Reading a Chest Xray

You should feel confident reading a chest x-ray (CXR). It is one of the few films that will follow you from rotation to rotation. It doesn't matter if it is pediatrics, internal medicine, or surgery - You need to know how to read a CXR. Below are a couple sources to choose from because not everyone teaches or learns this in the same way. Here are a couple tips that I learned during my rotations from studying, my preceptors, or just plain screwing up!

• The first thing you should check is the name/date/type of film! (On one of my rotations, an intern (1st yr resident) was asked to read a chest X-ray for one of our patients who had just gotten a chest tube placed. He did a great job with lung pathology and describing the fluid - and he was also able to pick out that the chest tube was perfectly placed. I was impressed until the chief resident said "great job, you just harmed your patient." The chief had purposefully put up a CXR from 2 years ago when the pt had rec'd another chest tube. He then pulled up the current CXR to reveal that the tube was improperly placed. )
• Read every film in the same order every time. 
• Learn the anatomy of what you are reading. 

Step by Step Tip for reading CXRs

University of Washington's Method

1. PA or AP, supine or upright

2. Pt rotated? Check for vertebral and clavicle symmetry.

3. Lung volumes

4. Tube & line placement

- ETT 3-5 cm above carina

- NGT in stomach

- FT in stomach/duodenum

- Central line in SVC/R atrium

- Swan in PA

5. Pneumothorax: check apices on upright film, deep sulcus sign at bases

6. Pleural effusion, pleural thickening

7. Mediastinum: normal contour, wide

8. Heart: normal size, cardiomegaly

9. Lung parenchyma: masses, opacites, look for silhouette sign

10. Soft tissues: foreign bodies, SQ air, breast shadows

11. Bones: fractures, osteopenia, abnormalities

Silhouette Sign = obscuring of normal borders on radiograph caused by intrathoracic lesion.

Obscured R heart border = R middle lobe

Obscured L heart border = Lingula

Obscured diaphragm = Lower lobe

PANCE REVIEW: Esophageal Dysmotility

 Esophageal Dysmotility in a nutshell.

6 types that you need to know about:

1- Neurogenic dysphagia

• caused by brain stem injury
• difficulty swallowing BOTH solids and liquids

2- Zenker's Diverticulum

• Regurgitation of undigested solids/liquids several HRS after eating

3-Esophageal Stenosis

• hard to swallow SOLIDS
• slow progress = usually benign (rings)
• fast progress = usually malignant

4- Achalasia

• global motor dysfunc of esophagus
• decrease peristalsis, increase sphincter tone
•  SLOW, PROGRESSIVE dysphagia with episodic regurg and chest pain
• **Parrot-beak** on barium swallow

 5- Esophageal spasms

• intermit chest pain and dysphagia
• may or may not be associated with eating

6- Scleroderma

• often dz progression to esophagus
• decrease in peristalsis, decrease in sphincter tone
• s/sx of reflux

Question: What are the definitions of odynophagia and dysphagia?

Labs:
A. Barium swallow: good for both structural and motility problems
B. Esophagoscopy: must be done to clarify strictures
C. Esophageal manometry: looks at peristalsis

Tx:
Neurogenic? Treat underlying cause.
Stricture? BENIGN = dilation, MALIGNANT = resection



Answer: Odynophagia = painful swallowing, Dysphagia = difficulty swallowing





Pic: http://www.umm.edu/imagepages/19507.htm, http://www.bristolsurgery.com/page.aspx?id=184
Source: AAPA/PAEA Exam Review Book

Cardiothoracic Imaging Resource

Yale's Introduction to Cardiothoracic Imaging. It includes cardiothoracic anatomy, imagining, case, and reference resource. Very high quality.

Learning Radiology

LearningRadiology.com has been putting out a fantastic video podcast for a couple of years now. Dr. Herring has created a great series podcasts that teaches you how to read different types of studies, quizzes you on the "most common" diagnosis in a flashcard style, and lastly, quizzes you on "good calls and pitfalls" - essentially he will show you a film and give you the diagnosis that was originally given to the pt and asks you whether it is the right or wrong diagnosis. It is incredibly interesting and he does an amazing job at explaining and zooming in on the areas that he is talking about. I highly recommend it. I have learned a lot during my commute to work on the T thanks to this podcast. Below are some screen shots...

In addition, the LearningRadiology website also has outstanding resources such as ppt of common radiological dx, Weekly Cases, and Quizzes.

Each podcast has a brief overview 

He always points out exactly what he is referring to which makes it easy to learn

Explanation of his point

From the website

Ultrasound, My New Obsession

I have never used an ultrasound machine, but I am fascinated by the possibilities of its use. We recently had a 4 hour lecture/lab on the uses of ultrasound in the ED and I was immediately hooked. Unfortunately, like a lot of PA school, we only get a taste of many subjects and we rely on our clinicals to gain more knowledge - but I am, by nature, impatient. It is the curse of a Type-Aer.

So if you are like me or you were just curious about ultrasound - when it is used? how to use a machine? how to read an ultrasound image? (or if you are avoiding reading what is actually due this week) Check out some of the absolutely amazing sites that I found for ultrasound tutorials.

Ultrasound Guide for Emergency Physicians, An Intro
Beatrice Hoffmann, MD, PhD, RDMS

Society of Ultrasound in Medical Education
[Learning Modules]

Detection of Pleural Effusion - Ultrasound