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45 - Chest x-ray

from Section 11 - Surgical radiology

Published online by Cambridge University Press:  05 July 2015

Hardi Madani
Affiliation:
Clinical Radiology, Royal Free Hospital, London Deanery, London, UK
Petrut Gogalniceanu
Affiliation:
Postgraduate School of Surgery
James Pegrum
Affiliation:
Queen Mary University
John Curtis
Affiliation:
University Hospital Aintree
Helen Marmery
Affiliation:
Royal Free Hampstead NHS Trust, London, UK
Petrut Gogalniceanu
Affiliation:
Specialist Registrar, General and Vascular Surgery, London Deanery
James Pegrum
Affiliation:
Orthopaedic Registrar, Oxford Deanery
William Lynn
Affiliation:
Specialist Registrar, General Surgery, North East Thames
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Summary

Introduction

‘This is a chest radiograph in AP/PA erect/supine view with no/some rotation. It is (is not) adequate.’

Summary

Examination sequence ABCDEF:

  1. A Address

  2. A Adequacy of film

  3. A Airway

  4. B Breathing

  5. B Bones

  6. B Breasts

  7. C Circulation

  8. D Diaphragm

  9. D Danger areas

  10. E Everything else

  11. F Foreign objects

Checklist

Address

• Name and date of birth of patient

Adequacy

RIPO:

Rotation – symmetrical distances between spinous processes and clavicular heads

Inspiration – 5–6 anterior ribs cross the mid-clavicular line and diaphragm

Penetration – vertebral bodies seen behind heart

Orientation – PA usual, AP if patient is unwell

Airway

• Trachea:

• central or deviated

• carina: position and angle (widened by malignant carinal lymphadenopathy)

• endotracheal tube: tip should be 2 cm above carina

• Branches:

• inhaled foreign body: commonly right lower lobe, although may affect any lobe

Breathing (lung fields)

• Mediastinal shift: tension pneumothorax

• Lung parenchyma:

• increased lucency (black): pneumothorax (absent lung markings), bullae, COPD

• increased opacity (white): consolidation, pulmonary oedema, collapse, effusion, haemothorax, empyema

• Lobar involvement: ill-defined edges:

• right middle lobe: poor definition of right heart border

• right lower lobe: poor definition of right hemi-diaphragm

• left upper lobe/lingual lobe: poor definition of left heart border

• left lower lobe: poor definition of left hemi-diaphragm

• Hila: position (usually left higher than right), size, masses

Bones

• Fractures: ribs, sternum, clavicles, humerus, scapulae, vertebrae

• Dislocations: humerus, clavicles

Breast (in women)

• Present/absent (only relevant if at least one breast is seen)

• Breast implants

Circulation

• Mediastinum: pericardial effusion, pneumopericardium, left lower lobe collapse, hiatal hernia

• Heart size > 50% of thoracic diameter on PA radiograph = cardiomegaly

• Aorta: widened (aneurysm, dissection, unfolded)

Diaphragm

• Above diaphragm: loss of costophrenic angle (effusion, consolidation, lower lobe collapse)

• Below diaphragm:

• air below diaphragm: hollow viscus perforation, Chilaiditi's sign

• air below the diaphragm is physiological if on the left side and part of gastric bubble (air in fundus of stomach).

Type
Chapter
Information
Physical Examination for Surgeons
An Aid to the MRCS OSCE
, pp. 386 - 395
Publisher: Cambridge University Press
Print publication year: 2015

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