Chest X-ray

ID

 * name
 * age
 * date
 * modality

Marker

 * Right or Left

Position

 * Medial ends of the clavicles should be equidistant from the spinous processes at the midline to rule out rotation

Quality

 * Penetration
 * thoracic disc spaces should be just visible through the heart
 * overexposure → too dark
 * underexposure → too white

Respiration

 * good inspiration → 6th anterior, 10th posterior ribs at MCL
 * right hemidiaphragm at 6th anterior rib
 * poor inspiration:
 * poor aeration, vascular crowding, widened central shadow

Hardware

 * Comment on any lines, lead placements, tubing, etc.

Bones

 * C-spine, T-spine → alignment, disc space spacing, lytic or blastic lesions
 * shoulder girdle, ribs, humerus, sternum → fractures, osteopenia, deformities
 * vertebra OA (lateral view)
 * subchondral (beneath the cartilage) sclerosis
 * subchondral cysts
 * narrowing of joint space
 * osteophytes

Extrathoracic soft tissue

 * breast shadow, nipple
 * supra-clavicular, axillary areas → masses
 * subcutaneous emphysema

Mediastinum

 * size, shape
 * mainstem and segmental bronchi, lymph nodes
 * great vessles
 * hila → relationship, size

Trachea

 * position (centered, some rightward shift at level of carina)
 * shift - pneumothorax, mass
 * carina widened - LA enlargement, subcarinal node

Heart Shadow

 * cardiothoracic ratio (only on full inspiration PA views)
 * should be < 50%
 * enlarged chambers
 * LA - double shadow on right border
 * RA - ↑ width of right hemidiaphragm
 * LV - ↑ heart width
 * RV - lateral view: retrosternal space ↓
 * calcifications
 * aortic knuckle - unfolded due to age

Chest Wall

 * follow pleura for signs of pneumothorax
 * loss of lung markings in the periphery
 * line of visceral pleura seen on expiration view
 * pleural thickening
 * ↑ width of white line along inside of ribcage, esp. near diaphragm
 * costophrenic angles → pleural effusion
 * small effusions (< 100 mL) may be only seen in the lateral view

Diaphragms

 * compare hemidiaphragms
 * obscured → lower lobe pneumonia, pleural effusion
 * flattened → hyperinflation, tension pneumothorax
 * elevated → phrenic nerve paralysis, hepatomegaly
 * air under diaphragms → perforated GI tract

Lung Fields

 * compare lung fields in the ICS on L vs. R, up vs. down

Air Space Disease

 * cardinal features:
 * air bronchogram
 * fluffy, patchy poorly marginated appearance
 * lobar or segmental distribution
 * ddx:
 * pus (pneumonia)
 * fluid (pulmonary edema)
 * blood

Interstitial Disease

 * pathology involves the interlobular connective tissue
 * cardial features:
 * linear densities - Kerley B lines (< 2 cm long, 1 mm thick, reach lung edge)
 * reticular pattern (thin, well defined linear densities, honeycomb arrangement)
 * nodular pattern
 * ddx: pulmonary edema, collagen disease (fibrosis), sarcoidosis, viral pneumonia

Pulmonary Edema

 * edema initially collects in the interstitium
 * loss of definition of pulmonary vasculature
 * peribronchial cuffing
 * bronchi seen end-on appear as white rings
 * in CHF, the normally thin-walled bronchi become framed in interstitial fluid
 * best seen in vicinity of hila
 * Kerley B lines
 * reticulonodular pattern
 * thickening of interlobar fissures
 * with progression, fluid begins to collect in the alveoli, causing diffuse air space disease (bat wing or butterfly pattern), tend to spare the intermost lung fields
 * ddx: cardiogenic, renal failure

Atelectasis

 * cardinal signs:
 * deviation of a fissure
 * crowding of vessels
 * hilar, mediastinum shift
 * common causes: obstructive, compressive
 * in absence of a known etiology, bronchogenic carcinoma must be ruled out

Lymphadenopathy

 * lymph node groups: paratracheal, hilar, aorto-pulmonary window, subcarinal
 * hilar, AP window → widen mediastinum, flatten AP window contour
 * lung cancer, lymphoma, sarcoidosis, and tuberculosis
 * subcarinal - ↑ angle of tracheal bifurcation to 90°

Abdomen
- free air under diaphragm - pneumoperitoneum
 * liver size
 * spleen size
 * stomach (gastric bubble)
 * colon (bowel gas)

CHF

 * upper lobe redistribution of vessels
 * Kerley B-lines (usually seen near diaphragm)
 * right effusion at base
 * perivascular cuffing
 * pulmonary edema (interstitial, then airspace consolidation)
 * venous engorgement
 * normally extend 2/3 of the distance to periphery
 * vessels seen to extend farther than normal

Unilateral Left Sided Effusion

 * trauma, infection, SLE, PE, malignancy

Mediastinal Mass

 * anterior mediastinum
 * thyroid masses, thymomas, teratomas, lymphomas
 * middle mediastinum
 * lymphadenopathy, lymphoma, aortic aneurysm
 * posterior mediastinum
 * aneurysm of descending aorta, esophageal masses, hiatus hernia
 * lateral view
 * RVH
 * effusion → accentuation of lines of major and minor fissures