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Wright, 2016 1
Chest and Abdominal X-ray Interpretation: Honing Your Skills Wendy L. Wright, MSN, RN, APRN, FNP, FAANP, FAAN Adult/Family Nurse Practitioner Owner - Wright & Associates Family Healthcare @ Amherst, NH Owner – Wright & Associates Family Healthcare @ Concord Owner – Partners in Healthcare Education, LLC Disclosures Wright, 2016 ►Owner – Wright & Associates Family Healthcare @ Amherst and @ Concord ►Partner – Partners in Healthcare Education ►Speaker Bureau: Novartis, GSK, Sanofi- Pasteur, Takeda, Merck, Vivus, Boehringer ►Consultant: Vivus, Takeda, Sanofi- Pasteur (^2) Wright, 2016 3 Objectives
- Upon completion of this lecture, the participant will be able to: - Identify a step approach to the interpretation of chest and abdomen - Discuss various abnormalities identified on x- rays of the chest and abdomen - Systematically interpret x-rays of the chest and abdomen
Wright, 2016 4 Radiography
- X-rays account for > 80% of all diagnostic studies ordered - Chest x-rays and extremity films are the 2 most commonly ordered x-rays
- X-rays are meant to be used in combination with the patient’s history and physical examination to assist with an accurate diagnosis Wright, 2016 5 Remember… - The goal of this workshop is not to make you a radiologist but… - It will provide you with a great starting point to begin chest x-ray interpretation Wright, 2016 6 Radiography
- X-rays are made when an x-ray beam passes through an area on the patient producing different shadows on the films - The amount of shadowing is determined by the type of material or tissue the beam is flowing through - Denser structures such as bone absorb more x-ray whereas air (least dense of all) absorbs very little
Wright, 2016 10 Four Basic Densities or Shades
- 4 basic shades/densities on a film
- Water (blood and soft tissue)
- Bone
- Appear almost white on x-ray Wright, 2016 11 Figure 1-2A: PA View
Bone
Muscle
Wright, 2016 12 In Addition
- The following also appear white:
Wright, 2016 13 Terminology
- Density: brightness or any area of whiteness on an image
- Lucency: blackness on an image
- Shadow: anything visible on an image: any density or lucency
- Edge: visible demarcation between a density and a lucency
- Line: thin density with lucency on both sides
- Stripe: Any edge or line
- Silhouette: another term for an edge
Adapted from Procedures for Nurse Practitioners; Springhouse: Penn; 2001
Wright, 2016 14 X-rays
- Two dimensional look at the body (which is 3 dimensional) - Therefore, multiples views of an area are often standard - This is why PA and lateral views are often performed on the chest (in an upright patient) - Provides additional view that may identify something not visible on a single view Wright, 2016 15 PA View
- Patient’s chest is against the film
- X-ray beam passes from posterior region (patient’s back) to the anterior region (chest)
- X-ray machine is approximately 6 feet away
- Great view of things that sit anterior:
- This view is better to see the heart (because heart is anterior)
Wright, 2016 19 Basic Information
- First and foremost, x-ray interpretation requires a systematic, logical approach
- You must approach the x-rays in the same way every time to prevent omissions
- You must also have an understanding of basic anatomy and physiology
- So, let’s begin…
Wright, 2016 20
Chest X-Rays Wright, 2016 21 Indications for Chest X-ray
- Based upon your history and physical examination, a chest x-ray may be ordered to assess to: - Detect and assess lung disease - Pneumonia, CHF, COPD, Cancer - Assess for chest trauma - Placement of tubes/devices
Wright, 2016 22 Basic Information Regarding Chest X-rays
- The most common chest film is a PA film
- Performed at a distance of 6 feet
- AP is often done on hospitalized patients (portable or supine film)
- If the clinician just writes for a Chest x-ray: Lateral view is also routine - Left side is against the cassette - Lateral view is essential for any lesions behind the heart, mediastinum, or diaphragm as these are often missed on a PA film Wright, 2016 23 Figure 1-1A: PA View Wright, 2016 24 Figure 1-1B: AP View
Look at the differences
Wright, 2016 28
Figure 1 – 7 A: Expiration
Cardio-
megaly
Wright, 2016 29 Figure 1-7B: 2 hours Later: Inspiration Wright, 2016 30 Systematic Approach is Essential
- PA or AP film is hung on the view box like you are facing the patient from the front
- Start reading the x-ray by looking at the least important areas first - Then move to the most important areas; the reason you ordered the x-ray in the first place
Wright, 2016 31 Figure 1-2A: PA View Wright, 2016 32 Systematic Approach
- Verify name, age, and date of birth
- There have been a number of occasions when the wrong name has been applied to a film or the wrong patient’s film has been hung on the box Wright, 2016 33 Step 2
- Assess:
- Technique utilized
- PA, AP, lateral
- PA and lateral preferred (PA clearer)
- Position of the patient
- Upright, supine, decubitus, lordotic
- Inspiratory Effort
- Normal, hyperinflated, hypoinflated Adapted from Mettler, et. Al. Primary Care Radiology. 2000; WB Saunders.^ – Rotation
Wright, 2016 37 Figure 3-1B Wright, 2016 38 Figure 3-1B
Costophrenic
Left diaphragm sulcus
heart
Aortic arch
trachea
hilum
carina
stomach
Ascending
aorta
Wright, 2016 39 Posterior-Anterior View
Wright, 2016 40 Left Lateral View Wright, 2016 41 Pneumonic
- Helpful when trying to remember your systematic approach to chest x-ray interpretation - Are There Many Lung Lesions? - Abdomen - Thorax (soft tissues and bones) - Mediastinum - Lung (unilateral) - Lungs (bilateral)
Goodman, L. R. Felson’s Principles of Chest Roentgenology; 2nd^ ed. 1999.
Wright, 2016 42 Start With The Abdomen
- Start in the right upper quadrant
- Scan across the abdomen
- Normally, you will see the following:
- Liver
- Stomach bubble
- Splenic flexure of the colon
- Diaghragm (right diaphragm is higher than left)
- Spleen may or may not be visible
Wright, 2016 46 Figure 3-5B
Identify the 4 structures
In the abdomen
Liver
Stomach bubble
Splenic flexure of colon
Diaphragm
Wright, 2016 47 Move to the Right Lung Base
- Start with the right base, looking at:
- Soft tissues (Muscles, breasts)
- Chest wall
- Ribs
- Anterior ribs descend from lateral to medial
- Posterior ribs descend from medial to lateral
- Only the upper ribs are completely seen on x-ray
- Shoulder girdle (scapula)
- Scan up to the clavicle
- Then work down the left lung to the base
- Compare right to left Wright, 2016 48 So….
- Look for:
- Right breast
- Anterior ribs
- Posterior ribs
- Scapula
- Clavicle
- Left breast
Wright, 2016 49 Figure 3-6A Wright, 2016 50 Soft Tissues, Ribs, Shoulder Girdle Wright, 2016 51 Soft Tissues, Ribs, Shoulder Girdle
Right breast
Posterior rib
Scapula
Clavicle
Anterior rib
liver^ Stomach
Wright, 2016 55 Mediastinum Wright, 2016 56 Mediastinum
Trachea
Carina
Aortic Knob
Ascending
Aorta
Hilum Descending Aorta
Heart
Stomach Bubble Costophrenic Angle
Wright, 2016 57 Now, Look at the Lungs
- Since most chest x-rays are ordered to look at the lungs, these are saved for last
- We always need to look at the lungs twice when examining the x-ray - First examination is looking at each lung individually - Second examination is a comparison between the right and left lung - Also…use this as an opportunity to look again at the costophrenic angles and the hilum
Wright, 2016 58 Figure 3-8A Wright, 2016 59 What’s the Abnormality? Wright, 2016 60 Figure 3-9B: 1 year prior
