Professional Documents
Culture Documents
Brenda Buikema, MD
M3 Inpatient Internal Medicine
Curriculum
Images taken from www. google.com unless labelled
Normal Anatomy
Things To Know
• Cardiac Anatomy
• Lung anatomy
• Bones
Heart Borders
• PA
– Right Border - Right Atrium
– Left Border–Left ventricle
• Lateral
– Anterior Border–right ventricle
– Posterior Border–left ventricle/left atrium
• Overall size – Less than 50% of the
transthoracic width is normal
Aortic Arch
Right
Pulmonary
Artery Left
Pulmonary
Artery
Left
Ventricle
Right
Atrium
Aortic arch
Left Atrium/
Left
ventricle
Right
Ventricle
Right
diaphragm
Left diaphragm
IVC
Valves
Aortic
Valve
Tricuspid
Valve
Abnormalities with Heart Borders
• Left Atrial Enlargement –Multiple changes
– Third Mogul sign –
• 1st – aortic knob
• 2nd – pulmonary artery
• 3rd – Left Atrium
– Splaying upward of the left mainstem bronchus
– Double density –a shadow to the right of the T spine –
superimposed behind the right atrial shadow
– Remember that the left heart border should be
concave –NOT CONVEX!!
Abnormalities with Heart Borders
• Right Atrial enlargement – Prominent right
heart border
• Right ventricular enlargement – if large
enough will produce a Boot-Shaped Heart
– We depend on the Lateral more for this (see
later)
• Left Ventricular enlargement – depend
more on lateral for this – left ventricle will
project 2 centimeters behind the IVC
Left Atrial Enlargement
Note: is
more
convex
here
than
concave
(third
mogul)
Lung Anatomy
• Right side –
– 3 lobes – right upper, middle and lower
• Remember right middle lobe abuts the right heart border,
right lower lobe does not
• Left side –left upper and lower lobes and lingula
• Other structures –
– Pulmonary vessels
– Diaphragms –right hemidiaphragm should always lie
higher than the left
Trachea
Right
main Carina
stem
bronchus
Left main
stem
bronchus
Right
hemidiaphragm
Left
Right hemidiaphragm
costophr-
enic
Angle
(off the Gastric
screen) bubble
Lung Anatomy
• Right upper lobe and Right middle lobe
separated by the horizontal (minor) fissure
• Right lower lobe separated from middle
and upper by the oblique (major) fissure
• Left lower lobe separated from left lower
lobe by the oblique (major) fissure
Lung Anatomy
Minor
(horizontal)
fissure
Right Lung on PA
Right
upper
lobe
Horizontal
fissure
Right
middle
lobe
Right Lung on Lateral
Minor
(horizontal)
fissure
Major
(oblique)
fissure
Spaces on Lateral
• Retrocardiac –
– Look for infiltrates here
• “spine sign” –as the spine goes down, the T spine should
stay clear – when it does not – this is likely infiltrate
• This is also where the IVC is –if “filled up” think left
ventricular enlargement
• Retrosternal –
– if too small –think right ventricular enlargement
– If too big –think COPD
Retrosternal
space
Retrocardiac
space
Bones
• Ribs –beware fractures
• Clavicles –check the heads
• Spinous processes
• T spine
First rib Clavicles
Spinous
process T spine
Systematic Approach
To Interpreting Chest Xrays
On the PA/AP. . . . .
1. A -Adequacy
• 1. Check the name and date
• 2. Organize –check right and left
• 3. AP vs PA?
– Heart will look slightly larger on the AP as compared
to the PA
• 4. Check for rotation
– Clavicles centered evenly over the vertebral column
– Measure the distance from the medial end of each clavicle to
the spinous process of the vertebrae at the same level – should
be equal
1. A -Adequacy
• 5. Check for penetration –especially when
comparing to priors –should be able to
barely see the thoracic vertebrae behind
the heart
• 6. Exposure – Make sure you can see the
whole film –need to be able to identify the
costophrenic angles and the apices
1. A -Adequacy
• 7. How many posterior ribs should be
seen in order to consider a chest Xray
adequate in terms of inspiration?
– A. 6
– B. 7
– C. 8
– D. 9
1. A -Airway
• Ensure the airway is visible
– If not midline:
• Pushes away from abnormality –pleural effusion, tension
pneumothorax
• Pulls towards abnormality -atelectasis