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Tearshaped spinousprocess 1. Check the Spinal Processes to Assess for Rotation is ⿞Objective: Checking the spinal process ensures that the patient is not rotated in in the X-ray film for an accurate reading ⿞If the patient is rotated then that can result in ‣ Difference in lung size ‣ Heart may appear enlarged ‣ Misinterpretation due to inaccurate patient placement How to Assess? • Check the spinal processes of the upper spine • The processes should look straight, vertical, and oval shaped (Tear shaped) • If the x-ray is rotated it will look like Tucan Beak shape (Horizontal) Carina Trachea 2. Mediastinum • Objective: To check if there is a shift in the mediastinum • The Mediastinum is a space in between the right and left lung that contains structures such as the esophagus, aorta, and heart. • The position of the mediastinum (whether regular or shifted) can be assessed by looking at the Carina which is it where the trachea bifurcates • What does a shift in the Carina indicate? ⿞Pathology of the lung which can either directly or indirectly affect the mediastinum ⿞Ex. Direct: Tumor growing in the mediastinal space which can push the Carina to the left or right lung ⿞Ex. Indirect: lungs are being affected (such as lung scaring) which can pull the mediastinum along with it. • Splaying of the Carina: The carina is splayed as a result of the enlarged atrium pushing up from underneath causing the angle of the Carina to widen over 90 degrees How to Assess? Borders ofcolumn • Check the trachea and the Carina • The Carina should be within the confines of the outline of vertebra the vertebral column • Abnormal pathology: If the mediastinum is shifted then the Carina will be outside of the borders K • In the case that the mediastinum is shifted, check the angle of the Carina (around 90 degrees) ⿞Abnormal pathology: splayed Carina (over 90 degrees) 3. Costophrenic angle • Objective: To check for large amount of fluid accumulation (Pleural effusion) • The costophrenic angle is the area where the diaphragm meets the ribs • Pleural space is lubricated with 3ml of fluid • Found only in 2D scans (like a X-ray scan) and will not be seen in 3D scans (like a CT scan) • Fluid is found in the costophrenic angle due to gravity • Typically increased amount of fluid will not be seen in an X- ray unless it’s over a minimum of 300 ml (CT scan will definitively identify fluid accumulation) r u • What causes fluid accumulation? costophrenic ⿞Obstruction of the lymphatic vessels angles ⿞Infection and inflammation ⿞Pneumonia How to Assess? • Check the costophrenic angles and look for a dark downward deep V indentation. • If the the shape of the costophrenic angle (deep V) is identifiable then there is no significant amount of fluid • The costophrenic angle may look hazy due to overlying breast tissue (Normal) • Abnormal pathology: The costophrenic angle will be blunt (deep V is completely whited out) which indicates pulmonary effusion 4. Apex of the Lung • Objective: To check for air accumulation in the lung nterstitiallung markings (Pneumothorax) Apex • The apex is the superior part of the lung that is above the clavicle • What causes air accumulation? ⿞Injury to the lungs such as a lung puncture How to Assess? • Check for lung markings that surpass the clavicle • Abnormal pathology: If there is air accumulation (pneumothorax) then the apex will be pitch black and depending on the size of the pneumothorax then the lungs will be condensed downwards Hilum 5. Hilum of the Lung • Objective: To check if the hilum is enlarged and to check the function of the lymphatic system • The hilum is the area at which structures ( blood vessels, lymphatic system, airway) enter and leave the lung • What causes an enlarged Hilum? XP ⿞congestion of the lymphatic Vessels due to cancer, heart failure, and inflammation How to Assess? • Check the hilum of the lung for a kidney bean shape (concave indentation in the middle of the hilum) which will be fully visible in the right lung with only the top of the left hilum being visible due to the heart covering the rest of the hilum • Abnormal pathology: an enlarged hilum will lose its concave indentation and will become convex (oval shaped) 6. Heart • Objective: To check if the heart is enlarged • What causes enlargement of the right side of the heart? ⿞Pulmonary embolism escalating the pressure in the lungs causing pulmonary hypertension • What causes enlargement of the left ventricle ? ⿞Chronic disorder (chronic hypertension) • What causes enlargement of the left atrium? ⿞In the case where there is left atrial enlargement and a normal sized left ventricle then that indicates the Y recent occurrence of heart pathology such as a heart attack How to Assess? • 1. Right side of the heart: Check if the right side of the heart is convex and forms to create an angle with the diaphragm ⿞Abnormal pathology: the outline will be blunted and there will be a loss of the convex shape • 2. Left side of the heart: Check if there is space between the apex (tip) of the left ventricle and the chest wall ⿞Abnormal pathology: the apex of the left ventricle will stretch out and meet the chest wall • 3. Left atrium: top chamber of the heart should have two slopes, one going down (represents the left atrium) and one coming out (represents left ventricle). ⿞Abnormal pathology: instead of the typical two slopes, it will only be one slope going down 7. Lungs • Objective: To check for infiltrates, opacities, and consolidation • Interstitial lung markings will be more prominent the closer they are to the hilum ⿞the vessels in the apex will look faint compared to the base of lung which will look more prominent (due to gravity) ⿞Blood vessels should be prominent near the hilum ⿞Blood vessels should not be visible near the chest wall • What causes lung markings near the chest wall? ⿞pulmonary vascular congestion brought on usually by heart failure • What may cause infiltrates, opacities, and consolidation? ⿞Fluid ⿞Inflammation ⿞Infection ⿞Blood ⿞Pus ( due to inflammation) ⿞Mass (consolidation) Prominentlung markingsnear arenotvisables the hilumbthe near thechest base wall How to Assess? • 1. Read the lungs in a zig zag fashion to asses for an overall level of uniformity (separately for each lung then asses if both lungs look similar to each other) • 2. Lung markings should be prominent near the hilum but fade out towards the chest wall ⿞Abnormal pathology: lung markings are found near the chest wall • 3. Check for lung infiltrate ( markings going through the lungs) • 4. Check for opacities (cloudy markings) • 5. Check for consolidation (completely white mass or marking) NORMAL CHEST X-RAY The patient is not rotated due to the spinous processes not being rotated themselves. The mediastinum does not appear to be shifted with no mass effect. No definitive pleural effusions are evident. The apices of the lungs have interstitial markings that extend upwards with no obvious findings of a pneumothorax. The hilum looks of normal shape bilaterally. The heart does not appear enlarged, with the left and right atrium appearing to be of normal size. In regards to the lung markings there is a uniformity distribution from top to bottom with some allowance of more interstitial markings of the bases.