ABSTRACT
Background: Chest x-ray remains a major tool for diagnosis and management of many diseases ravaging mankind.
Aim: To assess the chest-x-ray referral patterns and findings in the University of Nigeria Teaching Hospital Ituku-Ozalla, Enugu.
Patient and Method: A retrospective study of 377 patients who underwent chest x-ray examination at the University of Nigeria Teaching Hospital, Ituku-Ozalla.
Result: Chest x-ray (6,592) constituted above half of the total referrals(11,306) to the Radiology department in year 2012. More females, (58.62%, n = 221) were referred for chest x-ray than the males, (41.38%, n = 156). The highest indication for chest x-ray in the University of Nigeria Teaching Hospital is HTN, (35%, n = 132). Patients between the age bracket of (41 – 50) have the highest referral for chest x-ray. Most of the chest x-ray referrals are on out patients, GOPD (61.27% n = 231), MOP (11.14%, n = 42). More than half of the chest x-ray referrals (52.79%, n = 199) appear radiologically normal while the remainder (46.15%, n = 174) were abnormal. The chest radiographs of 92.86% (n = 14) of those for medical exam/Routine check appeared radiologically normal
Conclusion
Conventional chest x-ray remains the primary diagnostic tool for most diseases of the chest region. However appropriate clinical diagnosis should always be conducted to reduce the number of normal chest-x-rays diagnosed. Routine chest x-ray should be discouraged as it almost amounts to unnecessary irradiation of patients with low diagnostic yield.
Key words: Chest, x-ray, referrals, indications, patterns of findings, UNTH Ituku-Ozalla, referring units.
TABLE OF CONTENTS
Title Page--------i
Approval page-------ii
Certification -------iii
Dedication--------iv
Acknowledgement-------v
Abstract--------vi
Table of contents-------vii-xiii
CHAPTER ONE: Introduction
1.0 Background of the study---- - 1-2
1.1.0 Statement of Problem------ 3
1.1.1 General Objectives of the study--- - - 3
1.1.2 Specific Objectives of the Study---- 3
1.1.3 Significance of the Study----- - 4
1.2.0 Scope of the Study------ - 4
1.2.1 Source of Data------ - 4
1.2.3 Review of Related Literature---- 5-16
CHAPTER TWO: Theoretical Background
2.1.0 Understanding the Chest Radiography---- - 17
2.1.1 Gross anatomy of the Chest----- 18
2.1.3 The RIBS------- 18
2.2.0 The Sternum------ 19
2.2.1 The Vertebrae------ 19
2.2.2 The Clavicles------ 19
2.2.3 The Scapulae------ 19
2.3.0 The Soft tissue components of the Chest-- 20
2.3.1 The Heart------- 20
2.3.2 The Lungs------- 20
2.3.3 The wind Pipe------ 20
2.4.0 The Oesophagus------ 21
2.4.1 Diaphragm------- 21
2.4.2 Mediastinum------ 21
2.4.3 Equipments and Accessories used for Chest x-Rays------- 22
2.5.0 The x-Ray Machine----- 22
2.5.1 X-ray cough------ 22
2.5.2 Chest stand/Erect Bucky---- 23
2.5.3 The Grid------- 23
2.6.0 X-ray Films & Cassettes---- 23
2.6.1 Sand Bags/Foam pads----- 23
2.6.2 Other Accessories------ 23
2.6.3 Chest X-ray Techniques----- 23
2.7.0 Posterior Anterior (PA) View---- 24
2.7.1 Anterior Posterior (AP)----- 24
2.7.2 Patient Preparation for Chest x-ray--- 24
2.7.3 The Chest x-ray Examination---- 24/25
2.8.0 Exposure Values------ 25
2.8.1 Posterior Anterior------ 26
2.8.2 Pathologic Indications for Chest x-ray-- 27
CHAPTER THREE: RESEARCH METHODOLOGY
3.0 Research Design------ 28
3.1.0 Area of Study------ 28
3.1.1 Scope of the study----- 28
3.1.2 Sources of Data------ 28
3.1.3 Sample Size Determination---- 28-29
3.2.0 Method of Data Collection---- 29
3.2.1 Data Analysis Technique---- 29
CHAPTER FOUR: DATA ANALYSIS AND PRESENTATION
Table 1.0 Distribution of clinical Indications Across Referring Units-----32
Fig 1.0Graph of Frequency against Indications-35
Table 1.1 Frequency of Referred Patients against The Referring Units----36
Table 1.2 Distribution of Indication Across Age-37
Table 1.3 Indications and Patterns of radiological Diagnosis------39
Table 1.4 Distributions of Indications Across Gender-41
CHAPTER FIVE: DISCUSSION, SUMMARY OF FINDINGS,
RECOMMENDATION, LIMITATION OF THE STUDY, CONCLUSION AND AREA OF FURTHER STUDY
5.0 Discussion-------43-46
5.1.0 Recommendation------48
5.1.1 Limitation of the Study-----49
5.1.2 Conclusion-------- 49
References
Appendix
INTRODUCTION
Chest x-ray is a radiological investigation that makes use of x-radiation to obtain diagnostic information about the chest region.1, 2, 3. Chest x-ray is the commonest radiologic examination4. The chest examinations are done because of certain clinical indications which include, tuberculosis, pneumonia, to visualize air-fluid level in trauma cases, preoperative chest x-ray, cancer, cardiac bypass, surgical empyema, hypertensive heart disease, bronchitis, broncholitis, routine chest x-ray to check for inserted lines, chest wall and mediastinum5,.At some other times they are done for screening ,pre-admission and medical examination purposes.Chest x-ray has overtime served as a veritable tool for the diagnosis of many pathologic conditions6.The main regions where a chest x-ray may identify problems may be categorized as;A,B,C,D,E,F by their letters.These include Airways(hilar adenopathy or enlargement) ,Breast shadows,Bones e.g fractures and lytic bone lesions, Cardiac silhouette, detecting cardiac enlargement, Costophrenic angles, including pleural effusions . Others include Diaphragm, e.g showing evidence of free air edges such as apices for fibrosis,pneumothorax,pleural thickening or plaque fields(lung parenchyma being evidence of alveolar filling) and then Failure e.g alveolar air space disease with prominent vascularity with or without pleural effusions1. Patients are often referred to the radiology unit for chest x-rays.These come from different medical/surgical units like ICU,MOPD,GOPD,A&E, Oncology, Paediatric, Casualty, Neurology, Enterology, etc. The extent of the usage of the radiology department by these units is not known. There is need, therefore, to establish the degree of these referrals, as well as the extent of usage of the chest radiography by the different units.
Most of the time, chest x-rays are done without any significant abnormality detected.This could be as a result of referrals done without critical and adequate clinical diagnosis by the referring clinicians.Noting how many chest x-ray examinations undertaken which were able to point to any abnormality will help to weigh this out.It is also necessary, to find out how often the chest x-rays are done, the indications as well as the nature of the results of such examinations. How many come out normal, negative or abnormal? Is there actually any correlation between clinical indications and radiologic findings? Are chest x-ray examinations necessary in all conditions? The Nigerian Federal University Teaching Hospitals have higher number of patients of varying social strata.This is because it is believed that medical services are offered at a relatively lower cost there than is obtainable in other hospitals.As a result, The University Of Nigeria Teaching Hospital, Ituku-Ozalla was chosen for this study because it is a Nigerian University Teaching Hospital that has high patient through put. Patients are referred to the hospital from the neighbouring rural communities and States, with varying pathological conditions. Specialist, private and state-owned hospitals were not considered in this research as they may not have enough data for the research purpose.
Many other imaging modalities like MRI, CT etc can be employed to obtain most of this diagnostic information but routine conventional chest x-ray still offers primary information about a greater number of them7
