Picture the scene…
You are in majors seeing an obese 75yr old man who is acutely short of breath. He was a miner, keeps parrots, smokes 20 / day, has prostate cancer, and was recently immobile due to a sprained ankle.
You go to review his portable CXR Majors is brightly-lit, someone is shouting loudly in the adjacent bay and the PACS monitor is covered in fingerprints and pen marks….
Learning Objective
To learn about Chest Xray interpretation including an anatomy refresher for CXR interpretation and how to use a systematic approach to detect and diagnose CXR abnormalities.
RCEM Curriculum
CAP 6 (Breathlessness)
CAP7 (Chest Pain)
Task 1 – Read
Complete this short tutorial. It covers CXR anatomy and introduces a system for reviewing CXRs.
Findings can be subtle and human factors in the ED make interpretation even more difficult so you need to be systematic and thorough to minimise error.
Some of you will be more familiar with the ABCDE system. It doesn’t matter which one you use, as long as you can remember it and use it for every CXR you review.
Task 2 – Read
Now complete the Radiology Masterclass tutorial on CXR abnormalities. It covers abnormalities broken down by anatomical structure or region and uses the system described in Task 1.
Task 3 – Discuss
This part of the teaching session should be lead by an experienced clinican. Learners should look at the images and try to describe all of the findings they can see, using the techniques taught in task 1. You can click on each image to open them as full screen in a new window.
Case 1 – A 65 year old patient with shortness of breath, cough and fever
Describe the Xray above
Relatively well-defined area of consolidation behind the left heart. Right lung clear. AP view so unable to comment on heart size.
Appearances are consistent with pneumonia however the patient requires a follow-up in 6-8 weeks to ensure that it isn’t actually a cancer.
Case 2 – A 73 year old patient with shortness of breath and haemoptysis
Describe the Xray above
“Veil-like” opacity left hemithorax. You can still see lung markings through it, particularly at the lung base. Well-defined lucency around the aortic arch (luftsichel sign). The left hemidiaphragm is slightly raised and there is loss of volume on the left causing mediastinal shift. Right lung clear.
Diagnosis: Left upper lobe collapse, probably malignant. This makes PE much more likely as the reason for the acute presentation. The luftsichel sign and veil-like opacity signs are absolutely classic of LUL collapse.
Case 3 – A 28 year old patient right sided chest pain
Describe the Xray above
Right pneumothorax, approx 5cm at the apex.
Left lung clear.
Normal heart and mediastinum.
Case 4 – a 67 year old with severe abdominal pain for one day with fever
Describe the Xray above
Free gas beneath both hemidiaphragms and in the midline below the heart consistent with a perforated viscus. Lungs clear. Normal mediastinal contour. The weird line behind the heart in the midline is where the pleural reflections come together and is normal.
Case 5 – A 32 year old with heavy marujana use presents with cough, sputum and fever
Describe the Xray above
Thick-walled cavity in the left upper zone that contains a ball of soft tissue. This is most likely due to post-primary TB or a fungus ball (usually an aspergilloma) that has formed in a pre-existing cavity. In an older patient this might be a cavitating cancer.
Severe bullous emphysema right upper and mid zones. Not to be mistaken for a pneumothorax! It can be caused by smoking marijuana, crack cocaine or associated substances
Task 4 – Summary
In this session we have reviewed CXR anatomy, learned a system for interpreting CXRs with examples of common pathology, and then applied that system to some real clinical problems.
CXRs can be challenging. Radiology registrars usually report a few thousand CXRs before they are signed off as independent, and will report many thousands more before they are considered subject matter experts.
Treat this as the start of your CXR journey. Northwick Park run excellent CXR interpretation courses and there are plenty of textbooks available for you to develop your skills further. You can always talk to your friendly neighbourhood radiologist about getting advanced teaching or about individual cases.
Task 5 – Reflect
In order to embed today’s learning further, reflect on what you have learnt and record in your portfolio whether it has had any impact (or is expected to have any impact) on your performance and practice.
Was this a topic that you were confident you knew already? Which parts were new to you? Were there elements that you will use on your next clinical shift.
Dscuss this session with your colleagues – were there people who missed it who you can share the highlights with?
References and Further Reading
- De Lacey G, Morley S, Bernam L. The Chest X-Ray: A Survival Guide. 2nd Ed. Elsevier; 2008.
- Akhtar, Mohammed Rashid & Ahmed, Na’eem & Khan, Nihad & Rodrigues, Mark & Qureshi, Zeshan. (2017). The Unofficial Guide to Radiology: 100 Practice Chest X Rays with Full Colour Annotations and Full X Ray Reports. 1st Ed. Zeshan Qureshi; 2017.
- Department of Health and Social Care. Guidance to Ionising Radiation (Medical Exposure) Regulations 2017.
Lesson plan written by Dr Lisa Shannon (Consultant Radiologist, Barnsley Hospital). Twitter: @docshannon