Interpreting Chest X-ray

By Yasser Al-Obudi (5th year Medical Student)

Patient identifiers
Date & time of film
Indication & previous imaging
Quality: Projection (usually PA erect), Exposure/Inspiration (top to diaphragm, 5-6 ribs anteriorly), Penetration (vertebrae visible behind heart)
Obvious abnormalities (include which zone), foreign bodies & artefacts (e.g. drains)
Airways: tracheal deviation, masses, carina & bronchi, hilar structures
Breathing: compare each lung field zone & trace pleural margins
Cardiac: cardiothoracic ratio if PA, borders and angles
Diaphragm: flattening, angles and air under the diaphragm
Everything else: soft tissue, fractures, artefacts, aortic knuckle displacement

Airways:

• Trachea deviates towards a collapse or pneumonectomy, away from a tension pneumothorax or pleural effusion
• Hila contain vessels and major bronchi. Enlargement can occur in sarcoidosis (usually bilateral) or malignancy (usually asymmetrical or unilateral)

Breathing

• Divide into upper/middle & lower zones. Trace margins to identify a pneumothorax or pleural thickening

Cardiac

• The cardiothoracic ratio should be less than 50%. RA makes the right border and LV makes most of the left border. Unclear borders suggest consolidation and collapse.

Paediatric Cardiovascular Exam

Introduces self	0	1
Confirms name & age of patient	0	1
Explains & gains consent from parents and child	0	1
Washes hands	0	1
Exposes patient from waist up and positions at 45 degrees	0	1
Asks if patient is in pain	0	1
Asks to see red book to check growth and vaccination history. Offers to plot current height and weight	0	1
General inspection around bed & patient (breathing, scars, sounds, dysmorphic features of Downs, Turners and Marfans)	0	1
Feels hands for temperature changes, cyanosis, capillary refill time	0	1
Checks hands for nail clubbing, splinter haemorrhages, Janeway lesions and Osler nodes	0	1
Feels radial pulse and comments on rate & rhythm	0	1
Asks to feel for brachial-brachial and radiofemoral delay	0	1
Asks for blood pressure	0	1
Feels carotid pulse, comments on volume & character	0	1
Checks for water hammer pulse	0	1
Inspects eyes for conjunctival pallor	0	1
Inspects mouth for central cyanosis, high arched palate	0	1
Assesses and comments on JVP	0	1
Palpates apex beat	0	1
Palpates for heaves & thrills	0	1
Auscultates over mitral area on expiration leaning on left. Listens for radiation in axillary area	0	1
Auscultates over tricuspid area with patient leaning forward on both inspiration and expiration	0	1
Auscultates over pulmonary area on inspiration	0	1
Auscultates over aortic area on expiration and carotid for radiation	0	1
Auscultates under left clavicle and on the back between shoulder blades	0	1
If murmur present comments on intensity, site, character, pitch, radiation	0	1
Listens over lung bases	0	1
Feels for oedema	0	1
Thanks patient and offers help to redress	0	1
Washes hands	0	1
Requests to palpate pulses, ECG, dip urine, fundoscopy	0	1
Summarises appropriately with only key findings	0	1
Offers appropriate differential diagnoses	0	1
Patient global score	0	1	2

Rohit's Chest Pain

Name	Rohit Clark
DOB	09/11/1953 (61 years)
Occupation	Financial director
History	I am a talkative person who needs to be interrupted. I had a really sudden, really painful pain in the centre of my chest. It was so bad that I lost consciousness which was embarrassing as I was in a meeting at the time. It was a tearing pain that moved to my back. The pain was 10/10 in severity if not 11/10. Nothing made it worse or better. If pressed, I remember feeling a little dizzy before I collapsed and this feeling that I was going to die. When I regained consciousness I was not confused. I cannot think of anything that triggered this pain.
Past Medical History	I have never suffered from chest pain or any other diseases. I am not aware of having high blood pressure but the rest of my family does have it.
Drug History	Nil
Family History	My father, mother and brother all have very high blood pressure. I have been meaning to get it checked.
Social History	I do smoke around 10 per day but I don't drink. The smoking is just to cope with stress. I do not take recreational drugs. I live with my wife who I would really like to call and have so far been unable to do so.

Introduces yourself	0	1
Confirms name & age of patient	0	1
Explains reason for consultation & builds rapport	0	1
Gains consent	0	1
Asks open question	0	1
Establishes site	0	1
Asks about onset	0	1
Elicits character of pain	0	1
Asks if pain radiates	0	1
Asks for nausea and sweating	0	1	2
Asks for shortness of breath	0	1
Asks for palpitations	0	1
Asks for loss of consciousness and dizziness	0	1	2
Asks for loss of sensation, balance, vision and weakness	0	1	2
Asks for seizure and confusion following waking up	0	1
Asks for fever, cough	0	1
Asks for heartburn/abdominal pain	0	1
Enquires about exacerbating factors including physical activity	0	1
Enquires about alleviating factors including rest	0	1
Asks about duration and changes to pain over time	0	1
Checks severity of pain	0	1
Asks about previous chest pain	0	1
Asks about recent illness and past medical history	0	1	2
Asks specifically for previous heart disease, stroke, diabetes, high cholesterol, hypertension and asthma	0	1
Asks about any family history of disease	0	1
Asks specifically if any family members have had cardiac disease below <55 years, cardiac disease, pulmonary embolism or sudden death	0	1
Establishes any drugs patient is on	0	1
Asks if patient has any allergies	0	1
Asks if patient smokes, drinks or takes recreational drugs	0	1
Asks about diet and lifestyle	0	1
Elicits patients occupation	0	1
Explores and responds to ideas	0	1
Explores and responds to concerns	0	1	2
Explores and responds to expectations	0	1
Shows empathy	0	1
Avoids jargon	0	1
Summarises back to patient	0	1
Thanks patient	0	1
Patient global score	0	1	2
Gives reasonable differential diagnosis (aortic dissection, myocardial infarction, aortic valve disease)	0	1