wayang kulit, no 1 a fundamentals
DESCRIPTION
From Dr Ng Kian Seng:"Please send this out to all those coming, it is just a revision of the fundamentals. I dont intend to go through this at the workshop.I will go straight to the Systematic Reading of the Chest Radiographs. It will take only 10 minutes to run through this powerpoint, so please run through it before coming."TRANSCRIPT
CHEST RADIOGRAPHS, WAYANG KULIT
A REVISIONOF THE FUNDAMENTALSDr Ng Kian SengMBBS (Singapore) MCGP (Malaysia)Master Of Medicine (Internal Medicine, Singapore)FAFP (Malaysia) Cert In Occupational MedicinePh D (Theology, USA)
Hippocrates of C
os, Fath
er of Medicine
ANATOMY IN THE CHEST RADIOGRAPH
A Normal Chest Radiograph
Some examiners like you to call x ray films radiographs; strictlyspeaking you can’t actually see the x rays themselves.
A Chest Radiograph,Not A Chest X-Ray
Anatomy in the Chest Radiograph
The right main bronchus is slightly larger than the left & comesoff at a less acute angle than the left (hence septic material &foreign substances are more likely to be inhaled into the right lung than into the left).
Trachea Apex Of Lung
Carina
Aortic arch
Left ventricle
Gastric Air Bubble
Right para-tracheal stripe
MainPulmonaryArtery
Left Atrialappendage
Descending thoracic aorta
Chest Radiograph, PA View, No 1
Right lower lobe pulmonary
artery
Right hilum
Right upper lobe pulmonary
vein
Right Cardiophrenic Angle
Right Costophrenic Angle
Right atrium
Horizontal fissure
Chest Radiograph, PA View, No 2
Chest Radiograph, PA View, No 3
Scapula
Breast Soft Tissue
Diaphragm
Anterior Rib
Posterior Rib
Spinous process
Clavicle
Left Bronchus
Right Bronchus
Lung TissueSuperimposedOn diaphragm
Retrocardiac vertebra
Chest Radiograph, PA View, No 4
Anatomy Of the Heart In The Chest Radiograph
THE MEDIASTINAL STRUCTURES IN THE C-XRAY
Aorto-pulmonary window. The aorto-pulmonary window lies between the arch of the aorta and the pulmonary arteries. It contains the ligamentum
arteriosum, the recurrent laryngeal nerve, lymph nodes, and fatty tissue. ...
AortoPulmonaryWindow
From the level of the clavicles to the azygous vein the right edge of the trachea is seen as a thin white stripe. This appearance is created by air of low density (blacker) lying either side of the comparatively dense (whiter) tracheal wall. If this stripe is thickened
(normally less than 5 mm) this may represent pathology such as a paratracheal mass or enlarged lymph node. The left side of the trachea is not so well defined because
of the position of the aortic arch and great vessels.
RIGHTPARA-
TRACHEALSTRIPE
Anatomy in the
LateralChestX-ray
1. Ascending thoracic Aorta2. Sternum3. Right ventricle4. Left ventricle5. Left atrium 6. Gastric air bubble7. Right Hemidiaphragm8. Left Hemidiaphragm9. Right upper lobe bronchus10. Left upper lobe bronchus11. Trachea.
NAME THE STRUCTURES IN THE LATERAL CHEST X-RAY
9
10
1.Trachea2. Aortopulmonary window 3. Sternum4. Right ventricle 5. Right Hemidiaphragm 6. Left Hemidiaphragm 7. Left atrium 8. Scapula 9. Right Upper Lobe Bronchus10. Left upper Lobe Bronchus
The mediastinum is divided by a plane passing from the sternal angle to T4-T5 into: Superior mediastinum and The inferior mediastinum
The inferior mediastinum is further subdivided into three regions namely:Anterior mediastinum Middle mediastinumPosterior mediastinum
These divisions are for descriptive purposes, theymerge into each other imperceptibly. There are no distinct boundaries between them.
THE MEDIASTINUM
ZONES OF THE CHEST RADIOGRAPH
UPPERZONE
MIDDLEZONE
LOWERZONE
Apex to a line drawn throughThe lower borders of theAnterior ends of the 2nd costalCartilage.
From the 1st line to one drawnThrough the lower borders of the4th costal cartilage & includesThe Hila of the lungs
From the 2nd line to theBases of the lungs.
THE FISSURES OF THE LUNGS
Oblique Fissure From 4 th Dorsal spine sweeping downObliquely to the 6th rib in mid mammary line or the 6th costo Chondral junction, anteriorly.Horizontal Fissure. Runs from the 4th costo chondral junction To meet Oblique Fissure at the mid axillary line.
THE LOBES & FISSURES OF THE LUNGS
Base of the Lung: 6th costochondral junction, obliquely to the 10th rib in anterior Axillary line,
then horizontally to 12th thoracic vertebra
Oblique Fissure : From 4th Dorsal spine sweeping downObliquely to the 6th rib in mid mammary
line or the 6th Costochondral junction, anteriorly.Horizontal Fissure. Runs from the 4th costochondral
Junction to meet Oblique Fissure at the mid axillary line.
OBLIQUE FISSURE , HORIZONTAL FISSURE
From 4th Dorsal spine sweeping down Obliquely to the 6th rib
in midmammary line or the 6th
Costochondral junction, anteriorly.
THE RIGHT & LEFT OBLIQUE FISSURES
Horizontal Fissure. Runs from the 4th costochondral junction to meet Oblique Fissure at the Mid Axillary Line.
THE HORIZONTAL FISSURE
WHAT IS THE ABNORMALITY HERE?
ACESSORY FISSURE, THE AZYGOS FISSURE
.The azygos lobe appears starting in a teardrop shape at around the level of T5 to the right of the midline as a pale line curving outward and upward and then back in to meet the root of the neck, the line is the infolding of the pleura. Also described as a “curvilinear opacity,Inverted comma, tadpole.” (See Notes in “Companion”, J)
NORMAL VARIANTS IN THE CHEST RADIOGRAPH
Louis P
asteur
NIPPLE SHADOWS
NIPPLE SHADOWS
RIGHT NIPPLE
LEFT NIPPLE
Confirm these are indeed nippleShadows by using metal markers!
ASYMMETRY OF THE BREASTS
Breast asymmetry is very common, even to the extent that no breast tissue is visible on one side.
It should not be assumed that the patient has had a mastectomy, unless this is known from
the history.
BONE ISLAND IN THE RIB
DROMEDARY HUMP IN THE DIAPHRAGM
EXAMINE THE FIRST & SECOND RIBS ON BOTH SIDES
FUSION OF FIRST & SECOND RIB ON THE LEFT
PSEUDO-ARTHROSIS OF THE FIRST TWO RIBS ON THE LEFT
BIFURCATED RIB
Soft tissue fat This close-up demonstrates a normal fat plane between layers of muscle. Fat is less dense than muscle and so appears blacker. Note that the edge
of fat is smooth. Irregular areas of black within the soft tissues may represent air tracking in the subcutaneous layers. This is known as
surgical emphesyma
What is the bony abnormality in this patient?
Chest radiograph is showing well developed bilateral cervical ribs.
Cervical rib is an extra rib that arises from the 7th cervical vertebrae. How do you know these are cervical ribs? And
not the 1st thoracic ribs?
Look at the transverse processes that articulate with these ribs. Cervical transverse processes points down while thoracic transverse processes points up.
CervicalTransverseProcessesPoints Downwards=CD
ThoracicTransverseProcessesPoints Upwards =TU
THE BLACK & WHITERADIOLOGICALTERMS
Edw
ard Jenner
AIR
FAT
BLOOD
MUSCLE
BONE
BARIUM
RADIOLUCENT
RADIOPAQUE
INC
RE
AS
ING
RA
DIO
DE
NS
ITY
DE
CR
EA
SIN
G R
AD
IOD
EN
SIT
Y
RADIODENSITY SCALE
radioLucent = bLack radiopaquE = whitE
Radiodensity : Physical quality of an object that determines how muchradiation it absorbs from the X-Ray beam. Radiodensity is determined
by composition ( atomic weight) and thickness
“WHITE IMAGES” “BLACK IMAGES”
The greater the density, the lesserthe penetration of the X-Raysthrough the object.
The lesser the density, the greaterthe penetration of the X-Raysthrough the object
The film remains less exposed The film is more exposed
White Image Black Image
Term used : RadiodenseOr Radiopaque
Term Used : Radiolucent
RADIODENSITY SCALE
Term Density Appearance Example
Radiolucent Low Black Air, Fat
Radiodense(Opaque)
High White Bone, Barium
RADIODENSERADIOPAQUE
RADIOLUCENT
RADIODENSE VERSUS RADIOLUCENT
“What is the student but a lover courting a fickle mistress who ever eludes his grasp?”
Sir William Osler
Antonie
von Leeuw
enhoek
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