Chest X-ray Features
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Questions and Answers

What is the maximum transverse diameter of the heart in relation to the maximum transverse diameter of the chest?

  • 50% of the maximum transverse diameter of the chest (correct)
  • 70% of the maximum transverse diameter of the chest
  • 60% of the maximum transverse diameter of the chest
  • 80% of the maximum transverse diameter of the chest
  • What is the criteria for ensuring a satisfactory chest radiograph has no rotation?

  • The vertebrae behind the heart are barely visible
  • The diaphragm can be traced up until reaching the edge of the spine
  • Medial borders of the clavicle are equidistant from the spinous processes of the vertebral bodies (correct)
  • Ten ribs visible posteriorly in the mid clavicular line on the frontal chest radiograph
  • What is the purpose of ascertaining that there are ten ribs visible posteriorly in the mid clavicular line on the frontal chest radiograph?

  • To confirm that the chest radiograph has no rotation
  • To confirm that the patient has made a good inspiratory effort (correct)
  • To confirm that the chest radiograph has good penetration
  • To confirm that the heart size is normal
  • What is the effect of gravity on the pulmonary vascular structures?

    <p>90% of the pulmonary vascular structures are appreciated at the mid and lower zones</p> Signup and view all the answers

    What is the name of the sign that describes the visibility of densities on a radiograph?

    <p>The Silhouette Sign</p> Signup and view all the answers

    What should be barely visible in an X-ray with good penetration?

    <p>The vertebral bodies behind the heart</p> Signup and view all the answers

    What is the orientation of the standard chest radiograph where the heart size is measured?

    <p>Posterior-Anterior (PA) orientation</p> Signup and view all the answers

    How many densities are visible on any radiograph according to Benjamin Felson?

    <p>Three densities</p> Signup and view all the answers

    What does the disappearance of a normal silhouette imply?

    <p>The adjoining area has transmuted into the same density as its neighboring structure</p> Signup and view all the answers

    What is the main reason to evaluate the lung apices?

    <p>To identify a neoplasm</p> Signup and view all the answers

    What is the simplest solution to diagnostic uncertainty in the lung apices?

    <p>Request a supplementary apical view</p> Signup and view all the answers

    What is the commonest neck mass to displace the trachea?

    <p>Thyroid mass</p> Signup and view all the answers

    What does the trachea deviated to the contralateral side indicate?

    <p>A tension pneumothorax</p> Signup and view all the answers

    What is the hilar point on either side of the heart?

    <p>The intersection of the pulmonary arteries and veins</p> Signup and view all the answers

    What is the significance of the gastric air bubble on the left side?

    <p>It is a normal variant</p> Signup and view all the answers

    What is the purpose of reviewing the subdiaphragmatic region?

    <p>To identify free gas or bowel</p> Signup and view all the answers

    What is the normal relationship between the left and right hilar points?

    <p>The left hilar point lies higher than the right.</p> Signup and view all the answers

    What is the significance of the aorto-pulmonary window?

    <p>It is a common site for malignant lymphadenopathy.</p> Signup and view all the answers

    Why is bone review important in chest radiographs?

    <p>To exclude fractures or dislocations.</p> Signup and view all the answers

    What is a feature of cardiac failure in chest radiographs?

    <p>Increased cardiothoracic ratio.</p> Signup and view all the answers

    What is the principle used to diagnose lobar consolidation?

    <p>The silhouette principle.</p> Signup and view all the answers

    Which of the following is not a feature of lobar consolidation?

    <p>Right heart border</p> Signup and view all the answers

    Which pulmonary lobe is associated with the left hemidiaphragm?

    <p>Left lower lobe.</p> Signup and view all the answers

    What is the significance of the transverse or minor fissure?

    <p>It demarcates the right upper lobe.</p> Signup and view all the answers

    What is the characteristic of a pneumothorax on an erect radiograph?

    <p>Separation of lung edge from the chest wall</p> Signup and view all the answers

    What is the characteristic of a pleural effusion on an erect radiograph?

    <p>Increased density with a meniscus rising up the lateral chest wall</p> Signup and view all the answers

    What is the characteristic of a right upper lobe consolidation?

    <p>Consolidation above and terminating at the minor fissure</p> Signup and view all the answers

    What is the characteristic of a right middle lobe consolidation?

    <p>Consolidation below and terminating at the transverse fissure</p> Signup and view all the answers

    What is the characteristic of a left upper lobe consolidation?

    <p>Produces a fuzzy 'veiling' effect with consequent reduced conspicuity of the aortic knuckle's silhouette</p> Signup and view all the answers

    What is the characteristic of a tension pneumothorax?

    <p>Mediastinum is displaced to the contralateral side and there is inferior displacement of the ipsilateral hemidiaphragm</p> Signup and view all the answers

    What is the indication of a horizontal fluid level within the chest?

    <p>Hydropneumothorax with air in the pleural space</p> Signup and view all the answers

    When should an expiratory view be requested?

    <p>When there is a clinical suspicion of pneumothorax</p> Signup and view all the answers

    Study Notes

    Normal Features of a Chest X-ray

    • A satisfactory chest radiograph should have:
      • No rotation, confirmed by ensuring the medial borders of the clavicle are equidistant from the spinous processes of the vertebral bodies.
      • Good inspiration, confirmed by ascertaining that there are ten ribs visible posteriorly in the mid clavicular line on the frontal chest radiograph.
      • Good penetration, where the vertebrae behind the heart are barely visible, and the diaphragm can be traced up until reaching the edge of the spine.

    A System for Reviewing the Chest Radiograph

    • Check for AP or PA orientation
    • Evaluate the heart size:
      • The maximum transverse diameter of the heart should not exceed 50% of the maximum transverse diameter of the chest on a standard posteroanterior (PA) radiograph.
      • This measurement is known as the Cardiothoracic Ratio.
    • Assess pulmonary vascularity:
      • Pulmonary venous vessels should not be discretely visible in the outer third of the lung fields.
      • Approximately 90% of the pulmonary vascular structures are appreciated at the mid and lower zones due to the effect of gravity.
    • Review the lung fields:
      • The Silhouette Sign: only three densities are visible on any radiograph (bone, air, and soft tissue).
      • The diaphragm and heart borders are adjacent to lung lobes.

    Review Areas

    • Subdiaphragmatic region:
      • No free gas should be present under the diaphragm on an erect chest radiograph.
      • A gastric air bubble is frequently seen on the left side, while interposed small or large bowel may occasionally be seen on the right.
    • The lung apices:
      • Evaluating the lung apices can be difficult, particularly in older patients where there is asymmetrical calcification of the costochondral junctions.
      • Request a supplementary apical view if there is diagnostic uncertainty or an asymmetry in the apical appearances.
    • The trachea:
      • The trachea should be midline, and any deviation may be due to pathology within the neck or chest.
    • The hilum:
      • The hilar point on either side of the heart represents the intersection of the pulmonary arteries and veins.
      • The left hilar point normally lies higher than the right.
      • The hila should always be equal in size and density.
    • The aorto-pulmonary window:
      • The reviewer should follow the left edge of the mediastinum from its superior aspect to identify the aortic knuckle and pulmonary artery.
      • There should be no convexity or mass within the aorto-pulmonary window.
    • Bones:
      • Review bones for two reasons:
        • Trauma: to exclude fractures or dislocations, particularly at shoulder level.
        • Neoplasia: to exclude infiltration and destruction, particularly in metastatic disease and myeloma.

    Common Pathologies

    • Cardiac Failure:
      • Increased cardiothoracic ratio
      • Increased (venous) pulmonary vascularity
      • Kerley B lines
      • Pleural Effusions
      • Bat or Angel Wings
    • Lobar Consolidation:
      • The confident and accurate diagnosis of lobar consolidation rests on an understanding of the Silhouette Sign.
      • Identify the missing silhouette to determine which pulmonary lobe is affected.
    • Pneumothorax:
      • Divided into simple and tension pneumothorax.
      • Tension pneumothorax is diagnosed radiologically when the mediastinum is displaced to the contralateral side and there is inferior displacement of the ipsilateral hemidiaphragm.
      • Accompanying clinical distress is also present.
    • Pleural Effusions:
      • Typical appearances on an erect radiograph are those of an area of increased density with a meniscus rising up the lateral chest wall.
      • A horizontal fluid level within the chest suggests a hydropneumothorax with air in the pleural space.

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    Description

    This quiz covers the normal features of a chest X-ray, including the positioning, inspiration, and penetration of the image. Understand the key characteristics of a satisfactory chest radiograph.

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