Xrayted - Xray Answers

Time for answers!  Each answer corresponds to the slide number!





1.  Normal
2.  Right lower/mid zone pneumonia - patch consolidation
3.  Pulmonary oedema - a classic exam question is list the 6 xray findings of heart failure/pulmonary oedema

A - Alveolar Oedema (Haziness around the hlium looks like bat wings)
B - Kerly B lines
C - Cardiomegaly
D - Dilated prominant upper lobe vessels
E - Pleural Effusions
F - Fluid in the horizontal fissure (right lung)


4.  Left hilar mass - well circumscribed coin shape lesion likely lung cancer
5.  Pneumoperitoneum
6.  Large right sided pleural effusion
7.  Large well circumscribed lesion in the right midzone likely lung carcinoma
8.  Tension pneumothorax on the right side - note the tracheal and cardiac deviation AWAY from the lesion
9.  Multiple pulmonary metastasis - no they are NOT cannonball metastasis from a renal tumour, remember to check the two important areas, behind the heart and the apices this is a left apical primary - Pancoast Tumour
10. Aspiration pneumonia with a oesophageal stent - bilateral lower zone patchy consolidation R>L and a  oesophageal stent seen through the mediastinum
11. Bilateral pneumotharacies
12. Bilateral pleural effusions with a R sided tension pneumothorax - note the tracheal and cardiac deviation
13. A very large heart!  - This is a pericardial effusion
14. A white out in the left lung, the tracheal deviation away from the lesion makes this a large pleural effusion
15. My favourite X-ray! You can see three causes of air on this x-ray - this is Tuberculosis

• Pneumothorax - Right upper zone
• Cavitating lesions - throughout the chest, most easily seen in the right upper zone
• Air Bronchogram - This is a small air like tree seen in the right mid zone, this is present in pneumonia differentiating this from lobar collapse

Congratulations if you got them all right!

Xrayted - Chest Xray Interpretation

Today we're looking at basic CXR interpretation, a topic that I have seen come up at all stages of undergraduate assessment.  Basic radiological anatomy is essential for 1st and 2nd years students and by the end of medical school all students should have developed a system to look at chest xrays.  In this blog post I will quickly refresh anatomy and walk you through a common system used to interpret a chest xray.  To finish there is a quiz with 15 of my favourite patients i've seen (progressive difficulty!)

I'm sure everyone knows basic chest anatomy.  Ive seen the corresponding picture appear in junior year OSCEs with students having to label the diagram.

Film Description

In an OSCE setting examiners will be expecting you to comment on the details of the film itself.  You have to state the following:

1) Patient Name    2) Area of Xray   3) Orientation of the film AP/lateral/PA  (it should state on the Xray)

Next is the quality of the image looking at the following:

1) Rotation - Each head of the clavicle should be equidistant from the spinous process.

2) Penetration - The intervertebral discs should be visible behind the heart.

3) Inspiration - 9 posterior ribs should be seen before the diaphram

A great summary of these with questions can be found HERE

Image interpretation

Some people use the ABCDE approach but I find it awkward and unnatural in order.  I would advocate a visual approach, starting at the top and moving down through the middle and then back up through the lungs:

• Trachea - Is it central? It should overlie the vertebrae
• Mediastinum - Is it enlarged? If >3cm  it is
• Heart - Is there cardiomegaly? It should be less than half of the thorax ?Can I see the heart borders?
• Diaphram - Are they elevated?  Any gas below them?
• Costophrenic angles - Are they visable?  Obscuration may suggest a small pleural effusion
• Lung Fields - Any abnormalities, opacification, lung markings
• Bones - Any rib fractures?  How do the shoulders look?
• Special Areas - Apices and behind the heart

Simple!  Follow those steps and you'll have no problem at examination.  Now put them to the test with the below quiz and practice going through the quality of the film spheel!  The link to the answers is below, but try to come to a definite answer and description for each xray before you look!

ANSWERS