Q.A.

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in Diagnostic Radiology (H-7)

Checklist Guide for Quality PA Chest Radiographs

CORRECT EXPOSURE & E. Cardiac Shadow: Determining

IMAGE RECORDING heart position, shape and size is
FACTORS one of the most important reasons
for a PA chest x-ray. A fast
A. Controlled Film Densities: exposure time (0.1 Sec) is used to
The radiograph should be avoid motion blur. The 72" focal
properly exposed and fully distance is used so that heart-
developed. Here is a simple dimensions can be accurately
test. Place your finger between measured without distortion. The
the film and the viewbox and heart should not appear as a
in the area of the radiograph silhouette but with varying
above the patient's shoulder. density detected through the
The x-rays directly hit this area organ.
and it should be completely
black. If you can see your Note: The most common cause of
finger through the film: repeat studies is exposure error and
ƒ The exposure was too subsequent development failures. A
light, or more likely, technique chart should be used to provide the proper
ƒ The exposure was too high and the film was selection of kVp and mAs for the patient, which will
pulled from the developing tank too quickly to allow full development at the recommended time and
compensate for overexposure, or the processor temperature. The next most frequent problem is the
is not adjusted to give optimal development. absence of patient measurement or improper patient
measurement. The rule is to measure the thickest portion
B. Positive Patient Identification: A beautiful film is of the patient's chest cavity.
valueless without proper identification. This also
includes correct markers. Don't depend on CORRECT PATIENT POSITIONING
anatomical markings to verify true right and left side
of the patient. Although rare, Visceral-inversa or 1. Film at Proper Height to Patient: If the cassette is
Dextrocardia could cause the image to be read routinely fixed under the patient’s chin, often the
backwards (through the wrong side of the film). lungs project to the top of the film, leaving much
expanse under the diaphragm. On elderly patients,
C. Proper X-ray Imagery: A chest x-ray is intended especially with kyphosis of the spine, the apex of the
to display hilar lung and bronchus markings and lungs may actually be off the top of the film. Note:
other tissue detail, but is not meant to show ribs or Allow the top of the film to be about three fingers
other boney details. Optimally the ribs will be width higher than the patient's shoulders and don't be
projected to be almost transparent in appearance by afraid to put the cassette top directly under the
the use of high kVp techniques. patient’s nose.

D. Proper X-ray Penetration: An underpenetrated 2. Scapulas Out of Lung Fields: This is one of the
chest film would show a mediastinuin that was clear best steps to assure proper projection of the lung
and without information. A properly penetrated field.
exposure is one that just faintly shows the ƒ Place the back of the patient's hands along side
intervertebral disk spaces right above the of the thighs, so that they are above the hips, but
diaphragm. below the belt line.

Conference of Radiation Control Program Directors, Inc. (CRCPD)

205 Capital Avenue First published: April 1988
Frankfort, KY 40601
www.crcpd.org Reviewed/republished: September 2008
 ƒ Have patient's thumbs rotate out pointing away 5. Patient Centered to Film: The width of most
from the body. This creates tension in the patients will fit in 14". Chest exams are always
shoulders when the elbows are rolled forward. desirable in the upright position. Fluid levels would
ƒ Remind the patient not to hunch their shoulders result in a detectable "blunting" of the costophrenic
when taking their "deep breath”-- this would only angles of the lower lung margins and the outer
make the clavicals form a V, obscuring the hilar border of the diaphragm. This is of real clinical
lung fields. (See diagram) significance. A common occurrence is to have the
patient positioned off to one side and one of the
3. Holding a Full Breath: If two films were taken, costophrenic corners is then off the edge of the film.
one of full inflated and another with deflated lungs, When you encounter large patients, their
these films would not appear to be the same patient! diaphragms might be high enough to permit you to
The diaphragm, with full inflation, should be fully place the film cross-wise on the chest board and
descended to reveal all of the lungs with their subtle include all the lung fields. Note: Place the cassette
densities. Look for the gray region of air held in the so that the lead blocker for ID is up and only in the
trachea. On some films you may even detect the shoulder areas.
bronchial bifurcation. Note: A foreign body is more
likely to be inhaled into the patient's lower right
lobe. SUGGESTED METHOD OF PATIENT
MEASUREMENT FOR PA CHEST X-RAY:
4. True PA Projection: Patients are frequently left in
a slightly turned position. Check to see if the ¾ Place back of caliper behind the patient and at the
sternoclavicular articulations are symmetrical on lowest level of the scapula.
both sides of the spine. This is proof of a true PA.
The best evidence is to watch where the patients ¾ Slide in the movable bar to make contact with the
place their feet. If they do not point straight toward patient's front rib cage approximately 1 1/2" below
the chest board, it is almost certain that the body is the nipple.
rotated to one side. Use the squares in floor tile or
place colored tape on the floor to guide the feet and ¾ Read the cm. thickness with the patient in full
assure that the toes of each foot are an equal inspiration.
distance away from the chest board wall. It also
helps to permit the patient to lean on the plate,
which eliminates distortions and steadies the patient.

The information herein is for guidance. The implementation and use of the information and recommendations are at the discretion of the
user. The mention of commercial products, their sources, or their use in connection with material reported herein is not to be construed as
either an actual or implied endorsement by CRCPD.

Conference of Radiation Control Program Directors, Inc. (CRCPD)

205 Capital Avenue First published: April 1988
Frankfort, KY 40601
www.crcpd.org Reviewed/republished: September 2008