(THIRD YEAR SURVIVAL)

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I
Who, 2 Why’s and a What
Who
--- is the patient?
55 yo aaf with a history of heart disease.
ie-sex, age, ethnicity and pertinient history
Why
--- Chief complaint
She comes to the ED with complaint of SOB.
Why
--- Indication for the exam.
SOB
What
--- What image are you looking at?
This is a frontal projection of a chest xray.

D
EXAM QUALITY FINDINGS
EXAM
- Describe the exam and any details of how it was performed.
ie-AP portable chest x-ray done today in the ICU ie-Multiple sections from a CT exam of the abdomen available – IV contrast was administered.
Number of images
Single or multiple
Prior films for comparison ie-There is an upright PA and Lateral chest x-ray done yesterday for comparison.

EXAM -
QUALITY-
FINDINGS
( Inspiration, Position, Exposure )
Inspiration – Adequate or decreased .
Poor is not a good descriptive choice. Remember: The patient is sick, the technologist gets the best film possible, and you weren’t there.

EXAM-
QUALITY
FINDINGS
(Inspiration , Position, Exposure )
Position –
Satisfactory positioning or note rotation by clavicle position compared to the midline spinous process.
* If clavicles project higher than the ribs its lordotic angulation
* PA will have less magnification of the heart than an AP
* If it is a portable --it’s an AP
* If there is a lateral view --it’s a PA
* If you can’t tell---say FRONTAL

EXAM -
QUALITY
- FINDINGS
( Inspiration, Position, Exposure)
Adequate or satisfactory are good terms to use.
Penetrationis also a term used to describe exposure. This is assessment of overall whiteness or darkness of the image.
Underexposureimage is too white (not enough photons) This limits evaluation in retrocardiac region and can simulate
CHF or interstitial disease.
Overexposur eimage is too dark. This can limit evaluation in the periphery of lung field especially for nodules and pneumothorax. It can also simulate COPD.

EXAM - QUALITY-
FINDINGS
Depending on Attending physician’s preference:
Formal recitation of reading the chest x-ray or
Description of dominant positive findings
Some attendings prefer a specific format when reading a chest x-ray
Know: Formal or informal —Which is appropriate for the situation
You can obtain this info from observations of other students, interns and residents.

A good habit is to start by describing post –op changes, support catheters and devices.
*Note the distal location of the device / catheter
*** MALPOSITION OF LINES AND CATHETERS IS OFTEN OVER LOOKED
DUE TO PATHOLOGY ON THE IMAGE.
Terms for catheter / device description:
. examples…
… The ET tube is above the carina
… Central catheter enters on the left extending to the SVC
… Post-op changes from mediastinal surgery are seen

DESCRIPTIVE TERMS
FOR
NORMAL CHEST EXAMS
CHEST WALL There is no soft tissue abnormality / pathology.
SKELETAL - No traumatic or destructive lesions are seen.
(note-degenerative changes in spine)
HEART SIZE - The cardiac silhouette is within normal limits.
MEDIASTINIUM There is no mass or abnormality.
HILA - There is no hilar mass or suspicious adenopathy.
PULMONARY VASCULARITY Is not engorged.
LUNGS - Show symmetric ventilation without mass or consolidation.
PLEURA - Shows sharp costophrenic angles without effusion.

Use this phrase and fill in the blanks
There _
*
_ a/an ______ of ________density located______ which is of _______size
And shows ______shape and ________margin.
* is
* are
Let’s choose is
There is an ______ of ________density located______ which is of _______size
And shows ______shape and ________margin.

There __ a/an _
*
__ of _______density located______ which is of _______size and shows ______shape and ________margin.
* Area
* Region
* Zone
* Focus
* Nodule
Let’s choose area
There is an area of _______density located______ which is of _______size and shows ______shape and ________margin.

There __ a/an ___ of _
*
__density located______ which is of _______size and shows ______shape and ________margin.
* increased
* decreased
* mixed
* homogeneous
* heterogeneous
Let’s choose mixed
There is an area of mixed density located______ which is of _______size and shows ______shape and ________margin.

There is a ______ of ________density located___
*
___ which is of _______size and shows ______shape and ________margin.
* projecting over
* in the region of
* lateral / medial to
* extending from “X” to Y
* in the Rt. / Lt. chest hemithorax lung lobe
Let’s choose In the region of
&
Lt. lower lobe
There is an area of mixed density located in the region of the Lt. lower lobe which is of _______size and shows ______shape and ________margin.

There is a ______ of ________density located______ which is of ___
*
____size and shows ______shape and ________margin.
* Large
* Moderate
* Small
* Approximately 3cm in diameter or 3 to 4 cm in diameter
Note-rib width serves as a 1cm measurement
Let’s choose “moderate”
There is an area of mixed density located in the region of the Lt. lower lobe which is of moderate size and shows ______shape and ________margin

There is a ______ of ________density located______ which is of _______size and shows __
*
__shape and ________margin.
* round / rounded
* lobular
* oval
* triangular
* irregular
* wedge shaped
Let’s choose irregular
Curvilinear is a universal descriptor that fits about any shape other than straight
There is an area of mixed density located in the region of the Lt. lower lobe which is of moderate size and shows irregular shape and ________margin

There is a ______ of ________density located______ which is of _______size and shows ____shape and ___ * __margin.
* sharply defined
* ill defined
Let’s choose sharply defined
There is an area of mixed density located in the region of the Lt. lower lobe which is of moderate size and shows irregular shape and sharply defined margins.

E
C ompare
• Is there change from a previous exam.
• State your interpretation of the significance of the findings .
•
Discuss diagnosis and differential
Example
I would be concerned about ___
I think this is____
I would have to consider____
•Start by stating the most likely first.
•Mention the most significant that would be considered with this history and exam.
•Think in terms of general pathologic topics.
Infection, Neoplasm, Cardiovascular, Trauma

A
What are you going to do?
• observe
• compare with old studies
• repeat / new studies
• interventions
• lab studies
• additional physical exam
Example: * Plan to discuss with radiology about performing a percutaneous biopsy.
* Check to see if there are other previous exams.

Make statements
—don’t ask questions---Watch tone of voice!
Think simple, cheap, and safe as first step.
Be as general as you have to be and as specific as you can be.
Best film is the previous film
Hazy, ill defined, cloudlike, fluffy-------air space disease
Linear, reticular,coarse,-----interstitial disease
? Nodule-----repeat chest with nipple markers
? Pleural effusion----Decubitus film
? Apical disease----Lordotic film
Portable film----Repeat in department asap
? Retrocardiac mass----barium study---hiatal hernia
Chest wall lesion----get rib detail film
? Pneumothorax---get expiration film
Trace tubes & lines with your finger if exact position is not clear, tip is where problems arise.
Et tubes go distal into Rt. mainstem often. Practice finding carina.
Rib height = 1cm--Vertebral body=3cm
If it is calcified, goes away or remains stable over time = benign
X-ray / CT---------------------------density
Ultrasound----------------------echogencity / anechoic
Nuclear medicine------------intensity / activity
MR------------------------------------- intensity / signal