Chest X-ray (CXR)

CXR ●​ Radiographic imaging test ●​ Visualize structures within the chest cavity ●​ Use of low-dose X-ray for internal organ imaging ○​ Lungs ○​ Heart ○​ Airway ○​ Blood vessels ○​ Bones (thorax part) ●​ Used for Dx in MED Lungs ●​ Lung fields ●​ Lung marking ●​ Consolidation area ●​ Collapsed lung area Heart ●​ Cardiac size + shape ●​ Silhouette Mediastinum ●​ Trachea ●​ Major vessels ●​ Lymph nodes Pleura ●​ Pleural space ●​ Pleural effusion + Pneumothorax Bones ●​ Ribs ●​ Clavicles ●​ Thoracic vertebrae ●​ Scapula Indications ●​ Persistent coughing of patent ●​ Shortness of breath ●​ Chest p ●​ Fever + lung infection (suspected) ●​ Trauma on chest area ●​ Lung disease monitoring ●​ Heart size evaluation ●​ Tumor detection ○​ Or masses ●​ Pneumonia ●​ Tuberculosis ●​ Pneumothorax ●​ Pulmonary Edema Views on imaging ●​ Posteroanterior view ○​ PA ○​ Standard ○​ X-ray passes from back to front ●​ Anteroposterior view ○​ Bedridden ○​ Use for critical patients ●​ Lateral view ○​ Side view on chest ○​ Image helps to localise lesions Steps 1.​ 2.​ 3.​ 4.​ Patient stands or lies against X-ray detector plate Patient takes deep breath + holds X-ray passes through chest Image captured with detector CXR case study Patient Imaging ●​ Chest X-ray ●​ Posteroanterior imaging Radiograph analysis ●​ Localized area, increased opacity in right mid-lung zone ●​ Patchy and ill-defined ○​ Alveolar involvement ●​ Surrounding area seem to be clear ●​ Cardiac silhouette are in normal size and shape ●​ Diaphragmatic contours seems to be preserved ●​ Cannot see sign of large pleura effusion or pneumothorax Interpretation of Abnormality ●​ Circled part ○​ Lung consolidation ○​ Alveoli are filled with other external fluids ■​ Pus ■​ Blood ■​ Cells ○​ No airs are in there as normally ●​ Seems to be Pneumonia affecting on right lung Pathophysiology 1.​ Infectious organisms 2.​ Inflammation grows within alveoli 3.​ Alveoli fills up with exudate a.​ Fluid b.​ Immune cells c.​ Bacteria 4.​ Decrease in air content ⇒ production of radiopaque on CXR Differential Diagnosis ●​ Pulmonary Tuberculosis ●​ Lung Cancer ●​ Pulmonary Edema ●​ Pulmonary hemorrhage ●​ Lung abscess Further correlation is needed for diagnosis Cx ●​ CXR may be present with multiple s/smx ○​ Fever ○​ Productive cough ○​ Shortness on breaths ○​ Chest pain ■​ Pleuritic ○​ Fatigue ○​ Crackle heard ■​ Lung auscultation Diagnostic Evaluation ●​ When in further investigation, multiple test could be done ○​ Blood test ■​ CBC ■​ Inflammatory markers ○​ Sputum culture ○​ Blood culture ○​ CT scan on chest ○​ Pulse oximetry Mx ●​ Bacterial pneumonia ○​ Amoxicillin ○​ Azithromycin ○​ Ceftriaxone ●​ Supportive ○​ Oxygen therapy ○​ Hydration ○​ Antipyretics CXR case study 2 ​ ​ Patient imaging ●​ Chest X-Ray ●​ Posteroanterior chest radiograph ●​ Patient on left side ●​ Overall looks normal, no focal consolidation Lung ●​ Clear ●​ Well aerated ●​ No consolidation, masses ●​ No nodules ●​ No alveolar infiltrates Pleura ●​ No fair evidence on pleural effusion ●​ Pneumothorax cannot be seen Heart ●​ Cardiac silhouette in normal size ●​ No cardiomegaly Diaphragm ●​ Diaphragmatic dome visible ●​ Costophrenic angle sharp ○​ No accumulation of fluid Bones ●​ Ribs and clavicle intact ●​ Visible thoracic vertebrae intact ●​ Overall no fracture Interpretation ●​ Seems to be normal anatomy ○​ No significant pathological findings within CXR ●​ The patient is free form varying D. ○​ Pneumonia ○​ Pneumothorax ○​ Pleural Effusion ●​ Cardiac silhouette also in normal limit ○​ Cardiomegaly unlikely Systematic review ●​ A ○​ Trachea in midline ○​ No deviation ●​ B ○​ Lung = symmetric and clear ○​ Normal bronchovascular marking ●​ C ○​ Heart size normal ○​ <50% width thoracic ●​ D ○​ Diaphragmatic contour smooth ○​ Costophrenic angle sharp ●​ E ○​ Bones + soft tissues normal ○​ No signs of external medical device + abnormalities Cx ●​ Mild respiratory symptoms ●​ Early stage infections ●​ Non-pulmonary cause chest pain ●​ Need of routine check or examination Even with CXR image normal, patients might have other clinical symptoms CXR station 3 Patient imaging ●​ CXR ●​ AP erect portable radiograph ●​ Right side of patient ●​ Portable films are usually used for hospitalized patient or critically illed patient Lungs ●​ Bilateral opacities on both lungs ●​ Patchy and perihilar ○​ Fluid accumulation ○​ Inflammation widespread Heart ●​ Cardiac silhouette = enlarged ●​ Indication of cardiomegaly Pleura ●​ Blunting of costophrenic angles ○​ Fluid accumulation Diaphragm ●​ Could be seen clearly ●​ Increase in lung opacity Interpretation ●​ Bilateral diffuse pulmonary opacities ●​ Enlarged cardiac silhouette ==================================== ●​ Pulmonary Edema ●​ Congestive Heart Failure Pathophysiology 1.​ Left ventricular dysfunction a.​ Increase in pressure of pulmonary circulation 2.​ Fluid leak on pulmonary capillalreis ⇒ interstitial + alveolar spaces 3.​ Alveoli with fluid a.​ Bilateral opacities on CXR 4.​ Gas exchange a.​ Impaired i.​ Shortness of breath ii.​ Hypoxia Radiographic signs ●​ Wing like, bilateral perihilar opacity ●​ Cardiomegaly ●​ Kerley B lines ●​ Pleural effusions ●​ Pulmonary vascular masking increases Clinical presentation ●​ Severe shortness of breath ●​ Orthopnea ○​ Hardness in breathing upon laying flat on ground ○​ Frothy sputum ○​ Fatigue ○​ Cyanosis if severe Differential Dx ●​ ARDS ●​ Pneumonia ●​ Diffuse pulmonary hemorrhage ●​ Lung disease ○​ Interstitial These may give out similar result in CXR and could be misdiagnosed