Administrative. Patient name Date compare with previous Position markers R-L, upright, supine Technical quality

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1 CHEST X-RAY

2 Administrative Patient name Date compare with previous Position markers R-L, upright, supine Technical quality AP or PA ( with x-ray beam entering from back of patient, taken at 6 feet) Good inspiration 8-10 th post rib or 5-6 th ant rib If you see more ribs = hyperinflation If you see less = poor inspiration Rotation

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4 Pleural effusion

5 Upright Supine

6 INSPIRATION

7 Rotation

8 General Overview General body size, shape, symmetry Male or female, and approximate age Survey for foreign objects tubes, IV lines, EKG leads Easily overlooked areas Behind calcified first rib cartilage Behind heart Behind diaphragm

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12 Feeding tube L bronchus

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15 Mediastinum Edge of the mediastinum should be clear. Some fuzziness in cardiophrenic angle. Right border Left border Brachiocephalic vessels SVC Azyogous vein Right atrium Brachiocephalic vessels Aortic knob Pulmonary artery Left atrial appendage Left ventricle

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17 Mediastinum Lateral film Anterior contour Brachiocephalic vessels Ascending aorta Right ventricular outflow tract Right ventricle Posterior heart contour Left atrium Inferior vena cava

18 1.- ap window 2.- pulmonary outflow track 3.- right pulmonary artery 4.- left atrium 5.- right ventricle 6.- left ventricle 7.- inferior vena cava 8.- aortic arch 9.- left pulmonary artery 10.- left primary bronchus 11.- confluence of pulmonary veins

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20 Superior Mediastinum SVC margin should not bulge into lung Right paratracheal stripe - <4mm. Marker for subtle adenopathy Left subclavian stripe 1-1.5cm

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22 Left Subclavian Stripe

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27 Heart Overall size CT ratio <50% Calcifications, sutures, valves, pacemakers or any abnormally dense areas over the heart. Follow outline for specific chamber enlargement

28 1. SVC 2. IVC 3. R atrium 4. R ventricle 5. L ventricle 6. Aortic valve 7. Pulmonic valve 8. Tricuspid valve 9. Mitral valve

29 Mitral stenosis

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33 Aorta Track from root to descending portion Aortic arch always on the left Look for calcifications Evaluate size

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37 RIGHT AORTIC ARCH

38 Trachea Centrally located in upper mediastinum Lower portion displaced by aortic arch Lateral oblique angle posteriorly Bifurcation 50-70, more than 90 is abnormal

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42 Intrathoracic goiter

43 Lungs PA/AP Compare size and density of lungs Look for horizontal fissure normally from hilum to 6 th rib in axillary line Equal distribution of vessels Compare upper to lower lobe vessels Compare vessels on both lungs

44 Lungs Lateral film Compare lung in retrosternal area with retrocardiac area Horizontal fissure passes horizontally from midpoint of hilum to ant chest wall Oblique fissure passes downwards from T4/T5 to ant. 1/3 of diaphragm Vertebrae get darker caudally No densities over heart

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48 2006

49 2008

50 LLL Pneumonia spine sign

51 Localize lesions

52 Silhouette sign Cardiac margins are clearly seen because there is contrast between the fluid density heart and air filled alveoli. Silhouette Adjacent Lobe/Segment Right diaphragm RLL/Basal segments Right heart margin RML/Medial segment Ascending aorta RUL/Anterior segment Aortic knob LUL/Posterior segment Left heart margin Lingula/Inferior segment Descending aorta LLL/Superior and medial segments Left diaphragm LLL/Basal segments Diseases of the pleura and mediastinal masses can also obliterate silhouettes.

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56 Lung collapse/atelectasis One of many causes of white lung Signs of volume loss: R lung should be > than L lung R diaphragm usually higher than L Fissures: R horizontal fissure is higher = RUL collapse, lower = RLL collapse R heart border blurred =RML, left heart border blurred = lingular collapse Trachea should be central: if deviated to R = RUL collapse, viceversa

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58 LLL

59 LUL

60 RML

61 RUL

62 RLL

63 Atelectasis Pneumonia Volume Loss Associated Ipsilateral Shift Linear, Wedge-Shaped Apex at Hilum Normal or Increased Volume No Shift,or if Present Then Contralateral Consolidation, Air Space Process Not Centered at Hilum

64 Pleura Follow pleural surface along lung periphery Lung should abut inner margins of ribcage Check for calcifications, pneumothorax, fluid Lat view check posterior costophrenic recess. < 300mL not seen on PA

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72 Soft tissue and bone Check overall density and size of soft tissue Bone size, shape, density. Look for erosions, fractures. Joints articular relationships, space Spine and ribs alignment, vertebral body height and disc spaces.

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74 Abdomen Evaluate gastric and bowel gas If seen: evaluate enlarged spleen, liver Look for peritoneal air

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Chapter 2 Cardiac Interpretation of Pediatric Chest X-Ray

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