Special Thanks to Hasan Mohiaddin & Dalia Abdulhussein X-ray Teaching MM Clinical Skills Rami Abbass Special Thanks to Hasan Mohiaddin & Dalia Abdulhussein

X-rays in the OSCE Usually put at the end of the Resp exam You have around 1 and a half minutes to present it Let’s get started

The first thing you should say

Take the time to remember what is right and what is left Take time to scan the X-ray looking for likely abnormalities: Opacities Loss of lung markings

The first sentence is a mouth-full Practice this “This as a PA/AP chest radiograph of Mr/Mrs [Patient name], D.O.B [e.g. 17/11/95] (or unknown patient, as was in my OSCE). Taken on [This Date]. There are/ are no previous radiographs to compare”. Assume it is PA if not explicitly stated “Moving on I would now like to comment on the quality of the film”

“There is no Rotation, adequate Inspiration, Penetration and Exposure” RIPE

RIPE Rotation: Medial ends of the clavicle should be equidistant from the spinous processes of the vertebral bodies. If the x-ray is rotated we cannot assess for tracheal deviation Inspiration: Adequate inspiratory effort as indicated by presence of 6 anterior ribs and 10 posterior ribs. Penetration: How much x-ray goes through the lung and on to the film (next slide) Exposure: Can you see below the diaphragm and above the clavicle including the trachea

“Commenting on the most obvious abnormalities there is [for example] alveolar shadowing in the left lower zone of the right lung” “Commenting on the most obvious abnormalities there are [for example] loss of lung markings on the right lung”

“Looking systematically at the x-ray” Airways Bones and Soft Tissues Cardiac Diaphragm Edges Fields Gastric Bubble Hilar Region

“Looking at the airways, the trachea is central not deviated”[normally the trahcea might drift very very slightly to the right, still say central not deviated] “Looking at the bones and soft tissues, there are no fractures or abnormalities and no external objects [I mention external objects like ECG leads, NG tubes and Chest drains here also]” “Looking at the heart, the cardiothoracic ratio is normal” OR “Given this is an AP radiograph, I cannot comment on the cardiothoracic ratio” “Looking at the diaphragm it looks normal and the costophrenic angles are sharp” [what would blunting indicate?] OR “There is air under the diaphragm”

“Looking at the lung edges, there is no loss of lung markings or indication of a pneumothorax” “Looking at the lung fields they are clear” OR “Looking at the lung fields there is homogenous shadowing in the right upper and middle zone with a fluid line” OR “Looking at the lung fields there is alveolar (fluffy) shadowing in the right middle zone [REMEMBER IN X-RAYS WE TALK ZONES not lobes]

To be honest I just say G for gastric bubble to remind me of H “The gastric bubble is present” “Looking at the hilar region there is bihilar lymphadenopathy” OR “The hilar region is normal” OR “ Looking at the hilar region there is bilateral perihilar shadowing [also known as batwing shaddowing!]

Lets Practice Presenting in Pairs! 2 minutes for each x-ray

Can someone have a go at presenting this x-ray for me/ telling me what is wrong with it? This is a normal X-ray

https://www. med-ed. virginia. edu/courses/rad/cxr/pathology3chest https://www.med-ed.virginia.edu/courses/rad/cxr/pathology3chest.html RUL pneumonia

RML pneumonia https://radiopaedia.org/articles/pneumonia

Pneumonia Alverolar/ fluffy consolidation May contain air bronchograms (pockets of air within the opacity In the lower zones, may be difficult to distinuish from effusions – mention on differentials!

Pleural Effusion

Pleural Effusions Loss of costophrenic angles Homogenous opacification Fluid level (manifests as meniscus) May also cause tracheal deviation away from lesion Exudates vs Transudates Bil pleural effusions tend to be transudates Unilateral effusion tends to be exudates (eggsudates high in protein) Need to do pleural aspiration to determine type Amount of protein ( above or below 30g/l) used to determine type of effusion. May not always be accurate therefore Light’s criteria should be used (Pleural fluid protein to serum protein/LDH ratio) Transudates:Heart Failure/ Liver failure/ Protein loss (nephrotic syndrome/ protein-losing enteropathy), peritoneal dialysis (iatrogenic), Meigs syndrome (Ovarian fibroma+ ascites+ R pl effusion), Hypothyroidism Exudate: Pancreatitis, PE, Malignancy, Infection (pneumonia/TB)

Pneumothorax Loss of lung markings in the peripheral lung field Tension: tracheal/mediastinal deviation away from pneumothorax and flattening of ipsilateral dome of diaphragm NB: This should be diagnosed clinicallly! Treated immediately (insert cannula into 2 ICS) Causes: Spontaneous Iatrogenic/Trauma: pleural tap, mechanical ventilation Obstructive lung diseases: COPD, Asthma Infection: TB, CF, pneumonia CTD: Marfan’s, Ehler’s-Danlos

Quick Fire

Coin lesion: CRC metastases radiopaedia

Single coin lesion Causes: Malignant tumour: bronchial, single pulmonary metasasis Infection: pneumonia, abscess, TB, hydatid cyst Benign tumour: hamartoma, schwannoma Infarction Rheumatoid nodule

BHL

Hilar Lymphadenopathy Causes: Neoplastic: spread from bronchial Ca, lymphoma Infective: TB Bilaterally: Sarcoidosis Tumours: mets, bronchial Ca, Lymphoma Infection: TB, AIDS, recurrent chest infections

https://radiopaedia.org/cases/cavitating-lung-lesion

Cavitating lung lesion Abscess (staph/klebsiella) Neoplasm (Sq Cell) Cavitation around a pneumonia, TB Infarct Rheumatoid nodule

http://radiologyassistant.nl/en/p4c132f36513d4/chest-x-ray-heart-failure.html

Heart Failure A: Alveolar (interstitial) shadowing B: Kerley B lines (little white horizontal dashes usually in the lateral lower edges) C: Cardiomegaly (Cardiothoracic ratio >50%) D: Upper lobe blood Diversion (prominent upper lobe vasculature) E: Effusions F: Fluid in the horizontal fissure https://www.fastbleep.com/medical-notes/heart-lungs-blood/1/147

Reticulonodular shadowing

Interstitial Lung Disease Reticulo-nodular shadowing http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/pulmonary/interstitial-lung-disease/

COPD Chronic bronchitis: increased bronchovascular markings, cardiomegaly. Emphysema: Lung hyperinflation, flattened hemidiaphragms, small heart, barrel chest with widened AP diameter https://radiopaedia.org/articles/chronic-obstructive-pulmonary-disease-1

RLL collapse

Lobar Collapse (or Atelectasis) Loss of volume May be tracheal and mediastinal shift TWDS collapsed side Shadowing https://radiopaedia.org/articles/lobar-lung-collapse