1. INTERACTIVE CASE DISCUSSIONS
Medical Clerkship
Department of Radiological Sciences

2. HISTORY OF PRESENT ILLNESS
CC: cough
CASE 1
HISTORY OF PRESENT ILLNESS
1 wk PTC
(+) cough
(+) difficulty of breathing
(-) fever
Persistence.
Consult.
PHYSICAL EXAMINATION
VS HR 120/80 HR 96 RR 28 T 36.4°C
in respiratory distress, supraclavicular, intercostal and subcostal retractions
symmetric chest expansion,  BS left lower lung, (+) coarse crackles & rhonchi, L

3. CHEST X-RAY AP SUPINE LEFT LAT DECUBITUS
CLERK’S GUIDE: Discuss first the basics of a normal chest x-ray.

4. CC: Cough
action of the body takes to get rid of substances that are irritating the air passages
occurs when mechanical or chemical afferent nerves get irritated and trigger a chain of events
Air in lungs is forced out under high pressure.

5. Analysis Cough Acute < 3weeks Persistent >3weeks
Chronic >8weeks
Acute cough
Infectious
Non infectious

6. Acute Cough – signs and symptoms
Infectious
Non infectious
Fever, chills, body aches, sore throat vomiting, headache, sinus pressure, runny nose, night sweats, and postnasal drip. sputum, or phlegm,
exposure to certain chemicals or irritants in the environment,
coughs that may improve with inhalers or allergy medications

7. Indications for a Chest X-ray
For patient with acute cough
Abnormal vital signs
Chest examination suggestive of pneumonia
Patient: RR 28
in respiratory distress, supraclavicular, intercostal and subcostal retractions
symmetric chest expansion,  BS left lower lung, (+) coarse crackles & rhonchi, L

8. AP supine if px can’t assume upright position, though
can’t critically evaluate the size of the heart because of hypoventilation, diaphragmatic elevation pushing the base of the heart upwards.

9. Lateral Decubitus position
px lies on right or left side; the beam traverses the body in horizontal position
px w/pleural effusion, pneumothorax – presence of fluid gravitates to dependent portions
demonstrate fluid levels in cavities

10. Normal Chest X-ray

11. Chest anatomy: Evaluation
Ribs
Anterior ribs
obliquely placed
wider intercostals spaces
Posterior ribs
horizontally placed
narrower intercostals spaces
Intercostal Spaces

12. Chest anatomy: Evaluation
Diaphragm: right and left
middle segment partially obscured
Normal level
10th post rib / 5th ant rib
right higher than the left (liver)
dome-shaped
Costophrenic angle / sinus and Cardiophrenic angle
Sharp, well defined and not blunted

13. Chest anatomy: Evaluation
Trachea and mediastinum
radioluscent: means it has an air
bifurcates at T5 (carina) into right and left bronchus
normal: midline
right bronchus: shorter and more vertical
left bronchus: longer and more horizontal

14. Chest anatomy: Evaluation
Hila, bronchovascular markings
pulmonary artery and vein
bronchial artery and vein
bronchus
lymph nodes
Normal:
left hilum higher than the right
pulmonary artery crosses above the left and below the right bronchus
size of hilum varies depending on pulmonary blood flow

15. Chest anatomy: Evaluation
Lungs
Radiolucent
Inner, middle, outer zones
Inner zone: from sternoclavicular joint draw a vertical line following contour of the chest, big blood vessels are located
middle zone: medium blood vessels are located
outer zone: junction of the clavicle and 1st rib draw a vertical line; small blood vessels are located

16. Chest anatomy: Evaluation
Upper, middle, lower lung fields
landmarks: 2nd and 4th anterior ribs
upper lung field: further subdivided by the clavicle into supraclavicular (apex) and infraclavicular
significance: for localization of the lesions

17. Chest anatomy: Evaluation
Lobar anatomy
right lobe
major fissure: divides lower lobe from upper and middle
minor fissure: divides upper and middle
left lobe
for upper and lower lobes only

18. Chest anatomy: Evaluation
Heart shadow
Superior mediastinum
draw a line from the sternal angle to the 4th vertebra
Anterior mediastinum
bounded by posterior surface of the sternum and anterior surface of the heart
Posterior mediastinum
bounded by posterior part of the heart and anterior spinal muscle S A P

19. Chest anatomy: Evaluation
Size
Cardiothoracic ratio
Easiest gross determination
Compare size of the heart with the thorax
Normal 2:1
Get the widest transverse diameter of the heart compare with the widestinternal transverse diameter of the thorax
Shape
Variable
neonate: globular

20. Chest anatomy: Evaluation
Right border
Superior vena cava
Right atrium
Inferior vena cava

21. Chest anatomy: Evaluation
Right border
Superior vena cava
Right atrium
Inferior vena cava
Left border
Aortic knob
Main pulmonary trunk
Left ventricle

22. Lateral View Left atrium Left ventricle trachea AORTA
Main Pulmonary Artery RS
Left atrium
Left ventricle
Right ventricle RC

24. Patients Chest X-ray

25. CHEST X-RAY AP SUPINE LEFT LAT DECUBITUS
CLERK’S GUIDE: Discuss first the basics of a normal chest x-ray.

26. Patient’s chest xray Obscured diagphragmatic sulci at the left
Narrow intercostal space
No shifting of the mediastinal structures Cardiac shadow not appreciated
Hyperluscency of the right lung
Homogenous opacification of the left lung

27. Radiographic Differentials
Consolidation
Atelectasis
Pleural effusion
Mass lesions

28. Mass
Consolidation
Pleural effusion
Atelectasis
Duration
Chronic
Sub acute to chronic
Acute to sub acute
A-abdomen and thorax, costophrenc and cardiophrenic sulci, diaphragm
May be affected depending on the location of the mass
Blunted/ normal
Blunting of costrophrenic sulcus, nor visualization of hemidiaphragm, due to presence of fluid
Hemidiaphragm may be affected depending on the size of atelectasis
T-thoracic cage
normal
Normal
+/- widenend interspaces on affected side
Narrowed interspaces on affected side with compensatory widening on opposite side
M-mediastinum
+/- shifting depends on the size and location
+/- shifting contralaterally
+/- shifting ipsilaterally
LL- Lung comparison
Solitary , calcificied, ildefined, spiculations, irreguar, cavitations, hilar enlargement, effusions
Air bronchogram
Homogenous opacification with a lateral upward curve(meniscus sign)
Lat decubitus view- free fluid within the pleural space +layering oon the dependent part
Homogenous opacification of affected side

29. Atelectasis means “lack of stretch”
refers to collapse or loss of lung volume
2 types: Obstructive or Non obstructive

30. Atelectasis Obstructive Non obstructive blockage of an airway
Air retained distal to the occlusion is then resorbed from nonventilated alveoli
affected regions become totally airless
Non obstructive
caused by loss of contact between the parietal and visceral pleurae, parenchymal compression, loss of surfactant, or replacement of lung tissue by scarring or infiltrative disease.

31. Direct signs Indirect signs displacement of fissures
increased opacification of the airless lobe.
Indirect signs
displacement of hilar structures,
cardiomediastinal shift toward the side of collapse,
narrowing of ipsilateral intercostal spaces,
elevation of the ipsilateral hemidiaphragm, compensatory hyperinflation and hyperlucency of the remaining aerated parts of the lung, and
obscuring of structures adjacent to the collapsed lung, such as the diaphragm, heart, or pulmonary vessels.

32. ROLE OF MAGNETIC RESONANCE IMAGING
can distinguish between obstructive and nonobstructive atelectasis
Obstructive atelectasis
displays high signal intensity on T2-weighted images due to proton-rich mucus accumulation.
Nonobstructive atelectasis
low signal intensity on T1 and T2 weighted spin-echo images, since the residual alveolar gas has a low proton concentration, and magnetic susceptibility effects between alveolar walls lead to a decrease in signal.
The use of MRI in diagnosing atelectasis is still experimental, and more experience needs to be accrued

33. Treatment Continuous positive airway pressure (CPAP)
Fiberoptic bronchoscopy for the extraction of secretions
Mucolytic therapy 

35. NORMAL CHEST X RAY