CLIN SKILLS: Chest X-Ray Interpretation

Question 1

what details to check for in a CXR

Answer 1

• Pt identifying details
• date and time taken
• view: AP or PA, erect or supine, inspiratory or expiratory etc.

Question 2

why does it matter if the CXR is AP or PA

Answer 2

• if PA: more lung visible b/c they’re at the back so look bigger
• less heart visible b/c closer to front so looks smaller

Question 3

DRSABCDE method for interpreting X-rays

Answer 3

• Details
• RIPE (image quality)
• Soft tissue + bones
• Airway + mediastinum
• Breathing
• Circulation
• Diaphragm
• Extras

Question 4

how to check for image quality in a CXR

Answer 4

• rotation – check that medial clavicle ends equidistant from spinous process or scapulae are symmetrical
• inspiration – check whether its at full inspiration (want lungs to be expanded so we can see more). should be able to see 5-6 anterior ribs and 8-10 posterior ribs
• picture – straight vs oblique, entire lung fields, scapulae OUTSIDE lung fields, angulation (i.e. ’tilt’ in vertical plane)
• exposure (penetration) – adequate, over, under (can also indicate osteoporosis)

Question 5

what extras to check for in a CXR

Answer 5

• any other tubes, catheters, wires, foreign artefacts e.g. pacemaker, sternotomy

Question 6

what to check for in soft tissue and bones on a CXR

Answer 6

• ribs, sternum, spine, clavicles – check for symmetry, fractures, dislocations, lesions, density
• soft tissues – subcutaneous emphysema, masses
• check for calcification of great vessels and carotids

Question 7

what to check for in airway and mediastinum in a CXR

Answer 7

• trachea – central or deviated? patent?
• paratracheal/mediastinal masses or adenopathy
• carina & bronchi
• hilum – left hilum is usually smaller and higher

Question 8

how to check breathing in a CXR

Answer 8

• pleural thickening around the outside
• pleural effusion
• pneumothorax - don’t forget apices
• opacity/whiteness (abnormal - should be translucent)
• consolidation (white spots)

Question 9

how to check circulation in a CXR

Answer 9

• heart position – ⅔ to left, ⅓ to right
• heart shape
• heart size (up to 50% of chest space - cardiothoracic ratio)
• heart borders – R) border is R) atrium, L) border is L) ventricle & atrium

Question 10

how to check diaphragm in a CXR

Answer 10

• hemidiaphragm – R side higher
• cardiophrenic and costophrenic angles – clear and sharp
• gastric bubble/colonic air
• subdiaphragmatic air? (pneumoperitoneum)

Question 11

features of pneumothorax on CXR

Answer 11

• no lung markings (fully black)
• R hemidiaphragm @ same height as L