CXR

Question 1

What’s the first thing you do when interpreting a CXR?

Answer 1

Confirm the patient’s details:

• name, DOB, hosp no.
• date and time of film
• previous imaging

Question 2

What’s the next step after confirming patient’s details?

Answer 2

Assess the quality of the image (RIPE)

Question 3

What does RIPE stand for?

Answer 3

Rotation
Inspiration
Projection
Exposure

Question 4

What do you check for in ‘rotation’?

Answer 4

Clavicles should be equidistant to spinous processes

Question 5

What do you check for in ‘inspiration’?

Answer 5

5-6 anterior ribs OR

10-11 posterior ribs should be visible

Question 6

How do you know which ones the anterior ribs are?

Answer 6

The anterior ribs are the ones that curve downwards

Question 7

What do you check for in ‘projection’?

Answer 7

PA or AP

Question 8

Differentiate between AP and PA

Answer 8

PA = scapula more lateral 
AP = scapula more medial

Question 9

What do you check for in ‘exposure’?

Answer 9

Vertebrae should be visible behind the heart

Question 10

What is one key thing you should always remember about the AP?

Answer 10

Heart size cannot be assessed accurately on an AP as it is imaged from the front!! Therefore beware of it seeming like cardiomegaly when it’s actually normal!

Question 11

What does the ABCDE stand for?

Answer 11

Airway 
Breathing 
Cardiac
Diaphragm 
Everything else

Question 12

What do you look for when assessing the airway?

Answer 12

Trachea - is it deviated or central?
Carina and bronchi - association with NG tube
Hilar structures - are they symmetrical bilaterally or unilaterally?

Question 13

What could bilateral hilar enlargement suggest?

Answer 13

Sarcoidosis/TB

Question 14

What do you when assessing breathing?

Answer 14

Lung fields - look by thirds

Pleura - normally shouldn’t be visible

Question 15

What might a thickened pleura suggest?

Answer 15

Mesothelioma due to asbestos

Question 16

What might pleura that doesn’t extend to the edge suggest?

Answer 16

Pneumothorax

Question 17

What might opacification in the lower lobes suggest?

Answer 17

Pneumonia

Question 18

What do you assess when looking at the cardiac side of things?

Answer 18

Heart size (PA) 
Heart borders

Question 19

When would it be classified as cardiomegaly?

Answer 19

When heart size >50% thoracic width​

Question 20

What would reduced definition of the right heart border suggest?

Answer 20

Right middle lobe consolidation

Question 21

What would reduced definition of the left heart border suggest?

Answer 21

Reduced definition of left heart border = lingula consolidation​

Question 22

Which diaphragm is normally higher?

Answer 22

right one

left is lower

Question 23

What else do you look for when assessing diaphragm?

Answer 23

Costophrenic angles
-fluid
-consolidation
lung hyperinflation

Question 24

What do you call it when there is air under the diaphragm?

Answer 24

Pneumoperitoneum

Question 25

What counts as 'everything else'?

Answer 25

``` Aortic knuckle​ Mediastinal width​ Bones​ Soft tissues​ Tubes, valves, pacemakers​ ```

Question 26

Finally, what areas must you review?

Answer 26

HARP Hilar regions Apices Retrocardiac regions Peripheries

Question 27

What do you call metastatic lung cancer that presents as multiple fluffy spots in the lungs?

Answer 27

Cannonball metastases

Question 28

As part of management, what do you need to say?

Answer 28

Investigations as well as next steps

Question 29

What would be part of investigations? Bloods? Imaging? Other?

Answer 29

Bloods: - ABGs/VBGs - FBC - U&Es - D-dimer - Troponin - BNPs Imaging -echocardiogram Check for ankle swelling

Question 30

Management might include

Answer 30

``` Sitting them up, 45 degrees Oxygen Loop diuretics (if pul oedema, pleural effusion) Nitrate CPAP ``` Antibiotics

Question 31

What can venous blood gas tell you that ABGs won't tell you?

Answer 31

lactic acid

Question 32

When should you not give nitrates?

Answer 32

Aortic stenosis | Low BP

Question 33

What differentiates an AP xray?

Answer 33

Scapula shadow

Question 34

If you see a patient with consolidation that suggests pneumonia, what would you need to do?

Answer 34

``` If pneumonia, do CURB65 FBC U and E CRP/ESR Blood culture Arterial blood gas ``` Check whether the patient has had any previous hospitalisation due to similar chest infection

Question 35

What imaging test would you need to do if the pneumonia doesn't improve?

Answer 35

CT after 3 weeks