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  1. What are the different types of plain chest radiographs and when would you order them?

  2. What are the limitations of the anteroposterior (AP) film?

  3. How does the chest radiography differentiate between different types of pneumonia from atelectasis?

  4. What are the radiographic changes you should look for when considering acute, potentially life-threatening causes of chest pain?

  5. What radiographic abnormalities require follow-up?

Chest radiographs provide a snapshot of the patient's physiologic health and insights into a wide variety of systemic diseases. This chapter, as well as Chapter 108 on advanced chest imaging, provide the clinician with a systematic framework for ordering, interpreting films and reports, and consulting the expertise of radiologists.

The majority of hospitalized patients routinely have chest radiographs on admission or prior to surgery; they are also obtained to evaluate acute signs and symptoms, and to assess the possibility of a complication following a procedure. Chest X-rays are also used to monitor critical illness in the intensive care unit (ICU), response to therapy as in congestive heart failure or pneumonia, and stability of pulmonary nodules. Clinicians should always provide radiologists with sufficient information to interpret a radiograph in the clinical context of the patient. Otherwise, the radiologist may generate a wide differential diagnosis that may lead to unnecessary additional imaging or overlook subtle signs of infection in an immune compromised host. Consideration of chest radiographic findings that support the new diagnosis of a systemic disease almost always benefits from direct consultation with the radiologist; a study requisition does not allow an interchange of specific clinical information that can alert the radiologist to findings that might otherwise be ignored. Figures 107-1 and 107-2 show the normal structures that contribute to the radiographic appearance of the chest.

Figure 107-1

(A) Normal chest radiograph anatomic schematic drawing of fissures on PA radiograph. 1, minor fissure; 2–4, major fissure; 5, superior accessory fissure; 6, inferior accessory fissure. (B) Normal chest radiograph anatomy schematic drawing of structures on PA radiograph 1, normal apical opacity; 2, aortic nipple; 3, descending aortic interface; 4, air in esophagus; 5, aortic pulmonary stripe; 6, diaphragm.

Figure 107-2

Lobar and segmental anatomy of lungs. (Reproduced, with permission, from Doherty GM. Current Diagnosis & Treatment: Surgery. 13th ed. New York: McGraw-Hill, 2010. Fig. 18-7.)

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Practice Point

Baseline radiographs

  • When looking at radiographs without a radiologist, comparison with prior radiographs that look like the current examination can be most helpful. This is analogous to comparing a current ECG to a baseline ECG in a patient with possible cardiac ischemia.
  • The degree of inspiration affects the appearance of the lower zone vessels. Hesitate to diagnose basilar pneumonia or cardiomegaly if the radiograph has the domes of ...

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