APPROACH TO CHEST X RAYS

CHECK THE FILM  - PA vs AP / Inspiration adequate / Rotation         
​NOTE THE OBVIOUS PATHOLOGY IF POSSIBLE
​

A

Vertical Divider
​Airways and mediastinum 
Trachea - LMB higher than RMB 
Bullae / Pneumothorax

B

Vertical Divider
Volume Loss vs Hyperinflation ?Collapse pattern 
Apices vs Mid zones vs Lower zones
Alveolar vs Reticular vs Nodular vs Reticulonodular - Opacification
Collapse vs consolidation - Patchy vs Diffuse
Review Areas: apex, behind heart, around hila, costophrenic angles, below diaphragm
Lateral - lungs 'blacker' as you move down; change in heart opacification
BONES - ribs vertebrae - paravertebral stripes

C

Vertical Divider
CTR - Right heart border /  LHB
LA LV RA RV Pericardium IVC SVC Ao Pa Pulmonary Trunks
Halo around heart - pneumomediastinum

D

Vertical Divider
Diaphragm borders 
​Lateral: R Diaphragm runs front to back
Look below diaphragm
Deep sulcus sign-pneumothorax- hyperlucent RUQ
continuous diaphragm sign - pneumomediastinum

E

Vertical Divider
Extras - ETT/CVL/lines etc -Esophagus

F

Vertical Divider
Fluid - subpulmonic effusion, fissures, Layering

G

Vertical Divider
Gastric Bubble

H

Vertical Divider
Hilar position / Lumpy Bumpy?
CXR PATHOLOGY         
Develop a system for differentials - e.g. CHINNPARVOSTD (clearly not a great pneumonic!)
Congenital
Hormonal/ Metabolic / Endocrine
INEFFECTIVE INFLAMMATORY NEOPLASTIC
Bacterial Viral TB Fungal Parasites
SLE / RA / Sarcoid / Wegeners / Goodpastures / ARDS
Psychological
Autoimmune
Renal
Vascular 
Ao dissection / Cardiac failure / PE
Orthopedic
Surgical
Trauma
Toxins
​Drugs

CASES FOR PRACTICE

Case 1:
A 55 yo woman with a chronic cough. ​

Answer:

​A
Vertical Divider
A & mediastinum
trachea central - left main b not seen higher than rmb - ? L pathology
​B
Vertical Divider
R lung volum > L, L volume loss. Opacification over left lower lung well rounded and circumscribed
L H Border well defined i.e. not lingual disease
L diaphragm poorly defined = left lower lobe pathology
C
Vertical Divider
CTR ok
D
Vertical Divider
as stated

​Statement:
​Left lower lobe collapse with area of opacification lower lobe left 
potential causes:
Neoplasm - bronchial carcinoma vs metastasis
Pneumonic infection - bacterial more likely vs TB
Cardiac - old aneurysm? 
Case 2:
A 48 yo F with hemoptysis. ​

Answer:

​A
Vertical Divider
Trachea central - LMBronchus and hilum not seen - ?pulled down ? collapse left
​B
Vertical Divider
R Lung volume increased, L Lung volume decreased suggesting collapse
Lung parenchyma appears normal - mild reticular change right lung
C
Vertical Divider
CTR normal
D
Vertical Divider
Loss of Left silhouette sign -  diaphragmatic border w heart - cardiophrenic border - suggesting lower lobe pathology
E
Vertical Divider
None
F
Vertical Divider
? left effusion

​Statement:
Left lower lobe collapse/ consolidation with volume loss 
Possible causes -  
Neoplastic - bronchial ca / mets 
Infective - Pneumonia bacterial
FB ingestion / aspiration 
​PE - although less likely because central and not peripheral 
Case 3:

Answer:

​A
Vertical Divider
trachea central - M Bronchi ok
​B
Vertical Divider
poor inspiration, patchy bilateral alveolar opacification mainly in dependent zones
C
Vertical Divider
sharp demarcation R heart border and air around left heart border suggests pneumediastinum
D
Vertical Divider
loss of vertebrophrenic angles suggests bilateral lower lobe changes
E
Vertical Divider
nasogastric in situ (supporting aspiration diagnosis)
F
Vertical Divider