(Some Basics in X.

Ray)
Miscellaneous ‫" ← ممكن حاجة من‬Heart ‫ أو‬chest" ‫أغلب الحالت‬
30 ‫من الدرجة‬% → comment " Items"
70 ‫من الدرجة‬% → Diagnosis, III, ‫شغل نظرى‬
Com ment:-
1. Type of X. Ray:-

a) Plain
b) e contrast → Barium swallow ( LT atrial enlargement)

2. Type of the patient:

a) female " Breast shadow" lung ‫الـ درجة بياض تزيد كل ما تنزل تحت‬

b) male
c) child
3. view:-

a) post Anterior view

b) ant posterior view ( exception ‫) فى حالة طوارىء‬

False cardiomegally
False congestion
c) lat. View → ً‫غالبا‬ → R.t ventric. enlargement
→ L.t atrial enlargement
4. centralization:-

From clavicles, dorsal spine which appears as tear drops

We consider centralization if the space from dorsal spine to the medical
end of the clavicles is equal on both sides
‫ → خطأ شائع‬Don’t use trachea in diagnosis of centralization
Centralization ‫ ← من‬centralized or not ← trachea ‫نحكم على ← بمعنى‬
‫وليس العكس‬
5. Ribs :-
Ant half of the Rib differs from the post half of the Rib
a) post half → Horizontal, reach midline , more dense
 b) ant half → oblique, doesn’t Reach midline , less dense

N.B
Ant half of ribs don’t reach midline as it continues with costal
cartilage → radiolucent.
‫فىركز‬
‫ ← من المام وليس الخلف‬Horizontal Ribs ←COPD ‫حالت‬
Horizontal ← ‫ كده كده‬post Ribs ‫لن‬

‫عشان محدش يضحك عليك‬

Ribs‫ازاى‬
‫نعد إلى‬

Post Half " ← 1st Rib " ‫ تمثل الـ‬Bony thorax ‫•منأعلى نقطة فى‬
‫الخلف‬
Horizontal Ribs ← ‫•نعد من الخلف‬

Post Half " ← 1st Rib " ‫ تمثل ال الـ‬Bony thorax ‫أعلى نقطة فى‬
‫•من‬
‫المام‬
oblique Ribs ← ‫تيجى معاه على أدام وتعد من المام‬•

‫خطأ‬
• 1st Rib
concavity of theAppear Cavity
As

• Appear
Medical edge of scapula shadow
As
6. Diaphragm : - " items"

1. Borders
2. contour
3. level
4. costophrenic Angle
5. cardiophrenic Angle

1. Borders:-

 Normally :Smooth sharply well defined

 Abnormally: ill defined e.g lower labor pneumonic opacity

2. contour:- *Normally: convex upward

  Abnormally: flat or depressed → emphysema. pneumothorax
 ‫ * مشدود علية من فوق‬Tinting : fibrosis
3. level:-

Normally: at the 6th Rib "Anteriorly" at the 10th Rib "posteriorly"

N.B L.t copula < R.T copula with 2.3 cm

Abnormally: depressed or elevated
4. Costophrenic Angle:

Normally: Black
Acute Angles
Abnormally: White
Obliterated e.g. pleural effusion
5. cardiophrenic Angles:

Normally 90 "Right Angle"

6. Hilum:

* Structures of Hilum:
a) L.N ‫ل يرى‬
b) Main Bronchi ‫ل ترى‬
c) B.vs" Plum arteries and veins" →‫ترى‬
* CCC of normal Hilum:-
* Smooth and concave
* Branching
* appears as dots if end on view
* Diameter of R.t pulm 16m.m
L.T Plum 18mm
* Symmetrical density
* Causes of Hilar enlargement:-
L.V enlargement → festooned "lobulated"
Bronchogenic → unilat, ill defined
Pulm Hypertension → bilateral oligaemic lung"
 7. Mediastinum:-

1) Position: - Tracheal shift

Cardiac shift
Upper mediastinum = tracheal position = if centralized
N.B

At center slightly to Right

Lower mediastinum = cardiac position = if centralized

Provided normal sized Heart ← 1/3 Heart 2/3Heat

At the R.t of Midline at the left
2) Borders of Mediastinum:-
Normally:-sharply well defined ‫لنه أبيض مع أسود‬
Abnormally: - ill defined → upper or Middle lobar opacity
N.B Right Border: upper half → S.V.C and ascending Aorta lower half
Rt Border of R.T atrium.
L.T Border: - 1st space → Aortic Nukle
2nd space → main plum segment "pulm cone"
3rd space → cardiac waste L.T atrial appendage
5th space → Apex
Heat
1) Cardiothoracic ratio

Maxim Transverse cardiac diameter

= 1/2
Maxim Transverse Thoracic diameter

2) Individual chamber enlargement :-

a) L.T ventricle
- ↑ cardiothoracic Ratio
- Apex shifted out and downward
- Obtuse L.t cardiophrenic angle
 - dipping in the diaphragm
b) Right ventricle:-
- ↑ cardiothoracic Ratio
- Apex shifted out wand, Rounded and uplifted
- Acute left cardiophrenic Angle
- dipping in the diaphragm
‫الهم‬ On lat view
- obliterated Retrosternal space
‫ ← أكيد‬space ‫ لكثر من‬1/2 ‫الجزء السفل من ذلك‬
‫ ← ممكن‬space ‫ لكثر من‬1/3 ‫الجزء السفل من ذلك‬
c) Left Atrial enlargement:-
- Normally: most posterior structure ‫عامل زى الكورة‬
- obliteration of cardiac waste " Mitralization "
Straight
‫أو‬
Convex
- Double contour: In cases of huge lt atrium appears behind R.T Atrium
On lat View with Barium Swallow:
‫الهم‬
Back words Indentation of barium swallow
d) Right Atrium:
- Increase cardiothoracic ratio
- Cardiac shadow takes more then 1/3of right hemi thorax

Aorta Aortic dilatation:

- Increase convexity of upper half of R.T Border
- Prominent Aortic nukle

Plum Artery
* Plum dilatation :
- Main Plum cone → at 2nd space ‫أكبر‬
 - Hilar pulm vessals ‫كبيرة‬
- Lung field → Lung oligeaemia
* Plum congestion :
pulm vascular markings more in lower half than upper Half‫المفروض‬
‫ المرحلة الولى‬a) early upper half = lowerhalf
‫ المرحلة الثانية‬b) Hypoxia at lower half→ V.C
: upper half > lower half
( Redistribution , cephelization , Moustach sign)
‫ المرحلة الثالثة‬c) Transudation around B.Vs
→ interstitial pulm edema
( ground glass appearance )
‫ المرحلة الخيرة‬d) intra – alveolar edema
( Bat wings appearance)

Valves

Prosthetic valve: - ‫تعرف أزاى‬

* On the vertebral column → Aorta
* On the left side of the vertebral column → Mitral
* Mitral ← ‫ تحت الخط‬Aorta ← ‫فوق الخط‬
Pace
maker

SVC ‫ خلل‬Heart ← wire ‫بطارية‬,

Cardiac
aneurysm
Shouldering in the left Border of the Heart
Pericardial
effusion

- Increase of the cardiothoracic Ratio

- Borders are smooth and Regular
- Lung oligaemia "Hilar B.vs Faint , small, plum Vasc marking
attenuated
 ‫؟‬pericardial effuse ‫ بدلً من‬H.F ‫طيب ليه ميكنش‬
As both are similar at X-ray picture

But

H.F almost has "Plum congestion"

8) Lung Field:
* Normally it is black except intra plum vascular markings which is
Branching and fainting on going laterally and (White) in X-Ray
* Abnormalities:
a) Too Black b) Too White
"Hyper Translucency" "Radiopacity"

Unilateral Bilateral Homogenous Heterogeneous

- Pneumothorax - emphysema
-Compensatory
Emphysema

* Homogenous opacity
1) Total lung opacity
2) Lobar opacity
3) Opacity obliterating costophrenic Angle
4) Opacity with fluid level
5) coin shape opacity
6) Wedge shaped opacity "plum infarction"
* Heterogeneous opacity
- Linear - Reticulo nodular - Ring shadow
- Flossy cotton - Miliary shadow
(Homogenous opacity)
1) Total lung opacity lung ‫الـ يعنى تلقى‬
Heart ‫كلها بيضاء لدرجة مش باين منها‬
Causes
- massive pleural effusion →Trachea pushed to opposite side
 - total lung collapse → trachea pushed to the same side
- total lung consolidation → normal trachea Air Bronchogram
‫تبان سوداء على خلفية بيضاء‬ Bronchi ‫تفريعة الـ‬
2) Opacity obliterating costophrenic Angle:
- Pleural effusion:
Surface and Rising laterally toward axilla and well defined
But may be with Horizontal level if the condition is Hydropneumothorax
3) Opacity with fluid level:
a) Hydropneumothorax
Upper 1/2 → as pneumothorax
Lower 1/2 → as pleural effusion
b) Lung Abcess: cavity with fluid level

N.B Pneumothorax → Jet Black → it means absence of plum vascular making

‫معناه أسود أوى لنه من الممكن أن يكون لونه رمادى مش أسود‬ ‫مش‬
‫بمعنى‬
4) Coin shadow "Cannon ball shadow"
Not necessary to be perfectly Rounded But well defined
Causes: - Single
- Multiple
* Single - Bronchogenic carcinoma
- Single metastatic deposit
- Benign tumor
- Pneumonic stage of lung Abcess
- Fungal genuloma
-Rheumatoid Nodule
- Tuberculoma
- Plum infection "end on view"
* Multiple → Metastasis
5) Wedge shaped opacity → Plum infection "lat view"
(Heterogeneous opacity)
1) Flossy cotton
Multiple ill-defined patches of opacity
→ Perihilar → alveolar plum edema "Bat wings"
→ Bilat, Basal and asymmetrical → Bronchopneumonia.
→ Apical → T.B, fried Lander Bronchopneumonia
2) Reticulonodular: nodules ‫خطوط و‬
Coarse ( Honey comb) Bronchiectasis
→ Coarse lung fibrosis
Fine (Ground glass appearance)
→ Fine lung fibrosis
→ Interstitial plum edema

But
Lung fibrosis

- It is Retractile Tissue
- Diagnosed in X. Ray By
1) Reticulonodular shadow

2) Signs of volume loss as

- Pulled Trachea
- Elevated or tinted diaphragm
- Overcrowding of Ribs
3) Miliary shadow
Multiple dot like opacities which are Rounded small uniform in size and
Density.
Cause 1) Miliary T.B.
2) Sarcoidosis
4) Ring Shadow:-
- Large with Fluid level → lung Abcess
- Multiple, small→ Bronchiectasis
(Hyper Translucency)
Pneumothorax:-
 - Jet Black translucency
- Underlying lung collapse
- Mediastinum pushed to the opposite side
- Flat or depressed diaphragm
Emphysema:-
- Hyper Translucent lung field
- Ribbon shaped Heat
- Wide, Horizontal Ribs
- Wide costophrenic Angle
- Flat or depressed diaphragm
(Most common x. Ray for exam)
Chest:-
- Emphysema "COPD" + + + + + +
- Pneumothorax +++
- Total lung opacity +++++
- Total lung collapse ++
- Total lung pneumonia + + + +
- Coin shadow +++++
- Pleural effusion ++++++
- Hydropneumothorax + + + +
- Lung Abcess ++++
- Lung Fibrosis ++++
- Bronchiectasis +++
- Bronchopneumonia ++++++
- Miliary T.B
Heart: - Pericardial effusion ++++++
- Pulm Hypertension +++++
- Artificial valve ++
- Chamber enlargement + + + + + + + + +
X. ray (H.F) → (Cardiomegally + plum congestion + R.t side pleural
N.B
effusion).

With my best wishes,

DR.M.BASIONEY