RADIOLOGY EXAMINATION OF THORAX

General objectives:
1. Students are able to explain and give impression of radiology of thorax that relates to some
abnormalities dealing with lungs.
2. Students are able to explain and give impression of thorax radiology imaging that relates to
some abnormalities dealing with heart and vascular.
Specific objectives:
1. Students are able to explain and impression of radiology imaging of abnormality on lungs.
1.1. non specific inspection: Pneumonia/Bronchopneumonia, Bronchitis, bronchial Asthma,
effusion pleura, emphysematous lung
1.2. Trauma : Pneumothorax, Hidropneumothorax
1.3. Mass/Tumour on lungs /mediastinum
2. Students are able to explain and give impression of radiology imaging of heart.
2.1. Hypertension heart disease
2.2. Atherosclerosis
2.3. heart enlargement /cardiomegali
NORMAL CHEST X-RAY

I. INFECTION: NON SPECIFIC PROCESS IN LUNGS

A. Bronchitis
Commonly bilateral
Radiology imaging:
Infiltrate peribronchial
Air bronchogram imaging ; imaging of lucent lines going to hyllus direction
More bronchovascular characteristics, additional 1/3 to lung field lateral
Photo of Thorax, PA, erect, symmetrical, inspiration and sufficient condition
result:
- Hyperaeration is seen (hyperlucency) on both lungs, bronchovasculary characteristics increase.
- Left-right Sinus costofrenicus are sharp
- Left-right Diafragma are plain and slippery (air trapping +)
- Cor : CTR< 0,5, in the form of tear drop
- Spatium Intercostae is seen enlarging
Impression: chronic Bronchitis with Emphysematous lung
B. Bronchial Asthma
Radiology imaging:
Photo of Thorax, PA, erect, symmetrical, inspiration, and sufficient condition
result :
- Additional imaging of bronchovascular is seen with imaging
- Air bronchogram (+) on both lung fields.
- Left-right Sinus costofrenicus are sharp.
- Left-right Diaphragm are plain, slippery
- Cor ; CTR < 0,5
- No abnormality on musculoskeletal system is observed
IMPRESSION : chronic Bronchitis and cor is normal

C. Bronchopneumonia

- can be uni/bilateral
- radiology imaging :
infiltrate on peribronchial : causing bronchovascular characteristics to improve and air bronchogram (+)
infiltrate on paracardial, causing heart limit blurred (silhoutte sign)
On the lateral photo, infiltrate in central heart with unclear limit is seen.
Photo of Thorax, AP, supine, asymmetrical, inspiration and sufficient condition, result;
- Semiopaq inhomogen wrapping with bronchogram water (+) imaging is seen on both lung fields.
- both sinus costofrenicus are sharp.
- both diaphragm are slippery
- Cor ; CTR < 0,5
- no abnormalities are seen on musculoskeletal system
Impression: Bronchopneumonia duplex and cor size are normal.
D. Pneumonia
- commonly unilateral
- radiology imaging :
infiltrate on lung parenchyma, located on periphery (medium on central bronchopneumonia)
infiltrate limit is obvious (hitting one lobus, segment)
air bronchogram (+)

Photo of Thorax, PA, erect, symmetrical, inspiration and sufficient condition

result :
- Homogeny opacity/wrapping is seen, the limit is obvious on the right lung medius lobus.
- Left-right Sinus c.f are sharp
- Left-right Diaphragm are slippery
- Cor : CTR < 0,5
- No abnormalities are observed on musculoskeletal system.
Impression: Pneumonia is on lobus medius of the right lung normal cor is big
E.

Pleura Effusion
- is the liquid in vacuum pleura with more than normal amount
- radiology imaging :
1. Meniscus sign : bending line with periphery part is higher than central part.
2. homogeny wrapping imaging covers the lower structure of the lungs which are normally relatively
radioopaq with hollow upper surface, running from upper lateral to lower medial.

Photo of the position of Right Lateral Decubitus (RLD), sufficient condition

result:
- homogeny semiopaq is seen on the right hemithorax.
- bronchovaskuler characteristics increase
impression : right pleura effusion cor configuration is normal

Photo of Thorax AP, supine, symmetrical , sufficient inspiration

result ;
- Homogeny semiopaq wrapping is seen on right hemithorax basal aspect with meniscus sign (+) imaging.
- Right Sinus c.f is dull, right diaphragm is unclear.
- Left Sinus c.f is sharp, left diaphragm is slippery
- Cor : CTR > 0,5
- Intact bone systems
- Impression: right pleura effusion and cardiomegali
II.TRAUMA
1. Pneumothorax
- is the existence of air on cavum pleura, which occurs as the result of the tearing on pleura parietalis or pleura
visceralis that connects cavum pleura with outside air or with lung parenkim. Pressure difference causes
outside air come in and fill cavum pleura both from chest wall or lung paremkim. If the amount of air coming in
is abundant, it will press pulmo so that it will collapse and even press the mediastinum towards contralateral
with the tearing direction.
Radiology imaging:
- radiolucent imaging without lung characteristics on lung hemithorax is seen.
- On thorax PA photo, clear white line from pleura will be seen, separated from chest wall by radiolucent pleural
space.
- Sometimes diaphragm is seen being pressed downward on the lungs experiencing pneumothorax.
- In abundant air amount, lungs can collapse and mediastrinum moves towards contralateral with trachea seen
deviated towards contralateral.

Pneumothorax sinistra

Photos of Thorax, AP, supine, symmetrical, inspiration and sufficient condition

Result;
- Lucent area without lung characteristics is seen on the right hemithorax that moves mediastinum
towards the left side.
- Left-right Sinus c.f are sharp
- Left-right Diaphragm are slippery
- Cor : CTR < 0,5
- bone system is Intact
Impression: right Pneumothorax moves mediastinum towards the left side, Cor size is normal
2. Haemathothorax
- The presence of blood in cavum pleura that is caused by secondary causes, that is, open or closed trauma
from thorax.
- Thorax radiology imaging is often accompanied by fracture on costa.
- Radiology imaging : seen like imaging on pleura effusion
III. LUNGS TUMOUR

1. Primary Tumour
- can come from mediastinum or parenkim. Ca is the most from bronchus, that is, bronchogenic Ca.
- Radiology imaging :
- The existence of homogeny opaq on lungs
- psudopodia imaging: the radier tumour growth towards healthy tissue looks like legs.
- Pancoast tumour : tumour on sulcus superior on lung apex, located on posterior and
- Os costa experiences erosion.

2. Secondary Tumour
- Nodular type : imaging looks like small balls
- pneumonic type: like pneumonia but air bronchogram (-)
- reticular type : seen as lymph tissue (limphangitis type)
- milier type
- pleural Type, pleura effusion

HEART ABNORMALITIES
The size of heart radiologically depends on some conditions, some of the others are:
1. age : babys size is relatively big (CTR up to 60% still considered normal)
2. respiration; on inside cor inspiration is seen long.
3. Projection (photo positioning); on the posteroanterior position, magnification factor is 5%, while on AP
position, magnification may be more than 5%
4. body size; thin (heart size is like a pendulum) ; fat (the heart is large)
5. lungs abnormality, on bronchial asthma, heart size is tear drop

To analyze any heart abnormalities, photos of posteroanterior, left lateral, Left Anterior Oblique, Right Anterior Oblique
are used.
1. Posteroanterior, in this position, heart position is near the film so that it can downsize heart magnification.
2. left Lateral; it shows aorta ascendens, arcus aorta and aorta descendens is better
3. RAO (450-600) ; showing pressure of left atrium towards oesophagus
4. LAO (600-700) ; can show the hearts low rear limit by left ventricle.
Abnormalities often occurring on heart:
1. Hypertension heart disease
2. Aterosklerosis/aortosklerosis
3. heart enlargement /cardiomegali
4. Oedem Pulmo due to cardiogenic (Ventricle hypertrophy)
1. Hypertension Heart Disease (HHD)
- Causing hypertension configuration:
o Left ventricle enlarges to lower left side; apex towards lower side, heart waist narrows.
o aorta widens and lengthens (coartasio aorta), aortic knob bumps in the form of semilunar

Chronic heart Failure ; Cardiomegali with oedem pulmo, aortic knob (+)

Photos of Thorax, AP, lateral, sufficient condition

result :
- Vascular characteristics increases.
- Left-right Sinus costofrenicus are sharp
- Left-right Diaphragm are slippery
- Cor : CTR > 0,56; heart apex is lifted, heart waist is bumpy, retrosternal space is covered (sternal climbing + ).
- no abnormalities on musculoskeletal system
impression: right ventricular hypertrophy Pulmo is normal

Photos of thorax, AP, supine, symmetrical, sufficient inspiration

result :
- Vascular characteristics increases
- Left-right Sinus c.f are sharp
- Left-right Diaphragm are slippery
Cor : CTR > 0,5, apex cordis is seen as sunk
- No abnormalities on musculoskeletal System
Impression: left ventricular hypertrophy Pulmo is normal

lung Oedem Paru due to heart abnormalities

Image: Oedem pulmo due to decompensation cordis (CTR > 0,5, left ventricle enlargement: heart apex sunk. Vascular
characteristics looks increasing, blurring on both lung fields with kerley line (white arrow)

3. Aortosclerosis
marked by the presence of atherom that experiences calcification, the size looks like crescent (crescent calcification)

4. Cardiomegali
- The heart size is enlarging more than half of thorax cavity (CTR > 0,5)

CHECK LIST PAGE FOR ABNORMALITIES ON LUNGS AND HEART

NO
1

3
4
5
6

ASPECTS TO BE SCORED
Students are able to give judgement on the photo position
(AP/PA/Lateral/RLD symmetrical/asymmetrical, inspiration and
photo condition)
Students are able to give judgment on bronchovascular
characteristics:
- Bronchitis : bronchovaskuler characteristics increases with
imaging of air bronchogram (+)
- Pneumonia
:
inhomogen/infiltrate
wrapping
on
lobus/segment of lungs with air bronchogram imaging
- Bronchopneumonia : same as Pneumonia , but its wider :
uni/bilateral
- Pneumothorax : lucent imaging without lungs characteristics
- Effusion of pleura/Hidrothorax : homogeny semiopaq
wrapping on basal/lateral hemithorax
- Tumour/Mass : existence of imaging of homogeny/ lesion
nodular opacity on the lungs.
Students are able to give judgement on sinus costophrenicus: dull or
sharp
Students are able to give judgement on diaphragm : slippery or not
Students are able to give judgement on bone systems ; size of
thorax, costa, vertebra thorax
Students are able to give impression / radiology diagnosis

CHECK LIST PAGE ON CARDIOVASA ABNORMALITIES

NO

ASPECTS TO BE SCORED
0

1
2

Students are able to give judgement on photo position: PA, lateral

Students are able to give judgement on vascular characteristics: increasing
- decreasing
Students are able to give judgment on chamber/heart size
- CTR < 0,5
- CTR > 0,5
Students are able to give judgment on abnormalities on heart and
blood vessels.
- aortic knob : aorta bumping
- aterosclerosis : calcification on aorta
- the presence of cardiomegali
Students are able to give impression/radiology diagnosis on heart
abnormalities.