Medical Imaging Exam 1

This patient has a history of left mastectomy; what should you be cautious about when interpreting this CXR?

R breast accentuates pulmonary vessels at base of R lung — with mastectomy history, these accentuations can be mistaken for RLL infiltrates & the darker left lung can be misinterpreted as hyperinflation.

Nipple shadows

• seen in mid-clavicular line over lower half of R & L lungs

• if single nodule, refer to lateral CXR to confirm in the nodule projects within the lung

NOTE: IF nodule only seen in PA view, tape metallic BB marker and repeat PA view. If nodule aligns with BB = nipple shadow confirmed

Patient stands upright with chest against detector and beam entering from the back. What projection technique is this?

Posteroanterior (PA) projection

Patient lies supine, with beam entering from front with the detector behind them. What projection technique is this?

Anteroposterior (AP) projection

Main difference between PA vs. AP views?

• patient positioning

• beam direction

How is heart size affected in AP CXRs?

Heart size may appear larger due to magnification effects

Which CXR projection provide a more accurate depiction of heart size?

Posteroanterior (PA) projection

Benefits of upright PA view?

Allows for deeper breaths, producing better lung expansion and clarity of lung fields & provides a more accurate depiction of heart size.

Limitations of supine AP view?

Lungs may appear hypoinflated, lower lung fields may appear hazy, obscuring costophrenic angles and the heart may appear enlarged.

What CXR view minimizes distortion and allows for more accurate assessment of the heart and lungs?

Posteroanterior (PA) view

Diagnostic advantages of upright position CXR?

• enhanced lung visualization

• easier detection of pleural effusions

• improved visibility of pneumothoraces

• reduced anatomical distortion

Diagnostic limitations of supine CXR?

• limited lung inflation

• apparent heart enlargement

• difficulty detecting smaller pleural effusions and pneumothoraces

When would expiration view on CXR be beneficial?

In highlighting small pneumothoraces

Benefit of combined inspiration and expiration imaging?

Helps in detecting air trapping and mediastinal shifts caused by foreign body obstructions.

Suspicion of pneumothorax: inspiration or expiration imaging?

Expiration imaging

Flattened diaphragm on lateral CXR is a key sign of _________.

hyperinflation

CXR maging with ____ level voltage improves visualization of soft tissues, pulmonary vessels and the heart.

High voltage

CXR maging with ____ level voltage improves visualization of bones but lowers visualization of pulmonary vessels.

Low voltage

What CXR voltage level would be best to visualize a rib fracture?

Low voltage

What CXR voltage level would be best to visualize suspected injury of soft tissues, pulmonary vessels and the heart?

High voltage

Normal CXRs are taken at a relatively ____ voltage.

High

Prior to interpreting a CXR what should you do?

• confirm patient details (name, DOB, ID number)

• date and time the film was taken

• evaluate any previous imaging

RIPE is used to assess image quality- what does it stand for?

Rotation

Inspiration

Projection

Exposure

To carry out a structured interpretation of a CXR, the mneumonic ABCDE is often used. What does it stand for?

Airway (trachea, carina, bronchi, hilar structures)

Breathing (lungs, pleura)

Cardiac (heart size, borders)

Diaphragm (& costophrenic angles)

Everything else (mediastinal contours, bones, soft tissues, tubes, valves, pacemakers, wires)

Pleural effusion with tracheal deviation

Important landmark on CXR when assessing NG tube placement

Carina

NOTE: a correctly placed NG tube will bisect the carina

The ____ main bronchus is wider, shorter and more vertical than the ____ main bronchus.

right; left

It is more common for inhaled foreign objects to become lodged in the ____ main bronchus.

right

On CXR, the ___ hila should appear lower than the ___ hila

right hila appears lower than the left

On CXR, blurred vessels near hila may suggest infiltrates or fluid accumulation in what disease?

CHF

Normal CXR (PA & Lateral)

CXR view used to evaluate suspicious areas within the lung apices

Lordotic view

Visualization of more than __ ribs on CXR indicates adequate inspiratory effort.

More than 7

A cardiothoracic ratio above __ may indicate cardiomegaly.

0.5

The width of the heart should not be less than ___ the width of the thoracic cavity.

½ 

Which 3 mediastinal vessels are visible on the right side in mediastinal imaging?

• brachiocephalic vessels

• azygos vein

• ascending aorta

Name the mediastinal contours according to the numbers

1- superior vena cava

2- right atrium

3- inferior vena cava

4- aortic arch or knob

5- left pulmonary trunk

6- left pulmonary artery

7- left atrium

8- left ventricle

9- left cardiophrenic angle

Airway Structures on CXR

Which lung hilum should appear higher on CXR?

Left hilum

Name the lung lobes according to color 

Red = RUL

Green = RML

Purple = RLL (not seen in picture)

Yellow = LUL

Blue = LLL

Lung Mass:

Lung Infitrate:

What is this?

What is this? 

Broken rib

An endotracheal tube should be placed at least 1 cm above the carina. If improperly placed, what is a potential complication?

Improper placement of an endotracheal tube can lead to atelectasis (collapse) of a lung.

Name the structures according to number

1- superior vena cava

2- right atrium

3- inferior vena cava

4- aortic arch or knob

5- left pulmonary trunk

6- left pulmonary artery

7- left atrium

8- left ventricle

9- left cardiophrenic angle

Name the structures according to letter 

A – Trachea

B – Clavicle

C – Right Atrium

D – Diaphragm

E – Cardiophrenic angle  (Costocardio)

F – Left upper lobe

G – Gastric Bubble

H – Left Hilum

Air space pathology infiltrates: ______ & ______

alveolar & interstitial

Which type of infiltrate tends to be localized

alveolar

Which type of infiltrate is diffuse?

interstitial 

______ happens when the alveoli can’t inflate properly. It can be caused by pressure outside of the lung, blockages, low airflow or scarring. The most common cause is surgery with anesthesia. It typically resolves after treating the underlying cause.

Atelectasis

Radiographic finding described as poorly marginated density or “fluffy”

alveolar infilatrate

NOTE: alveolar infiltrates can appear as fluffy or as complete consolidations

Pattern seen on CXR or CT scans when air-filled bronchi become visible against a background of dense lung tissue.

Air bronchogram sign

Which air space pathology is usually diffuse, seen as thin white lines and sometimes may present with a honeycomb appearance?

interstitial infiltrates

Are interstitial infiltrates specific or non-specific?

non-specific

NOTE: can be caused by many processes such as CHF, pulmonary fibrosis, collagen vascular diseases etc.

Differentiate between Kerley A vs Kerley B lines.

• Kerley A: linear opacities extending from periphery to hila

• Kerley B: small, horizontal, peripheral lines seen at the lung bases (represent thickened interlobular septa on CXR)

Interstitial infiltrate pattern on CXR found in patients with interstitial pulmonary edema?

Kerley lines

How would you describe the interstitial pattern on CXR in pulmonary fibrosis?

Reticulonodular 

On a CXR, what is a spine sign?

A radiographic sign indicating pleural effusion, where the appearance of the spine becomes more visible due to the overlying fluid.

What microorganism is the most likely cause of interstitial pneumonia in normal adults?

Mycoplasma pneumoniae

PJP

is a type of pneumonia caused by the fungus Pneumocystis jirovecii, primarily affecting immunocompromised individuals. Evolves from a normal CXR to an interstitial pattern to an alveolar pattern.

CXR showing diffuse bilateral reticulonodular interstitial infiltrates. What is the most likely diagnosis?

Cystic PJP

What population does PJP most commonly affect?

Primarily immunocompromised individuals, such as those with HIV/AIDS, cancer, or those on immunosuppressive therapy.

Most common imaging feature of ARDS

bilateral airspace opacities and consolidations

What is the most common benign tumor of the lung?

hamartomas

When would a CT scan be indicated for a pulmonary nodule?

• > 3 cm in patients younger than 35

• any size in patients older than 35

Definitive diagnosing and staging of lung cancer?

Diagnosis = bronchoscopy

Staging = CT scan with contrast

Most common type of lung cancer; usually occurring peripherally.

adenocarcinoma

Lung cancer typically occurring centrally and with cavitation

squamous cell carcinoma

Type of lung cancer that often presents as an indistinct hilar or perihilar mass

small cell carcinoma

Type of lung cancer that can occur either peripherally or centrally and grows rapidly with early metastasis.

non-small cell carcinoma

What are common sites of metastasis with lung cancer

liver, adrenal glands, bones and brain

Type of lung cancer commonly occurring peripherally

adenocarcinoma

What type of lung cancer is this?

squamous cell carcinoma

Type of lung cancer that commonly exhibits mediastinal lymphadenopathy

small cell lung carcinoma (SCLC)

What is a pancoast tumor?

Type of lung cancer located at the lung apices

Silhouette sign?

Loss of normal contour between adjacent structures on imaging

Spine sign?

Radiological finding indicating a lung mass adjacent to the spine

What does spine sign look like on lateral CXR?

Localized opacity of the spine; due to a lung mass in the posterior mediastinum obscuring the normal appearance of the vertebral bodies