CXR

Question 1

Approach to CXR

Answer 1

Check pt details
Check X ray details - time, date, projection
Adequacy - E, RIP
Airway - tracheal deviation
Breathing - lung fields (opacity, vasculature, pneumothoraces)
+ check hila + apices
Cardiac - cardiomegaly? heart borders defined?
Diaphragm - well defined? shape (flat/ convex)? air under?
Delicates - bones, lines etc

CHECK - apices, hila, behind heart, costophrenic angles, under diaphragm

Question 2

Describe tracheal positioning

Answer 2

Should be central
If deviated - due to rotation of pt or pathology?
Pathology - is trachea being pulled to one side (volume loss eg lobar/ lung collapse) or pushed away (increased volume eg pleural effusion)

Question 3

Describe normal lungs

Answer 3

Left hilum should be higher than right
Vasculature all the way to lateral margins
No black areas

Question 4

Describe normal heart

Answer 4

Less than 50% of thoracic diameter

Borders clearly visible

Question 5

Describe normal diaphragm

Answer 5

Borders well defined
Upwardly convex
Right usually higher than left due to liver
Sharp costophrenic angle
Air underneath in stomach (left sided, thick wall of stomach)

Question 6

How can you tell apart the lung lobes in terms of consolidation/ collapse?

Answer 6

Diaphragm borders - left and right lower lobes
Right heart border - right middle lobe
Left heart border - left upper lobe

Question 7

What does a pleural effusion present as?

Answer 7

Blunting of costophrenic angle
Unilateral opacification
Fluid level with meniscus

Question 8

What does pulmonary oedema look like?

Answer 8

Alveolar shadowing (bats wings)
B lines (Kerley B lines - little white horizontal lines usually in lateral lower edge)
Cardiomegaly
Diversion of blood to upper lobes (increased vasculature in upper lobes)
Effusions

Question 9

What does a pneumothorax look like?

Answer 9

Air within pleural space
Loss of lung markings in peripheral lung field, may have a lung edge
Mediastinal and tracheal deviation away from tension pneumothorax + flattening of ipsilateral diaphragm

Question 10

What does a left upper lobar collapse look like?

Answer 10

Veil sign - whole lung field looks covered in a veil

Luftsichel’s sign - radiolucency in left upper zone around aortic arch due to hyperinflation of left lower lobe

Question 11

What does a left lower lobar collapse look like?

Answer 11

Sail sign - sharp line at same angle as left heart border

Medial part of left diaphragm will be indistinct but left heart border will be clear

Question 12

What does a right upper lobar collapse look like?

Answer 12

Increased opacification of right upper zone with raised concave horizontal fissure
Golden’s S sign = associated right hilar mass

Question 13

What does a right middle lobar collapse look like?

Answer 13

Indistinct right heart border

Difficult to see

Question 14

What does a right lower lobar collapse look like?

Answer 14

Sail sign on right

Medial part of right diaphragm unclear but lateral side and right heart border distinct

Question 15

Summary

Answer 15

Summarise findings 
Give differentials - hx + exam findings 
Review previous imaging 
Further investigations (CT?)
Management plan

Question 16

What does pneumonia look like?

Answer 16

Dense/ patchy consolidation

Can be difficult to distinguish from effusions so say both in differentials