OSCE Chest X-rays

Question 1

Before looking at a chest X-ray

Answer 1

Check database - is it the right patient, date, is it a PA or a AP X-ray; this will affect how you interpret the X-ray, are there previous images that you can compare the current one with
Considerations - size of the heart, scapula edges, AP slightly lower quality as acquired with portable machines

Question 2

Viewing the chest X-ray

Answer 2

Look at the chest X-ray as if your are looking at the patient face to face
Their left (and the heart) is always on the right when viewing the image

Question 3

Quality of the image

Answer 3

Exposure - can be changed digitally, toast, underexposed; too white, overexposed; too black

Question 4

Quality of position

Answer 4

Check the clavicles - is the distance equal on both sides
Shoulder rotation - is one rotated forwards compared to the other
Rotation impacts the ratios of the heart
Often unavoidable and is the normal posture of the patient

Question 5

A-H approach

Answer 5

Airways
Bones and soft tissue
Cardiac
Diaphragms
Expansion
Fields and fissures
Gadgets
Hidden areas

Question 6

Airway

Answer 6

Trachea and bronchi
Anything obstructing it
Straight or deviated
Central
Artificial
Pneumothorax - collapsed lung, increased pressure causes the trachea to deviate to the other side of the collapsed lung

Question 7

Bones and soft tissue

Answer 7

Scapula, vertebra, ribs, clavicles
Pathologies - fractures, dislocations, rib crowding, previous surgery; plates, pins, cages
Soft tissue - breasts, fat, air in muscles after surgery

Question 8

Cardiac

Answer 8

Normal - heart boarders; 1/3 to the right and 2/3 to the left, no larger than one half of the thorax
Cardiomegaly - big, huge, identified by the borders, hypertrophy of the heart
Pneumothorax - pressure pushes it over to other side
Silhouette sign - can’t see the heart boarders
Sail sign - wedge of collapsed tissue behind the heart boarder, appears like a boat sail

Question 9

Diaphragms

Answer 9

Normal - domed, different places; right it higher than the left due to the liver, different angles
Loss of costophrenic angle - rounded, fluid build up

Question 10

Expansion

Answer 10

Count the anterior ribs
Mid clavicular line - 5 to 7th rib means good expansion
The 7th rib should intersect with the diaphragm

Question 11

Fields and fissures

Answer 11

Lung markings - fine grey lines that extend throughout the lung fields to within 2cm of the lung edge, equal density within the left and right lung fields, looking for areas that appear whiter (dense tissue/ field) or darker (air) than you would expect
Fissures - horizontal, easier to see when there is an abnormality

Question 12

Gadgets

Answer 12

Examples - pacemaker, ECG leads, tracheostomy, chest drain, NG tube, sternal wires, ETT, spinal fixation

Question 13

Hidden areas

Answer 13

Hidden by the - clavicles, aortic notch, heart, diaphragms
Hilar - increased density around the hiller, bats wing pattern, suggests pulmonary oedema/ fluid overload/ heart failure and increased blood glow to the area