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47 Cards in this Set

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What defines a technically adequate CXR?

Film must be "RIPE":


- Rotation: clavicular heads are equidistant from thoracic spinous processes


- Inspiration: diaphragm is at or below ribs 8-10 posteriorly and ribs 5-6 anteriorly


- Penetration: disk spaces are visible but no bony detail of spine; bronchovascular structures are seen through heart


- Exposure: make sure all lung fields are visible

How should a CXR be read?

Check the following:


- Tubes and lines (check placement)


- Patient data (name, date, history #)


- Orientation (up/down, L/R)


- Technique (AP or PA, supine or erect, decubitus)


- Trachea (midline vs deviated, caliber)


- Lungs (CHF, mass)


- Pulmonary vessels (artery or vein enlargement)


- Mediastinum (aortic knob, nodes)


- Hila (masses, lymphadenopathy)


- Heart (transverse diameter should be <1/2 transthoracic diameter)


- Pleura (effusion, thickening, pneumothorax)


- Bones (fractures, lesions)


- Soft tissues (periphery and below the diaphragm)

What CXR is better: PA or AP? Why?

PA - less magnification of the heart (heart is closer to x-ray plate)

Classically, how much pleural fluid can the diaphragm hide on upright CXR?

It is said that the diaphragm can overshadow up to 500 cc

How can CXR confirm that the last hold on a chest tube is in the pleural cavity?

Last hold is through the radiopaque line on the chest tube; thus, look for the break in the radiopaque line to be in the rib cage

How can a loculated pleural effusion be distinguished from a free-flowing pleural effusion?

Ipsilateral decubitus CXR; if fluid is not loculated (or contained), it will layer out

How do you recognize a pneumothorax on CXR?

Air without lung markings is seen outside the white pleural line - best seen in the apices on an upright CXR

What x-ray should be obtained before feeding via a nasogastric or nasoduodenal tube?

Low CXR to ensure the tube is in the GI tract and NOT in the lung

What C-spine views are used to rule out bony injury?

CT scan

What is used to look for ligamentous C-spine injury?

Lateral flex and extension C-spine films, MRI

What CXR finding may provide evidence of traumatic aortic injury?

- Widened mediastinum >8 cm (most common)


- Apical pleural capping


- Loss of aortic knob


- Inferior displacement of left main bronchus; NG tube displaced to the right, tracheal deviation, hemothorax

How should a CT scan be read?

Cross section with the patient in supine position looking up from the feet

How should an abdominal x-ray (AXR) be read?

Check the following:
- Patient data: name, date, history number


- Orientation: up/down, left-right


- Technique: A-P or P-A, supine or erect, decubitus


- Air: free air under diaphragm, air-fluid levels


- Gas dilatation (3, 6, 9 rule)


- Borders: psoas shadow, preperitoneal


fat stripe
- Mass: look for organomegaly, kidney


shadow
- Stones/calcification: urinary, biliary,


fecalith


- Stool
- Tubes
- Bones
- Foreign bodies

How can you tell the difference between a small bowel obstruction (SBO) and ileus?

- In SBO there is a transition point (cut off sign) between the distended proximal bowel and the distal bowel of normal caliber (may be gasless)


- In ileus, the bowel is diffusely distended

What is the significance of the air-fluid level?

Seen in obstruction or ileus on an upright x-ray; intraluminal bowel diameter increases, allowing for separation of fluid and gas

Seen in obstruction or ileus on an upright x-ray; intraluminal bowel diameter increases, allowing for separation of fluid and gas

What are the normal calibers of the small bowel, transverse colon, and cecum?

Use the "3, 6, 9" rule:


- Small bowel <3 cm


- Transverse colon <6 cm


- Cecum <9 cm

What is the rule of 3's for the small bowel?

- Bowel wall should be <3 mm thick


- Bowel folds should be <3 mm thick


- Bowel diameter should be <3 cm thick

How can the small and large bowel be distinguished on AXR?

By the intraluminal folds:


- The small bowel plicae circulares are complete


- The large bowel plicae semilunares are only partially around the inner circumference of the lumen

Where does peritoneal fluid accumulate in the supine position?

Morison's pouch (hepatorenal recess), the space between the anterior surface of the R kidney and the posterior surface of the R lobe of the liver

What percentage of kidney stones are radiopaque?

~90%

What percentage of gallstones are radiopague?

~10%

What percentage of patients with acute appendicitis have a radiopaque fecalith?

~5%

What are the radiographic signs of appendicitis?

- Fecalith


- Sentinel loops


- Scoliosis away from the R because of pain


- Mass effect (abscess)


- Loss of psoas shadow


- Loss of pre-peritoneal fat stripe


- Very rarely, a small amount of free air, if perforated

What does KUB stand for? What is it?

Kidneys, Ureters, and Bladder: commonly used term for a plain film AXR (abdominal flat plate)

What is the "parrot's peak" sign?

Evidence of sigmoid volvulus on barium enema

What is the "bird's beak" sign?

Evidence of achalasia on barium swallow

What is a "cut off sign"?

Seen in obstruction, bowel distention, and distended bowel that is "cut off" from normal bowel

What are "sentinel loops"?

Distention or air-fluid levels (or both) near a site of abdominal inflammation (eg, seen in RLQ with appendicitis)

What is loss of psoas shadow? What does this suggest?

Loss of clearly defined borders of the psoas muscle on AXR; loss signifies inflammation or ascites

What is loss of the peritoneal fat stripe? What does this imply?

Loss of the lateral peritoneal / pre-peritoneal fat interface


- Implies inflammation

What is "thumb-printing"?

Non-specific colonic mucosal edema resembling thumb indentations on AXR

What is pneumatosis intestinalis?

Gas within the intestinal wall (usually means dead gut) that can be seen in patients with congenital variant or chronic steroids

What is free air?

Air free within the peritoneal cavity (air or gas should be seen only within the bowel or stomach); results from bowel or stomach perforation

Air free within the peritoneal cavity (air or gas should be seen only within the bowel or stomach); results from bowel or stomach perforation

What is the best position for the detection of FREE AIR (free intraperitoneal air)?

Upright CXR - air below the right diaphragm

If you cannot get an upright CXR, what is the second best plain x-ray for free air detection?

Left lateral decubitus, because it prevents confusion with gastric air bubble; with free air both sides of the bowel can be seen; can detect as little as 1 cc of air

How long after a laparotomy can there be free air on AXR?

Usually 7 days or less

What is Chilaiditi's sign?

Transverse colon over the liver simulating free air on x-ray

What should a post-op abdominal/pelvic CT scan for a peritoneal abscess be performed?

POD #7 or later, to give time for the abscess to form

What is the best test to evaluate the biliary system and gallbladder?

Ultrasound (U/S)

What is the normal diameter of the common bile duct with gallbladder present?

<4 mm until age 40, then add 1 mm per decade (eg, 7 mm at age 70)

What is the normal common bile duct diameter after removal of the gallbladder?

8-10 mm

What U/S findings are associated with acute cholecystitis?

- Gallstones


- Thickened gallbladder wall (>3 mm)


- Distended gallbladder (>4 cm AP)


- Impacted stone in gallbladder neck


- Pericholecystic fluid

What type of kidney stone is not seen on AXR?

Uric acid (think Uric acid = Unseen)

What med should be given prophylactically to a patient with a true history of contrast allergy?

Methylprednisolone or dexamethasone; the patient should also receive non-ionic contrast (assoc. w/ 1/5 as many reactions as ionic contrast, the less expensive standard)

What is a C-C mammogram?

Cranio-Caudal mammogram, in which the breast is compressed top to bottom

Cranio-Caudal mammogram, in which the breast is compressed top to bottom

What is an MLO mammogram?

MedioLateral Oblique Mammogram, in which the breast is compressed in a 45 degree angle from the axilla to the lower sternum

MedioLateral Oblique Mammogram, in which the breast is compressed in a 45 degree angle from the axilla to the lower sternum

What are the best studies to evaluate for a pulmonary embolus?

- Spiral thoracic CT scan


- VQ scan


- Pulmonary angiogram (Gold standard)