normal pleura are NOT visible
The 12-Steps
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}
1: Name
Pre-read
2: Date
3: Old films
4: What type of view(s)
5: Penetration
6: Inspiration
Quality Control
7: Rotation
8: Angulation
9: Soft tissues / bony structures
10: Mediastinum
Findings
11: Diaphragms
12: Lung Fields
}
}
Summarise as well!
"The trachea is central, the
mediastinum is not displaced. The
mediastinal contours and hila seem
normal. The lungs seem clear, with
no pneumothorax. There is no free
air under the diaphragm. The bones
and soft tissues seem normal."
Next
• Pathological findings and examples!