CXR Interpretation Flashcards
What must be done first?
Who is it of, and when was it taken?
Name and DOB
Assess image quality:
RIPE mneumonic - what is it?
Rotation
Inspiration
Projection
Exposure
https://www.youtube.com/watch?v=iKNBs8EU9i0&list=PLjE4r9GDEhhOoBZ21ial4TzbOWoKuayEk&index=6
Assess image quality:
Rotation - how can you tell if an image is rotated using the clavicles?
Inspiration:
- How many anterior ribs should be in view?
- How many posterior ribs should be in view?
- How would you know you are looking at anterior ribs on a PA CXR?
- Over how many anterior ribs suggests hyperinflation?
The medial aspect of each clavicle should be equidistant from the spinous processes
5-6 anterior ribs
10 posterior ribs
The posterior ribs are brighter so you would see the lighter anterior. Just use the direction of the CXR to determine it.
The opposite would be said for AP XR.
> 6 ribs
Assess image quality:
Inspiration:
- Why may cardiomegaly be mimicked in poor inspiration?
- Why may consolidation/collapse be mimicked in poor inspiration?
- What type of patient may have poor inspiration?
The heart is usually pulled down and elongated with inspiration so this doesn’t happen in poor inspiration.
Crowding of vessels at the lung bases
Those acutely unwell
In pain
Those unconscious
Assess image quality:
Projection:
- What 2 types of projection are there?
- If there is no label, what projection should be assumed?
Exposure:
- Does over-penetration look darker/whiter?
- Why is this important?
- How do you know if it is well penetrated using the hemidiaphragm and the vertebrae?
PA assumed
AP - anterior-posterior
PA - posteroanterior
It looks darker - less x-rays are getting through everything and not stopping at the bones and solid structures.
Causes a loss of definition and quality
Left hemidiaphragm visible to the spine
Vertebrae visible behind heart
Interpretation - ABCDE approach:
What does the mneumonic stand for?
Airway Breathing Circulation Diaphragm Everything else
Interpretation - ABCDE approach:
Airways - Trachea:
- Which side may the trachea normally be deviated to?
- What pushes the trachea away? - 2 - think of what adds to the volume
- What pulls the trachea towards it? - 1
- What part of the RIPE mneumonic may affect the appearance of the trachea?
The right side
Large pleural effusion
Tension pneumothorax
Consolidation with lobar collapse - causes uneven pressure in the thorax
Rotation - it may appear deviated
Interpretation - ABCDE approach:
Airways - Carina and Bronchi:
- What is the carina?
- Why is the right main bronchus more common for inhaled foreign objects to become lodged?
Airways - Hilar structures:
- What within the hilar region?
- Which hilum is higher than the other? - The left or right?
- Are the hilar regions usually symmetrical or asymmetrical?
- What is a hilar point?
- What does a loss of the hilar point suggest?
Where the trachea divides into the L and R bronchi.
It is wider, shorter and more vertical.
Main pulmonary vasculature
Bronchioles
Lymph nodes
Left - but it varies between individuals.
It is usually the same size and density - asymmetry raises suspicion of pathology
An indent into the hilum - descending pulmonary artery intersects the superior pulmonary vein
Lung tumour or enlarged lymph nodes
Interpretation - ABCDE approach:
Airways - Hilar structures:
- What does bilateral symmetrical enlargement suggest?
- What does unilateral/asymmetrical enlargement suggest?
The abnormal hilar position could be caused by a range of pathology.
- What can push on the hilum?
- What can pull the hilum? - think the same as trachea?
Sarcoidosis - BHL
Underlying malignancy
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Enlarge soft tissue mass - cancer
Lobar collapse
Interpretation - ABCDE approach:
Breathing - Lungs:
- How many zones (not lobes) do we divide the lungs into?
- What lung has 3 lobes?
- How do you look at both lung?
- What is a consolidation?
- What does increased airspace shadowing suggest? - 2
3 zones - upper, middle, lower
Right lung
You compare each zone on each lung
Lung consolidation occurs when the air that usually fills the small airways in your lungs is replaced with something else. Depending on the cause, the air may be replaced with: a fluid, such as pus, blood, or water. a solid, such as stomach contents or cells.
Consilodation (e.g. pneumonia)
Malignant lesion
Interpretation - ABCDE approach:
Breathing - Pleura:
- Are the pleura usually seen on XR?
- How do you check if there is no pneumothorax?
- What will hydro/haemothoraces look like?
- What does pleural thickening suggest?
No, they should not be seen
Check lung markings reacht he borders in each lung
Increased opacity
Mesothelioma
Interpretation - ABCDE approach:
Cardiac:
- What ratio is used to work out if there is cardiomegaly?
- What projection is used to calculate this?
Heart borders:
- What makes up most of the right heart border?
- What makes up most of the left heart border?
- What is the loss of definition of the right heart border associated with?
- What is the loss of definition of the left heart border associated with?
Left ventricle
Cardiothoracic ratio (<50%)
PA - AP exaggerates heart size
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Right atrium - that is why you can see if there is cor pulmonale with hypertrophy
Right middle lobe consolidation
Lingular consolidation
Interpretation - ABCDE approach:
Cardiac - Aortic knuckle:
- What structure causes the aortic knuckle?
- What does the loss of this knuckle suggest?
Cardiac - Aorto-pulmonary window:
- What structures cause this?
- What could the loss of the window suggest?
Left lateral edge of the aorta as it arches back over the left main bronchus
Space between the arch of the aorta and the pulmonary arteries
Mediastinal lymphadenopathy - malignancy
Interpretation - ABCDE approach:
Diaphragm:
- Which hemi-diaphragm is usually higher?
- What may be seen under the left-hemidiaphragm indicating the stomach?
- What is air under the diaphragm called?
- What is Chilaiditi syndrome and why does it cause the false appearance of air under the diaphragm?
- What should you do as a junior if you see free air under the diaphragm and why?
The right one due to the liver
Gastric bubble
Pneumoperitoneum
The colon becomes positioned between the liver and diaphragm.
Seek senior colleague
- Could be result of bowel perforation
Interpretation - ABCDE approach:
Diaphragm - Costophrenic angles:
- What is another way of saying you have lost the angle?
- What causes loss of the angle?
- Why does hyperinflation such as COPD cause a loss of the angle?
Costophrenic blunting
Consolidation or presence of fluid (pul O)
The diaphragmatic flattening cause subsequent loss of the acute angle
