Chest X-Rays

Question 1

What is the best film to order to examine the axillary ribs?

Answer 1

Oblique Film

Question 2

What are some common indications for ordering a CXR?

Answer 2

Respiratory distress (SOB, Pleuritic Px, Hemoptysis, etc)
Trauma
Chest Px / Cardiac Dz
Infection (Tb or Pneumonia)
Pre / Post Procedure

Question 3

What are 4 considerations a provider should keep in mind when examining CXR quality?

Answer 3

RIPE
Rotation
Inspiration
Position (PA vs. AP)
Exposure

Question 4

How many anterior ribs should be visible on an CXR for a good film?

Answer 4

At least 5 to 7 anterior ribs.

Fewer ribs indicates inadequate inspiration

Question 5

Which view is appropriate to clinically determine cardiomegaly?

Answer 5

PA view

Question 6

As a provider you are attempting to determine if the PT has a pneumothorax or pleural effusion…. What CXR image should you order? (Air trapping vs. Fluid)

Answer 6

Lateral decubitus film

Question 7

A good film MUST HAVE…. (what things visible)

Answer 7

PT identifier
NO ROTATION
Good Inspiratory effort (5 to 7 anterior ribs)
Entire thorax displayed
Thoracic vertebrae visible through heart (good measure of X-ray penetration)

Question 8

What is the systematic ABCDE approach to examining CXR’s?

Answer 8

Airway (Trach, Bronchus, Hila)
Breathing (Lungs, pleura, diaphragm)
Cardiac (Heart size, heart borders, vessels)
Disability (osteo-pathology)
Exposure / Everything else

Question 9

The trachea is pushing to the same side as the pathology… What conditions would you suspect?

Answer 9

Atelectasis
Non-tension pneumo

(Negative pressure / lung collapse pulls the trachea to the same side)

Question 10

Trachea is pushed to the opposite side of the pathology in the CXR… What conditions would be on your differential/suspect?

Answer 10

Tension pneumo
Pleural effusion (very large one)

Question 11

Bilateral hilar enlargement is visible on your 45 year old patients CXR with visible lymph nodes… What is your initial Dx?

Answer 11

Sarcoidosis

If unilateral think malignancy

Question 12

Unilateral hilar enlargement is visible on your 70 y.o. patient’s CXR; what might you suspect from this finding?

Answer 12

Malignancy

(Malignancy may also appear with well demarcated borders) (effusions are usually diffuse)
(If bilateral it would be sarcoidosis)

Question 13

T/F

You should be able to visualize the pleura in healthy individuals CXR.

Answer 13

False

The pleura are not normally visualized in healthy individuals CXR

Question 14

Costophrenic blunting can indicate what conditions if visualized on a patients CXR?

Answer 14

Consolidation (i.e. effusion) in that area

Also can occur secondary to hyperinflated lungs (COPD)

Question 15

Air appears to be present between the diaphragm, costophrenic angle, and liver; what condition do you suspect?

Answer 15

Pneumoperitoneum

(Surgical emergency) There should never be distinguishable space b/t the diaphragm and liver

Question 16

If the cardio-thoracic ratio is greater than what value; cardiomegaly can be Dx’d?

If cardiomegaly is determined; what conditions could cause this?

Answer 16

> 50% (PA View ONLY)

Valvular Dz
Cardiomyopathy
Pulmonary HTN
Pericardial Effusion

Question 17

Loss of definition of the Aortic Knob/Knuckle on CXR may indicate what kind of clinical condition?

Answer 17

Aneurysm