1. Diagnosis of Congestive Heart
Failure
:Presented by
Dr. Mahmood Yaseen Hachim

2. CHEST X-RAY

3. X-Ray

4. R
Mahmood Yaseen
22/9/1076
PA
Male Standing
Routine Check Up
Step Action Findings Notes
1 Identifications data
a. Patients Name
a. Date of Birth (Age)
a. Sex
a. Indication for CXR Clinical suspicion and provisional
diagnosis

5. R
Mahmood Yaseen
22/9/1076
PA
Male Standing
Routine Check Up
2 Side Marker (Orientation)
Right Side and Left Side of the CXR One side is labels usually either • Look to the CXR as you
R=right or L=Left are looking at the patient
= the patient's right side
is on your left side and
vice versa

6. R
Mahmood Yaseen
22/9/1076
PA
Male Standing
Routine Check Up
3 Technical Considerations of CXR
quality
a. Position of the Patient: Standard • Check if any mark • Sitting: means severe illness, unable to stand
position is standing stating the patients was o Raised diaphragm
not standing during the o Reduced inflation of lungs
CXR o Folded soft tissue of the patients front like skin
• Supine: means very severe illness, unable to sit
o The fluid level will be lost

7. R
Mahmood Yaseen
22/9/1076
PA
Male Standing
Routine Check Up
a. Projection: • If the cassette is in the back and the beam pass • Objects near the cassette will appear
direction of X-Ray from front to back =(AP)=Anterior -Posterior in their size but the organs far from
beam passage • If the cassette is in the front and the beam pass the cassette will look falsely enlarges
through the patient from back to front =(PA)=Posterior-Anterior as a shadow, it is so importnat in case
of heart size assessment
• Either right or left side of the chest = Lateral
• So AP is not used to check heart size,
it should be PA

8. AP PA

9. R
Mahmood Yaseen
22/9/1076
PA
Male Standing
Routine Check Up
Rotation • Spinous processes of thoracic vertebra should • Rotation can cause abnormal
appear at the center of each appearance of the mediastinum
• The spinous process of T4 should be between and other structures
the heads of the clavicle
• if it isn't the body is rotated

10. R
Mahmood Yaseen
22/9/1076
PA
Male Standing
Routine Check Up
Quality and Exposure of X-Rays • Is the film penetrated • Too little exposure will make lungs appear too
properly? white
• In a properly penetrated film • Too much exposure will make structures more
the vertebral interspaces dark and mask the signs
should be visible behind the
central (cardiac) shadow

11. R
Mahmood Yaseen
22/9/1076
PA
Male Standing
Routine Check Up
a. Inflation : Proper CXR should be • There must be more than 9 ribs visible posterior to • If poor inflation then the
taken with full inflation of lungs say the inspiration was perfect lung will appear more
(deep inspiration and hold breath) • So count the ribs starting from the 1st rib dense
• Trachea will be drawn to
the right side
• Heart will look abnormally
enlarged

12. Poor Inspiration Good Inspiration

13. R
Mahmood Yaseen
22/9/1076
PA
Male Standing
Routine Check Up
a. Inclusions: the CXR felid should • Check if the lung
include all the chest structures apices are shown
• Check if both
costophrenic angles
are seen

14. R
Mahmood Yaseen
22/9/1076
PA
Male Standing
Routine Check Up
4 Look for different intensities • Black=gas
• Dark Grey=fat
• Light Grey=soft tissue or
fluids
• White=bone and calcifications
• Intense white=metal

16. R
Mahmood Yaseen
22/9/1076
PA
Male Standing
Routine Check Up
5 Clinical Interpretation
a. Mediastinum • Examine the Mediastinal
Border for abnormality

19. R
Mahmood Yaseen
22/9/1076
PA
Male Standing
Routine Check Up
5 Clinical Interpretation
a. Mediastinum • Look to the trachea and the
bronchi

20. R
Mahmood Yaseen
22/9/1076
PA
Male Standing
Routine Check Up
Heart • Any visible valves (in case of metal valves) • The heart size is enlarged in
• Cardiac Size should be less than 50% of the Congestive heart failure
thoracic width in PA file measured by RULER

22. R
Mahmood Yaseen
22/9/1076
PA
Male Standing
Routine Check Up
a. Mediastinal masses,
calcification or free air

24. R
Mahmood Yaseen
22/9/1076
PA
Male Standing
Routine Check Up
Examine the hila: regions of lung • Hila should be rounded • Look for difference
connection to central circulation, looks and symmetrical in densities
opaque on the right and left side of • The right hila is 1 cm • Asymmetry
mediastinum, they are made mainly by lower than the left hila • Loss of normal
pulmonary arteries and veins concavity

25. Pulmonary
Hypertension

26. R
Mahmood Yaseen
22/9/1076
PA
Male Standing
Routine Check Up
Lungs: • Lung feilds of equal densities • In heart failure there will be pulmonary edema
• Right hemidiaphragm slightly higher than the left • Bilateral , lung shadowing classically in the middle
• Sharp costophrenic angles and cardiophrenic angel and upper zones causing bat wings appearance
• The horizontal fissure in the right lung passes horizontally from • Pulmonary vessels engorgement (blood vessles
the midpoint of the right hilum to about the 6th rib in the axillary more than 5 mm in diameter in upper zone
line • Kerley B lines: short horizontal white lines close to
• The pleura should be thin and symmetrical the lung periphery cuased by edema of
interlobular septa

28. R
Mahmood Yaseen
PA
22/9/1076
Male Standing
Routine Check Up
Look for the remaining structures
a. Bones : examine their densities • Examine the shoulder girdle • Lytic lesions
and trabecular pattern • Ribs • Sclerosis
• Clavicles • Erosions
• Thoracic vertebrae • Fractures
• Dislocations
a. Soft Tissue • Check Surgical Emphysema • Air pockets in soft tissue
a. Breasts • In females • Missing breast by disease or surgery
• Nipples are rounded opacities that may be
misdiagnosed as lesions
a. Abdomen • See air in the stomach below left • Gastic bubbles seen as rounded top
hemidiaphragm and horizontal base shape
• Free air under diaphragm • Free air appear between liver and right
hemidiaphragm or above gastric
bubbles

32. Step Action Findings A B F
1 Identifications data 1 0.5 0
a. Patients Name
a. Date of Birth (Age)
a. Sex
a. Indication for CXR
2 Side Marker (Orientation) 0.3 0.15
Right Side and Left Side of the CXR
3 Technical Considerations of CXR quality 1.2 0.5 0
a. Position of the Patient: • Standing 0.2
• Sitting
• Supine
a. Projection: • (AP or PA or Lateral) 0.2
a. Rotation • Rotated or not 0.2
a. Quality and Exposure of X-Rays • Too little exposure 0.2
• Too much exposure
a. Inflation : • Proper inhalation or not 0.2
a. Inclusions: • lung apices are shown 0.2
• both costophrenic angles are seen
4 Clinical Interpretation 1.5 0.75
a. Mediastinum • Mediastinal Border for abnormality 0.25
• Trachea and the bronchi
a. Heart • Any visible valves 0.25
• Cardiac Size
a. Mediastinal masses, calcification or free air 0.25
a. Examine the hila: • Density 0.25
• Symmetry
a. Lungs: • Lung fields densities 0.25
• costophrenic angles
• cardiophrenic angel
• The horizontal fissure
• The pleura
5 Look for the remaining structures 1 0.5
a. Bones • Examine the shoulder girdle 0.25
• Ribs
• Clavicles
• Thoracic vertebrae
a. Soft Tissue • Check Surgical Emphysema 0.25
a. Breasts • Shape 0.25
• Nipples are rounded opacities that may be misdiagnosed as lesions
a. Abdomen • Gastic bubbles 0.25
• Free air under diaphragm

33. CXR in Congestive Heart Failure

35. Kerley B Lines
Oedema of the interlobar septa
Horizontal, non branching, white
Seen at periphery above costphrenic angle