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X-rays
Dr Will Dooley
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Plan
• Chest X-Rays• Abdominal X-Rays
• Exam approach
• Presentation skills
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Question 1: EMQ
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Question 1: EMQ- answers
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Chest X-Ray - Systematic Approach
• D Details• R RIP – Image Quality
+/- OBVIOUS ABNORMALITY
• A Airways and mediastinum• B Bones and soft tissue• C Cardiac silhouette and vessels• D Diaphragm• E Extras and Edges
CLINICAL CORRELATION
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CXR - Systematic Approach
• D Details• R RIP – Image Quality
+/- OBVIOUS ABNORMALITY
• A Airways and mediastinum• B Bones and soft tissue• C Cardiac silhouette and vessels• D Diaphragm• E Extras and Edges
CLINICAL CORRELATION
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Details
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Details: Image projectionPA CXR
Better quality
More accurate heart size
AP CXR
Patient can sit or lie down
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Details: Image projection
AP PA
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CXR - Systematic Approach
• D Details• R RIP – Image Quality
+/- OBVIOUS ABNORMALITY
• A Airways and mediastinum• B Bones and soft tissue• C Cardiac silhouette and vessels• D Diaphragm• E Extras and Edges
CLINICAL CORRELATION
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Image Quality
• R-otation• I-nspiration• P-enetration
Check quality first to avoid false reassurance or diagnosis
Can the clinical question still be answered?
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Rotation
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Normal rotation
Spinous processes of the thoracic vertebral bodies between the two clavicular heads
Rotation
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Expiration
Inspiration
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Penetration
Underpenetrated Overpenetrated
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CXR - Systematic Approach
• D Details• R RIP – Image Quality
+/- OBVIOUS ABNORMALITY
• A Airways and mediastinum• B Bones and soft tissue• C Cardiac silhouette and vessels• D Diaphragm• E Extras and Edges
CLINICAL CORRELATION
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Asymmetry of lower zone soft tissue
+ on ROR- on L
Left mastectomy
Bones and Soft Tissue
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CXR - Systematic Approach
• D Details• R RIP – Image Quality
OBVIOUS ABNORMALITY
• A Airways and mediastinum• B Bones and soft tissue• C Cardiac silhouette and vessels• D Diaphragm• E Extras and Edges
CLINICAL CORRELATION
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Extras
What tube?
In correct location?
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Chest Drain
Central Line
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CXR - Systematic Approach
• D Details• R RIP – Image Quality
OBVIOUS ABNORMALITY
• A Airways and mediastinum• B Bones and soft tissue• C Cardiac silhoeutte and vessels• D Diaphragm• E Extras and Edges
CLINICAL CORRELATION
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Case Examples
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Clinical infoCoughFeverRaised WCC
CXRL hemi-diaphragm obscuredConsolidation of L base
Dx L Lower lobe pneumonia
Mr Andrew Smith
01/10/1987
17/02/16
18.00
PA
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Presenting CXRIntro: READ THE QUESTION
This is a (AP/PA + Erect/mobile) chest radiograph of… Pt name / Age, taken at… Date / Time
Image quality: Adequate or inadequate (why- RIP?)
?Main abnormality- describe
Or/and: Using a systematic approach• Trachea central? • Mediastinum• Upper / middle / lower zones• Costaphrenic angles• Heart size and cardiophrenic angles• Abnormalities of bones/soft tissues
In summary:•This is a chest radiograph which demonstrates evidence of … which is consitent with the given clinical picture
Further investigations:• Full history• Bedside e.g. Sputum culture/peak flow• Blood tests e.g. Inflammatory markers, BNP• More imaging e.g. Further XR, CT• Special tests e.g. Spiromotry, echo
Management
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Sail Sign
Left lower lobe collapse
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Clinical infoFever Productive cough
R heart border obscuredCrisp line in horiz fissureMild consolidation above
DxR middle lobe consolidation
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Consolidation
Compare R with L
Check costaphrenic angles
Systematic check of fissues
Check cardiophrenic margins
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Clinical InfoFall from 20 foot wallTrauma to chest
CXRAir in pleural spaceVisible pleural edge No lung markingsRib fracture with callus
DxL pneumothoraxSecondary to rib fracture
?tension pneumothorax
No evidence of tension pneumothorax- No shift of trachea - No mediastinal shift
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R Tension pneumothorax
Mediastinal shiftLoss of lung markings
CXR you should never see!
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Pneumothorax
Compare R with L
- Evidence of tension pneumothorax
- Underlying bone lesion or chest drain
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Clinical infoLife long smokerWeight lossIncreasing SOB
DxLarge L pleural effusion?Underlying bronchogeniccarcinoma
Pleural effusionL lower zone whiteObscured costophrenic angleand L hemidiaphragmBlunting of R CP angleConcave edge on top“meniscus sign”
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Small bilateral pleural effusions
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Pleural Effusion
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OSCE:
History: A 69 yo male
smoker with
progressive shortness
of breath and
decreased exercise
tolerance
1: What imaging
abnormalities can be
seen in this
radiograph?
2: What is the most
likely cause of this
abnormality?
3: What is the most
appropriate imaging
follow up technique?
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A
B
C
D
E
Heart failure
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Clinical infoChronic smokerProgressive SOBChronic coughNo infective symptoms
CXRHyper-expansionBoth CP angles bluntFlattened diaphragmDistorted lung markings
DxCOPD
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Clinical hxChronic coughHaemoptysisNight sweats
DxTuberculosis
Staph infectionSquamous cell carcinomaLung infarctRheumatoid arthritis
Central area of necrosis in cavitating lesion on L middle zone
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OSCE marks CXR
• Correctly identifies patient
• Correctly notes time and date
• Correctly states PA or AP
• Comments on image quality
• Comments on medical devices - O2 tube/pacemaker etc
• Assesses lung expansion
• Accurately assesses heart size
• Comments on salient abnormality using correct terminology
• States correct diagnosis
• Offers appropriate management plan
• Requests appropriate next image
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Marilyn Monroe
Chest and Pelvic Xray
1954
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Abdominal X-Ray
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ClinicalAcute severe abdo painGuardingHigh ETOH intakeL-Term NSAIDs use
DxPneumoperitoneum
Erect CXRPt should be upright for10-20 mins for air to rise
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Question 2: SBA for Small Bowel Obstruction
A 65 year old woman presents with abdominal pain and distension with vomiting. She reports that she had some “bowel surgery” 20 years ago.
Her AXR reveals:
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What is the most likely underlying cause?
A) Inguinal hernia B) Adhesions C) Volvulus D) HaemorrhoidsE) Colonic carcinoma
Main causes of SBOAdhesionsMalignancyHernia
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ClinicalPrevious bowel surgeryVomiting +++Absolute constipation
DxSmall Bowel obstruction?adhesion = cause
SBO is when bowel enlarged >3cm
AXRValvulae ConniventesPrevious surgery
(Anastamosis)
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OSCE:What abnormality can be seen?
Large bowel obstruction with haustra
LBO when enlarged above 5cm(or caecum when above 9cm)
Single Best Answer Question: What is the most likely cause of this abnormality?
A) Inguinal hernia B) Adhesions C) Volvulus D) Haemorrhoids E) Colonic carcinoma
65 yo man with weight loss,
abdominal pain and vomiting?
Main causes of LBOColo-rectal carcinomaDiverticular strictures
(Hernia)(Volvulus)
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Question 3: SBA for Large Bowel Obstruction
A 4 day old neonate presents with bile stained vomiting.
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What is the most likely cause of
these abnormalities?
A) Inguinal hernia
B) Adhesions
C) Volvulus
D) Haemorrhoids
E) Colonic carcinoma
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Presenting AXRIntro: READ THE QUESTION
This is a (erect/mobile) abdominal radiograph of… Pt name / Age, taken at… Date / Time
Image quality: Adequate or inadequate
?Main abnormality- describe
Or/and: Using a systematic approach• Bowel – location, ?dilated• Extra-luminal gas• Soft tissue/bone/calcification
In summary: This is a abdominal radiograph which demonstrates evidence of … which is consitent with the given clinical picture
Further investigations: • Full history• Bedside e.g. Urine dip• Blood tests e.g. Inflammatory markers• More imaging e.g. erect XR, CT abdo/pelvis• Special tests
Management
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Ulcerative colitis
Thumbprinting Lead Piping Toxic Megacolon
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AXR YOU SHOULD NEVER SEE
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AXR OSCE marks• Identifies patient
• Correctly notes time and date
• Comments on image quality
• Comments on medical devices
• Assesses bowel gas pattern
• Assesses soft tissues and bone
• Comments on abnormal calcification
• Offers appropriate management plan
• Requests appropriate next image e.g. eCXR/CT Abdomen
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1. Constipation2. Vascular calcification3. Arthritic Changes4. Ring pessary
Is this patient elderly?!
4 supportive findings?
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Question 4: EMQ
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EMQ- Answers
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And finally…
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A 60-year-old man who checked himself into Nishtar Hospital in Multan, Pakistan. He sought treatment because he claimed thieves had inserted a Pepsi bottle into his anus before stealing two of his buffalo
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Thank You…
Bibliographywww.meddean.luc.edu/www.lifeinthefastlane.comwww.radiologymasterclass.co.ukwww.askdoctorrclarke.comwww.rcr.ac.uk
Questions?