Chest Radiology

RADIOLOGY RESIDENCY HANDBOOK FOR CHEST RADIOLOGY

Section of Cardiothoracic Radiology Department of Diagnostic Radiology

Beaumont Health – Farmington Hills Botsford Campus

Reehan Ali, DO Section Chief Cardiothoracic Radiology

Rocky Saenz, DO – Program Director Timothy McKnight, DO – Assistant Program Director Michael Schwartz, MD – Department Chairman

Updated July 2015 to meet NAS Standards

GOALS AND OBJECTIVES

ROTATION 1

Competency-Based Goals & Objectives Medical Knowledge  Understand the various factors that affect a quality radiograph  Understand the technique and quality control for chest radiography from patient positioning to the images on PACS  Learn a methodical approach to analyzing a chest radiograph.  Develop skills in interpretation of chest radiography  Correlate pathologic and clinical data with radiographic findings.  Monitor chest exams and determine if additional images are necessary.  Begin to develop skills in differential diagnosis  Demonstrate ability to appropriately order follow-up imaging.  State clinical indications for performing chest radiography.  Dictate accurate, concise radiography reports.

Patient Care  Read and/or dictate images with the assistance/review of faculty radiologists.  Make preliminary decisions on all matters of image interpretation and consultation, recognizing need for and obtaining assistance in situations that require expertise of faculty radiologist.  Develop an understanding of ACR appropriateness criteria for chest radiology imaging.  Demonstrate knowledge of parameters contributing to patient radiation exposure and techniques used to limit radiation exposure.  Act as a consultant to referring clinicians and recommend appropriate use of imaging studies.

Interpersonal and Communication skills  Provide a clear dictated chest imaging report  Provide direct communication to referring physicians or their appropriate representative, and documenting communication in report for emergent or important unexpected findings  Demonstrate the verbal and non-verbal skills necessary for face to face listening and speaking to physicians, families, and support personnel  Participation as an active member of the radiology team by communicating with clinicians face to face, providing consults, answering phones, problem solving and decision-making  Practical experience in dictating radiological reports

Practice-based learning  Review all cases and dictate a preliminary report. Then review your interpretation with faculty and then correct report as needed before sending it to the faculty members report queue  Share good learning cases and missed diagnosis with others in the department

Systems-based learning  Review of literature related to imaging tests seen for this rotation, including ACR Appropriateness Criteria and ACR Practice Guidelines and Technical Standards

Assessment  End of rotation global assessment by faculty  Direct observation and feedback  Reading-out with faculty  Completion of assigned online modules in cardiothoracic radiology  ACR In-Service examination

Study Materials:

1. American College of Radiology teaching file 2. Radiology of Thoracic Diseases: A teaching File, Stephen J. Swensen. MOSBY 1993 3. Critical Care Imaging 3rd Edition, Lawrence Goodman, Charles E. Putman, WB Saunders Chapters 1-16 4. Thoracic Radiology: The Requisites, Theresa Mc Laud, Elsevier Mosby 1998 5. Cardiac Imaging 2nd Edition: The Requisites. Stephen Wilmot Miller, Elsevier Mosby 2005 6. A Radiologic Approach to Diseases of the Chest 2nd Edition., Irwin M. Freundlich, David G. Bragg, Williams and Wilkins 1997 7. The Core Curriculum: Cardiopulmonary Imaginge: Ella Kazerooni, Barry Gross Philadelphia, Lippincott Milliams & Wilkins, 2003

Web Sites:

1. Introduction to Chest Radiology http://www.med-ed.virginia.edu/courses/rad/cxr/ 2. http://rad.usuhs.edu/medpix/medpix_home.html?mode=default 3. http://chorus.rad.mcw.edu/index/3.html 4. Lobar Collapse Tutorial http://www.radiology.co.uk/srs- x/tutors/collapse/tutorial.htm 5. http://www.chestx-ray.com/ 6. Cardiac CT - Video Lectures from the 2006 STR Meeting http://www.thoracicrad.org/education/index2.htm 7. Education, Research, and Practice in Thoracic Imaging www.chestx-ray.com 8. ICU Chest Radiology http://www.med-ed.virginia.edu/courses/rad/chest/index.html 9. Introduction to Chest Radiology http://www.vh.org/Providers/Lectures/icmrad/chest/chest.html 10. UAB Department of Radiology Teaching File http://www.rad.uab.edu:591/tf/ 11. Cardiac MRI-University of Minnesota http://www.med.umn.edu/radiology/cvrad/chd/index.html 12. BrighamRAD MedShare Anatomy Query http://brighamrad.harvard.edu/education/online/tcd/bwh-query-anatomy.html 13. Society for Cardiovascular Magnetic Resonance http://www.scmr.org/ - see education tab 14. Cardiac Radiology - South Bank University London http://www.sbu.ac.uk/~dirt/museum/heart.html 15. Armed Forces Institute of Pathology http://www.radpath.org (see AFIP subject reviews) 16. Introduction to Cardiothoracic Imaging, Yale University School of Medicine http://info.med.yale.edu/intmed/cardio/imaging/ 17. A Curriculum In Chest Radiology For Diagnostic Radiology Residency With Goals And Objectives http://www.thoracicrad.org/str99/rescurr/index.htm 18. 2006 Cardiac Imaging Symposium - Society of Thoracic Radiology (18 online lectures with video) http://www.thoracicrad.org/education/index2.htm 19. ACR Case in Point http://caseinpoint.acr.org

ROTATION 2

Competency-Based Goals & Objectives Medical Knowledge  Continue to build on chest radiographic interpretive skills  Continue to build knowledge in differential diagnosis.  Refine approach to analyzing a chest radiograph.  Refine skills in interpretation of chest radiography  Correlate pathologic and clinical data with radiographic findings.  Monitor chest exams and determine if additional images are necessary.  Refine ability to appropriately order follow-up imaging.  State clinical indications for performing chest radiography.  Dictate increasingly accurate, concise radiography reports.

Patient Care  Read and/or dictate images with the assistance/review of faculty radiologists.  Make preliminary decisions on all matters of image interpretation and consultation, recognizing need for and obtaining assistance in situations that require expertise of faculty radiologist.  Become a more autonomous consultant and teacher.  Develop an understanding of ACR appropriateness criteria for chest radiology imaging.  Demonstrate knowledge of parameters contributing to patient radiation exposure and techniques used to limit radiation exposure.  Act as a consultant to referring clinicians and recommend appropriate use of imaging studies.

Professionalism  Recognize limitations in personal knowledge and skills, being careful to not make decisions beyond the level of personal competence.  Demonstrate compassion (be understanding and respectful of patient, their families, and medical colleagues).  Demonstrate excellence: perform responsibilities at the highest level and continue active learning throughout one's career.  Demonstrate honesty with patients and staff.  Demonstrate honor and integrity: avoid conflict of interests when accepting gifts from patients and vendors.  Demonstrate positive work habits, including punctuality and professional appearance.  Demonstrate the broad principles of biomedical ethics.  Demonstrate principles of confidentiality with all information transmitted during a patient encounter.  Demonstrate a responsible work ethic Interpersonal and Communication skills  Continue to build Technical, Communication and Decision-Making Skills learned in rotation 1.  Provide a clear dictated chest imaging report  Provide direct communication to referring physicians or their appropriate representative, and documenting communication in report for emergent or important unexpected findings  Refine the verbal and non-verbal skills necessary for face to face listening and speaking to physicians, families, and support personnel  Participation as an active member of the radiology team by communicating with clinicians face to face, providing consults, answering phones, problem solving and decision-making  Continue to gain experience in dictating radiological reports

Systems-based learning  Review of literature related to imaging tests seen for this rotation, including ACR Appropriateness Criteria and ACR Practice Guidelines and Technical Standards

ROTATION 3 and 4

Rotation 3 or 4 will be performed at William Beaumont Hospital – Royal Oak under the direction of Michael Farah, MD, Section Chief of the Cardiothoracic Imaging Division.

Competency-Based Goals & Objectives Medical Knowledge  Refine skills in interpretation of chest CT scans  Refine skills in interpretation of chest radiography  Develop skills in protocalling, monitoring and interpreting HRCT scans.  Develop skills in protocalling, monitoring and interpreting chest MR studies including cardiovascular MRI.  Develop skills in protocalling, monitoring and interpreting cardiac coronary CTA studies.  Correlate pathologic and clinical data with radiographic and chest CT findings.  Monitor chest CT exams and determine if additional images are necessary.  Demonstrate ability to appropriately protocol a chest CT, given patient history.  State clinical indications for performing chest radiography, CT and MRI.  Dictate accurate, consise radiography, chest CT and MR reports.

Patient Care  Read and/or dictate images with the assistance/review of faculty radiologists.  Make preliminary decisions on all matters of image interpretation and consultation, recognizing need for and obtaining assistance in situations that require expertise of faculty radiologist.  Become a more autonomous consultant and teacher.  Develop an understanding of ACR appropriateness criteria for chest radiology and cardiovascular imaging.  Demonstrate knowledge of CT parameters contributing to patient radiation exposure and techniques used to limit radiation exposure.  Act as a consultant to referring clinicians and recommend appropriate use of imaging studies.

Systems-based learning  Review of literature related to nuclear imaging tests listed in the Medical Knowledge section for this rotation, including ACR Appropriateness Criteria and ACR Practice Guidelines and Technical Standards

Assessment  Global Competency ratings by faculty  360 degree review from staff  Direct feedback from faculty  Reading out with faculty  Resident will have completed the AOBR Physics and Written exams.  ACR In-Service examination

CHEST RADIOLOGY

KNOWLEDGE-BASED LEARNING AND OBJECTIVES -Based on the Curriculum in Chest Radiology created and endorsed by the Society of Thoracic Radiology

Normal Anatomy: 1. Name and define the three zones of the airways 2. Define a secondary pulmonary lobule 3. Define an acinus 4. List the lobar and segmental bronchi of both lungs 5. Identify the following structures on the posteroanterior (PA) chest radiograph: - Lungs – right, left, right upper, middle and lower lobes, left upper and lower lobes, lingula - Fissures – minor, superior accessory, inferior accessory, azygous - Airway - trachea, carina, main bronchi - Heart - right atrium, left atrial appendage, left ventricle, location of the four cardiac valves - Pulmonary arteries – main, right, left, interlobar - Aorta – ascending, arch, descending - Veins – superior vena cava, azygous, left superior intercostals (“aortic nipple”) - Bones – spine, ribs, clavicles, scapulae, humerus - Right paratracheal stripe - Junction lines – anterior, posterior - Aortopulmonary window - Azygoesophageal recess - Paraspinal lines - Left subclavian artery 6. Identify the following structures on the lateral chest radiograph: - Lungs – right, left, right upper, middle and lower lobes, left upper and lower lobes, lingula - Fissures – major, minor, superior accessory - Airway - trachea, upper lobe bronchi, posterior wall of bronchus intermedius - Heart – right ventricle, right ventricular outflow stripe, left atrium, left ventricle, the location of the four cardiac valves - Pulmonary arteries – right, left - Aorta – ascending, arch, descending - Veins – SVC, IVC, left brachiocephalic (innominate), pulmonary vein confluences - Bones – spine, ribs, scapulae, humerus - Retrosternal line - Posterior tracheal stripe - Right and left hemidiaphragms - Raider’s triangle - Brachiocephalic (innominate) artery Monitoring and Support Devices: – “Tubes And Lines”

1. Be able to identify, state the preferred placement of, complications associated with malposition and identify the location on chest radiography for each of the following : - endotracheal tube - central venous catheter - Swan-Ganz catheter - feeding tube - nasogastric tube - chest tube - intra-aortic balloon pump - pacemaker and pacemaker leads - automatic implantable cardiac defibrillator - left ventricular assist device - atrial septal defect closure device (“clamshell device”) - pericardial drain - extracorporeal life support cannulae - intraesophageal manometer, temperature probe or pH probe - tracheal or bronchial stent 2. Explain how an intra-aortic balloon pump works

Signs in Chest Radiology:

1. Be able to define, identify and state the significance of the following on a radiograph: - air bronchogram - indicates a parenchymal process, including nonobstructive atelectasis, as distinguished from pleural or mediastinal processes - air crescent sign – indicates a lung cavity, often due to fungal infection - deep sulcus sign on a supine radiograph - indicates pneumothorax - continuous diaphragm sign - indicates pneumomediastinum - ring around the artery sign (around pulmonary artery on lateral chest radiograph) - indicates pneumomediastinum - fallen lung sign - indicates a fractured bronchus - flat waist sign- indicates left lower lobe collapse - gloved finger sign - indicates bronchial impaction, which can be seen in allergic bronchopulmonary aspergillosis - Golden S sign - indicates lobar collapse with a central mass, suggesting an obstructing bronchogenic carcinoma in an adult - luftsichel sign - indicates upper lobe collapse, potentially due to an obstructing bronchogenic carcinoma in an adult - Hampton’s hump - indicates a pulmonary infarct - silhouette sign - loss of the contour of the heart or diaphragm used to localize a parenchymal process (e.g. a process involving the medial segment of the right middle lobe obscures the right heart border; a lingula process obscures the left heart border; a basilar segmental lower lobe process obscures the diaphragm) - cervicothoracic sign – a mediastinal opacity that projects above the clavicles is retrotracheal and posteriorly situated while an opacity effaced along its superior aspect and projecting at or below the clavicles is situated anteriorly

- tapered margins sign - a lesion in the chest wall, mediastinum or pleura will have smooth tapered borders and obtuse angles with the chest wall or mediastinum while parenchymal lesions usually form acute angles - figure 3 sign – abnormal contour of the descending aorta, indicating coarctation of the aorta - fat pad sign or sandwich sign – indicates pericardial effusion on lateral chest radiograph - scimitar sign – an abnormal pulmonary vein in venolobar syndrome - double density sign – contour projecting over the right side of the heart, indicating enlargement of the left atrium - hilum overlay sign and hilum convergence sign – used to distinguish a hilar mass from a non-hilar mass

Interstitial Lung Disease:

1. Identify Kerley A and B lines on a chest radiograph and explain their etiology 2. Recognize the changes of congestive heart failure on a chest radiograph - enlarged cardiac silhouette, pleural effusions, vascular redistribution, interstitial and/or alveolar edema, Kerley lines 3. Define the terms “asbestos-related pleural disease” and “asbestosis;” identify each on a chest radiograph 4. Describe what a “B” reader is as related to the evaluation of pneumoconiosis 5. Identify honeycombing on a radiograph , state the significance of this finding (end-stage lung disease),and list the commo causes of honeycomb lung 6. Recognize progressive massive fibrosis/conglomerate masses secondary to silicosis or coal worker’s pneumoconiosis on radiography 7. State the radiographic classification of sarcoidosis

Alveolar Lung Disease:

1. List four broad categories of acute alveolar lung disease (ALD) 2. List five broad categories of chronic ALD 3. Name three pulmonary-renal syndromes 4. List five of the most common causes of adult respiratory distress syndrome 5. Name four predisposing causes of bronchiolitis obliterans organizing pneumonia (BOOP) 6. Suggest a specific diagnosis of ALD when supportive findings are present in the history or on the chest radiograph (e.g. broken femur and ALD in fat embolization syndrome, ALD and renal failure in a pulmonary-renal syndrome, ALD treated with bronchoalveolar lavage in alveolar proteinosis) 7. Recognize a pattern of peripheral alveolar lung disease on radiography or chest CT and give an appropriate differential diagnosis, including a single most likely diagnosis when supported by associated radiologic findings or clinical information (e.g. peripheral lung disease associated with paratracheal and bilateral hilar adenopathy in an asymptomatic patient with ”alveolar’ sarcoidosis, peripheral lung disease associated with a markedly elevated blood eosinophil count in a patient with eosinophilic pneumonia, peripheral opacities associated with multiple rib fractures and pneumothorax in a patient with acute chest trauma and pulmonary contusions Atelectasis, Airways and Obstructive Lung Disease:

1. Recognize partial or complete atelectasis of the following on a chest radiograph: - right upper lobe - right middle lobe - right lower lobe - right upper and middle lobe - right middle and lower lobe - left upper lobe - left lower lobe 2. Recognize complete collapse of the right or left lung on a chest radiograph and list an appropriate differential diagnosis for the etiology of the collapse 3. Distinguish lung collapse from massive pleural effusion on a frontal chest radiograph 4. Name 5 common causes of bronchiectasis 5. Recognize the typical appearance of cystic fibrosis on a radiograph 6. Name the important things to look for on a chest radiograph when the patient history is “asthma’” 7. Define tracheomegaly 8. Recognize tracheal and bronchial stenosis on chest CT and name the most common causes 9. Recognize alpha-1-antitrypsin deficiency on a chest radiograph and chest CT 10. Recognize Kartagener’s syndrome on a chest radiograph and name the 3 components of the syndrome 11. Define the term giant bulla, differentiate giant bulla from pulmonary emphysema and state the role of imaging in patient selection for bullectomy 12. State the imaging findings used to identify surgical candidates for giant bullectomy and for lung volume reduction surgery.

Mediastinal Masses and Mediastinal/Hilar Lymph Node Enlargement:

1. State the anatomic boundaries of the anterior, middle, posterior and superior mediastinum 2. Name the four most common causes of an anterior mediastinal mass and localize a mass to the anterior mediastinum on a radiograph, chest CT and chest MRI 3. Name the three most common causes of a middle mediastinal mass and localize a mass in the middle mediastinum on a radiograph, chest CT and chest MRI 4. Name the most common cause of a posterior mediastinal mass and localize a mass in the posterior mediastinum on a radiograph, chest CT and chest MRI 5. Name two causes of a mass that straddles the thoracic inlet and localize a mass to the thoracic inlet on a radiograph, chest CT and chest MRI 6. Name five etiologies of bilateral hilar lymph node enlargement 7. State the three most common locations (Garland’s triad) for lymph node enlargement to occur in the chest of patients with sarcoidosis 8. List the four most common etiologies of “egg-shell” calcified lymph nodes in the chest 9. Recognize a cystic mass in the mediastinum and suggest the possible diagnosis of a bronchogenic, pericardial, thymic or esophageal duplication cyst Solitary and Multiple Pulmonary Nodules:

1. State the definition of a solitary pulmonary nodule and a pulmonary mass 2. Name the three most common causes of a solitary pulmonary nodule 3. Name four important considerations in the evaluation of a solitary pulmonary nodule 4. Name six causes of cavitary pulmonary nodules 5. Name four causes of multiple pulmonary nodules

Benign and Malignant Neoplasms of the Lung and Esophagus:

1. Recognize abnormal contralateral mediastinal shift on a postpneumonectomy chest radiograph and state five possible etiologies for the abnormal shift 2. Name the most common location for adenoid cystic and carcinoid tumors to occur 3. Suggest the possibility of radiation change as a cause of new apical opacification on a chest radiograph of a patient with evidence of mastectomy and/or axillary node dissection 4. Describe the acute and chronic radiographic and CT appearance of radiation injury in the thorax (lung, pleura, pericardium, esophagus) and the temporal relationship to radiation therapy

Chest Trauma:

1. Identify a widened mediastinum on a trauma radiograph and state the differential diagnosis (including aortic/arterial injury, venous injury, fracture of sternum or spine) 2. Identify and state the significance of chronic traumatic pseudoaneurysm on a chest radiograph 3. Identify fractured ribs, clavicle, spine and scapula on a chest radiograph or chest CT 4. Name five common causes of abnormal lung opacity on a trauma radiograph 6. Identify an abnormally positioned diaphragm or loss of definition of a diaphragm on a trauma chest radiograph and suggest the diagnosis of a ruptured diaphragm 5. Identify a pneumothorax and pneumomediastinum on a trauma chest radiograph 6. Identify the fallen lung sign on a radiograph and suggest the diagnosis of tracheobronchial tear 7. Identify a cavitary lesion on a post-trauma radiograph and suggest the diagnosis of laceration with pneumatocele formation, hematoma or abscess secondary to aspiration 8. Name the three most common causes of pneumomediastinum in the setting of trauma 9. Recognize and distinguish between pulmonary contusion, laceration and aspiration

Chest Wall, Pleura and Diaphragm:

1. Recognize and name four causes of a large unilateral pleural effusion on a radiograph 2. Recognize a pneumothorax on an upright and supine chest radiograph 3. Recognize a pleural based mass with bone destruction or infiltration of the chest wall on a radiograph and name four likely causes 4. Recognize pleural calcification on a radiograph and suggest the diagnosis of asbestos exposure (bilateral involvement) or old TB or trauma (unilateral involvement) 5. Recognize the typical chest radiographic appearances of pleural effusion, given differences in patient positioning

6. Recognize apparent unilateral elevation of the diaphragm on a chest radiograph and suggest a specific etiology with supportive history and associated chest radiograph findings (e.g. subdiaphragmatic abscess after abdominal surgery, diaphragm rupture after trauma, and phrenic nerve involvement with lung cancer) 7. Recognize a tension pneumothorax and understand the acute clinical implications 8. Recognize diffuse pleural thickening, as seen in fibrothorax, malignant mesothelioma and pleural metastases 9. State and recognize the radiographic and CT findings of malignant mesothelioma

Infection (Immunocompetent, Immunocompromised and Post-transplant Patients):

1. Name the radiographic manifestations of primary pulmonary tuberculosis 2. Name the three most common segmental sites of involvement for reactivation tuberculosis in the lung 3. Define Ranke complex and Ghon lesion; recognize both on a radiograph and CT 4. Name and describe the four types of pulmonary Aspergillus disease 5. Identify an intracavitary fungus ball on chest radiography. 6. State the radiographic appearances of Cytomegalovirus pneumonia 7. Name the major categories of disease causing chest radiograph abnormalities in the immunocompromised patient 8. Other than bacterial infection, name 2 important infections and 2 important neoplasms to consider in patients with AIDS and chest radiograph abnormalities 9. Describe the chest radiograph and chest CT appearances of Pneumocystis carinii pneumonia 10. Name the 4 most important etiologies of hilar and mediastinal adenopathy in patients with AIDS 11. Describe the time course and chest radiographic appearance of a blood transfusion reaction 12. State the radiographic appearances of mycoplasma pneumonia 13. Describe the radiographic and CT appearance of a miliary pattern and provide a differential diagnosis 14. Name the diagnostic considerations in a patient who presents with recurrent or persistent pneumonias 15. Name the endemic mycoses, the specific geographic regions where they are found, and their radiographic manifestations 16. State the most common pulmonary infections seen after solid-organ (i.e. liver, renal, cardiac) transplantation 17. Describe the radiographic and CT findings of post-transplant lymphoproliferative disorders

Unilateral Hyperlucent Lung (or hemithorax):

1. Recognize a unilateral hyperlucent lung on a radiograph 2. Identify the common causes for unilateral hyperlucent lung on a chest radiograph 3. Give an appropriate differential diagnosis when a hyperlucent lung is seen on a chest radiograph, and suggest a specific diagnosis when certain associated findings are seen (i.e. absence of a breast in a patient after mastectomy for breast cancer, absence of a pectoralis muscle in a patient with Poland’s syndrome, unilateral bullous disease/emphysema, or air trapping on expiration in a patient with Swyer-James syndrome or an endobronchial foreign body

Congenital Lung Disease:

1. Name the components of the pulmonary venolobar syndrome 2. Recognize venolobar syndrome on a frontal chest radiograph, and explain the etiology of the retrosternal band of opacity seen on the lateral view 3. Recognize a mass in the posterior segment of a lower lobe on a chest radiograph and chest, and suggest the possible diagnosis of pulmonary sequestration 4. Explain the differences between intralobar and extralobar sequestration 5. Recognize bronchial atresia on a radiograph and chest CT, and state the most common lobes of the lungs in which it occurs

Pulmonary Vascular:

1. Recognize enlarged pulmonary arteries on a chest radiograph and distinguish them from enlarged hilar lymph nodes 2. Recognize enlargement of the central pulmonary arteries with diminution of the peripheral pulmonary arteries as pulmonary arterial hypertension and suggest the possible diagnosis of primary pulmonary artery hypertension 3. Name five of the most common causes of pulmonary artery hypertension

Thoracic Aorta and Great Vessels:

1. State the normal dimensions of the thoracic aorta 2. Recognize a right aortic arch and a double aortic arch on a radiograph, chest 3. State the significance of a right aortic arch with mirror image branching versus with an aberrant subclavian artery 4. Recognize a cervical aortic arch on a radiograph . 5. State the common cardiac anomalies associated with aortic coarctation

Cardiac Valvular Disease: 1. State the findings that indicate each of the following and identify each on chest radiographs: - enlarged right atrium - enlarged left atrium - enlarged right ventricle - enlarged left ventricle 2. Recognize an enlarged left atrium, vascular redistribution, and mitral valve calcification on a chest radiograph and suggest the diagnosis of mitral stenosis 3. Recognize an enlarged ascending aorta and aortic valve calcification on a chest radiograph and suggest the diagnosis of aortic stenosis 4. State the most common etiologies of the following: - aortic stenosis - aortic regurgitation - mitral stenosis - mitral regurgitation - tricuspid regurgitation - pulmonary stenosis 5. State the cardiac diseases associated with mitral annulus calcification 6. Identify endocarditis and/or complications of endocarditis on radiographs

Pericardial Disease:

1. Recognize pericardial calcification on a radiograph and list the most common causes 2. Describe and identify two chest radiographic signs of a pericardial effusion 3. State five causes of a pericardial effusion 4. State and recognize the findings of a each of the following on radiography - pericardial cyst - constrictive pericarditis - pericardial hematoma - pericardial metastases - partial absence of the pericardium - pneumopericardium

Congenital Heart Disease in the Adult:

1. Recognize increased vascularity, decreased vascularity and shunt vascularity on a chest radiograph and state the common causes of each 2. Recognize the following on chest Heart disease presenting during adulthood - Left-to-right shunts and Eisenmenger physiology - Atrial septal defect - Ventricular septal defect - Partial anomalous pulmonary venous connection - Patent ductus arteriosus - Coarctation of aorta - Tetralogy of Fallot and pulmonary atresia with ventricular septal defect - Congenitally corrected transposition of the great arteries - Persistent left superior vena cava - Truncus arteriosus - Ebstein anomaly - Cardiac malposition, including abnormal situs

Post-Operative Chest:

1. Identify normal post-operative findings and complications of the following procedures, on chest radiography: - wedge resection, lobectomy, pneumonectomy - coronary artery bypass graft surgery - cardiac valve replacement - aortic graft - aortic stent - transhiatal esophagectomy - lung transplant - heart transplant - lung volume reduction surgery