How to interpret CXRs for the OSCE

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Dim room lighting Check patient information - name, age, sex, date of radiograph Identify radiographic quality - AP/PA film, exposure, rotation, patient position (supine, sitting or erect) RIPE
Rotation. To determine the degree of rotation in a radiograph, measure the distance between the medial heads of the clavicles and the adjacent spinous processes in the upper thorax. In a truly straight film, the distances should be the same. Inspiration. To check for an adequate degree of inspiration, count the anterior ribs on the right. In a good radiograph, 6 anterior ribs should be visible above the right hemidiaphragm. Position. Identification of a gas-fluid level (often in the gastric fundus), alignment of the scapulae with the lungs, and a posteroanterior (PA) label all help establish that the patient was upright. Exposure. A good film must have both adequate penetration of the patient and sufficient contrast to distinguish between adjacent structures of different densities. If the intervertebral disks of the lower thoracic spine are visible through the heart and the pulmonary vessels posterior to the heart on the left can be identified, the exposure is probably adequate.

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Identify and check position of lines, tubes and other invasive devices Soft tissues foreign bodies (metal), thickness, contours, presence of gas, masses, mastectomy Lungs (parenchyma)- look for abnormal densities (opacity or lucency) or Pneumothorax -

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Look at lung volumes (hyperinflated in COPD) Look at each lobe and compare (esp. apices) Linear atelectasis If shadowing: look for air bronchograms

Hila - position, masses or lymphadenopathy Heart - size and shape Pulmonary vessels - artery or vein enlargement (follow outwards) Bones density, lesions or fractures. Clavicle, scapula, ribs. Pleura - thickening, calcification, effusion or Pneumothorax Trachea - midline or deviated, wall, lumen diameter Mediastinum - width and contour, discreet masses

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Check review areas - apices, especially right upper lobe, retrocardiac area, the peripheral lung margins, posterior costophrenic sulci, and the diaphragm.
CXR signs of heart failure: 1. 2. 3. 4. 5. Alveolar oedema Kerley B lines Cardiology Distended upper lobe vessels Pleural effusions

Causes of consolidation: infection, pulmonary oedema, sarcoidosis, neoplasm, infarction (following PE), haemorrhage.

Silhouette signs Anatomical relationships: Right heart boarder and RML Ascending aorta and RUL Left heart border and lingula Left anterior diaphragm and heart Aortic knob and LUL Right posterior diaphragm and RLL Left posterior diaphragm and LLL Lobar collapse Occurs due to proximal occlusion of a bronchus, causing a loss of aeration. The remaining air is gradually absorbed, and the lung loses volume. Causes:

1. Proximal stenosing bronchogenic carcinoma, which occludes a bronchus. Patients are middle aged or elderly, and almost always smokers. 2. Asthma: In a young adult or older child . Collapse occurs secondary to mucous plugging of the major airways. 3. In an infant consider an inhaled foreign body, such as a peanut. 4. Retention of secretions is a frequent cause of post operative collapse. Features of collapse on CXR: Tracheal displacement towards the side of the collapse. Mediastinal shift towards the side of the collapse. Elevation of the hemidiaphragm. Reduced vessel count on the side of the collapse. Herniation of the opposite lung across the midline. A hilar mass, which also suggests carcinoma as the cause. Other evidence of malignant disease (eg. rib metastases, lymphangitis, effusion) The presence of a foreign body; however these are rarely easy to see.

The presence of an endotracheal tube; is it sited too low?

Pleural effusions Meniscus sign Subpulmonic pleural effusion: effusion trapped between lung and diaphragm (resembles elevated diaphragm) Large effusions can cause the mediastinum to shift to opposite side Free flowing pleural effusion: use lateral decubitus views to identify Loculated pleural effusion: doesnt shift with a change in position, absence of air bronchogram, convex border pseudotumor is fluid trapped in a fissure Kerley lines: 2-3 cm long pleural perpendicular to lateral chest, represent thickened interlobular septa and edematous lymphatics