CXR How To

Question 1

What are the two options for projection?

Answer 1

AP vs PA

Question 2

Which projection is more common?

Answer 2

PA

Question 3

When is AP done?

Answer 3

haemodynamically unstable (sick patients) crAP

Question 4

What position is a patient in for AP and PA?

Answer 4

PA: standing/sitting
AP: supine

Question 5

What is the scapulae like in PA and AP?

Answer 5

PA: scapulae not overlapping lung fields
AP: scapulae overlapping lung fields

Question 6

What is the heart like in PA and AP

Answer 6

PA: no cardiac magnification
AP: cardiac magnification

Question 7

Can you comment on heart size in AP?

Answer 7

NOOO

Question 8

What is the air fluid level like in AP vs PA?

Answer 8

PA: air fluid level seen in stomach
AP: no air fluid level seen in stomach

Question 9

What must you mention in patient details?

Answer 9

1. Name
2. DOB/Age
3. When film taken
4. Indication for film

Question 10

What do you need to check for in technical quality?

Answer 10

1. Can you see lung apices?
2. Can you see lateral border of ribs?
3. Can you see costophrenic angle?

Question 11

What does RIP stand for?

Answer 11

Rotation, Inspiration and Penetration

Question 12

What do you look for in rotation?

Answer 12

Medial end of clavicle should be equidistant from spinous process of vertebral bodies

Question 13

What do you look for in inspiration?

Answer 13

adequate inspiratory effect: can see 6 anterior ribs and 10 posterior ribs

Question 14

What is good penetration?

Answer 14

able to see vertebral bodies behind the heart

Question 15

What colour would an overpenetrated film be?

Answer 15

black

Question 16

Why is it important to comment on rotation?

Answer 16

If patient is rotated makes it harder to comment on mediastinum shift

Question 17

How should the heart occupy the chest on a CXR?

Answer 17

1/3 right side and 2/3 left side

Question 18

What is an example of an opening phrase?

Answer 18

• This is a frontal chest radiograph of a young make patients
• The patient has taken a good inspiration and is not rotated and the film is well penetrated

Question 19

What obvious abnormalities should you look for?

Answer 19

1. Which lung?
2. Which zone/lobe
3. Size?
4. Shape: well/poorly demaracted
5. Density/texture: uniform/patchy/dense

Question 20

What is the ABCDE approach for CXR?

Answer 20

1. Airway
2. Breathing
3. Circulation
4. Diaphragm
5. Extras

Question 21

What do you comment on in airway?

Answer 21

Is trachea deviated

Question 22

When would trachea be deviated away?

Answer 22

1. Tension pneumothorax

2. Large pleural effusion

Question 23

When would trachea be deviated towards?

Answer 23

1. Collapsed lung

2. Pulmonary fibrosis

Question 24

How do you assess ‘breathing’?

Answer 24

start from apices and work down to costophrenic angle comparing the right and left field

Question 25

What must you inspect in the breathing category?

Answer 25

1. Apices 2. Hila 3. Mediastinum 4. Edges of lung

Question 26

Which hilum is always higher?

Answer 26

left hilum should always be higher than right

Question 27

Which hila is denser?

Answer 27

hila should be same density

Question 28

What goes under circulation?

Answer 28

1. Cardiomegaly 2. Cardiac borders 3. Cardiophrenic angle

Question 29

When is it cardiomegaly?

Answer 29

heart shadow more than 50% width of chest cavity on PA film

Question 30

What should the cardiac border and cardiophrenic borders be like?

Answer 30

clear

Question 31

Which hemidiaphragm should always be higher?

Answer 31

Right

Question 32

What should you look for in the diaphragm section?

Answer 32

1. Note the shape and curvature 2. Costophrenic angles clear/blunted? 3. Air under diaphragm?

Question 33

What could air under diaphragm suggest?

Answer 33

pneumoperitoneum

Question 34

What is a good example of a chest summary?

Answer 34

1. Trachea is central 2. Mediastinum is not displaced 3. Mediastinal contours and hila appear normal 4. Lungs appear clear with no pneumothroax 5. No free air under the diaphragm 6. Bones and soft tissue appear normal - If find nothing look at review areas

Question 35

What are review areas?

Answer 35

1. Apices 2. Periphery of lungs 3. Under/beneath hemidipahragm 4. Behind the heart

Question 36

What are examples of extras?

Answer 36

leads, pacemakers, surgical emphysema

Question 37

What is an example of how to present finding?

Answer 37

1. This is an AP chest radiography of X taken on Y 2. It is a technically adequate film: not rotated has adequate rotation, and good inspiratory effort. There are no important areas cut off at the edges of the film 3. Most striking abnormality is X 4. Reviewing the rest of the film... 5. In summary this chest radiograph shows X 6. The most likely diagnosis is X although A, B and C may also be likely