CXR

Question 1

What is the first thing to do when you get a CXR? (3)

Answer 1

Check the history - age, gender, pacemakers, any long term conditions eg emphysema or heart failure.

Question 2

Describe the possible projections of a CXR. (5)

Answer 2

PA - posterior anterior - standing looking at the detector, away from the emitter - can comment on heart side on this one.
AP - anterior posterior - sitting, laying looking at the emitter.

Question 3

Explain how you check the adequacy of the film. (6)

Answer 3

R - rotation - spinous processes and clavicles at 90 degrees
I - inspiration - ribs 1-5 visible, and constophrenic angles.
P - penetration - vertebrae just visible through heart.

Question 4

Describe the ABCD approach to assessing x rays. 
A (2)
B (3)
C (3)
D (5)

Answer 4

Airways - central trachea, left hila higher than right.
Breathing - symmetry between each lung zone, crisp costophrenic angles, crisp edges to each lung.
Circulation - arch of the aorta, right heart border (RA to middle lobe) and left heart border (LV to lingula).
Dem bones / Diaphragm - free gas (not gastric bubble), nodules (small) or masses (big), fractures, dislocations.

Question 5

Describe the review areas of CXRs.
8 areas
13 things to look for in total

Answer 5

Apices - pneumothorax, pancoast tumours.
Thoracic inlet - superior mediastinal mass eg goitre.
Paratrachial stripe - lymph nodes, sympathetic chain, bones
Below diaphragm - pneumoperitoneum
Edges of films - does it include everything
Behind heart - masses
Bones - all there? Pancoast tumour dissolving them?
Artefacts - clothes, hair, surgical lines, pacemaker.

Question 6

Describe how mediastinal shift presents on CXR. (2)

Give causes of that. (4)

Answer 6

When the trachea is pushed or pulled to one side because of an increase or decrease in volume or pressure.
Push - tension pneumo, v large pleural effusion
Pull - ordinary pneumo, blockage to filling (eg bronchial tumour).

Question 7

Describe the presentation of pneumothorax on CXR. (2)

Answer 7

Lung markings not visible past the pleural edge, which is not in contact with the chest wall.

Question 8

Describe the presentation of pleural effusion on CXR. (5)

Answer 8

Collection in the pleural space creating a uniform white area causing a loss of costophrenic angle and hemidiaphragm. Meniscus on upper surface.
Be aware a supine CXR will give an all over haziness when gravity works the other way.

Question 9

Describe the presentation of lobar lung collapse on CXR. (2)

Answer 9

Elevation of ipsilateral diaphragm, mediastinal draw.

Question 10

Describe the presentation of consolidation on CXR. (2)

Answer 10

The filling of small airways with stuff causing dense opacification with a preserved volume.

Question 11

Describe the presentation of space occupying lesions on CXR. (4)

Answer 11

Nodules <3cm, mass >3cm, or diffuse - disseminated mets or miliary TB.

Question 12

Describe the presentation of pulmonary oedema on CXR. (1)

Answer 12

Fluid seen as consolidation within the lungs.