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OSCEazy MEGAN HODGSONCHEST X-RAYS FOR OSCEs HOW TO INTERPRET AN CXR IN AN OSCE PATHOLOGIES / FINDINGS SEEN ON CXR PRACTIEXAMPLESNTERPRETATION SESSION TIME: 2 HOURS ANA TOMY X-RA Y BASICS Air Fat Soft Bone Metal Tissue Front Back Anterior-Posterior (AP) Projection Heart X-ray Source Posterior-Anterior (PA) Projection Back Front 1. DENSITY DESCRIBING 2. POSITION X-ray Source ABNORMALITIES 3. SIZE 4. BORDERS SPOT DIAGNOSIS – P A THOLOGIES SEEN ON CXR A 24-year old man presents with pleuritic chest pain during his ruPRIMARY game. There was no trauma history. On examination, his right lunSPONTANEOUS has decreased vocal resonance. The trachea is not deviated PNEUMOTHORAX A 71 year old man presents with a 1 day history of severe dyspnoea.ACUTE On examination, there are course crackles bilaterally at lung DECOMPENSATED raised JVP and peripheral pitting oedema. A previous echocardioHEART FAILURE showed a reduced ejection fraction of the heart. A 62 year old man presents with dyspnoea and a dry cough after aEURAL EFFUSION recent infection. On examination, he had ’stoney’ dullness to percussionY TO and reduced air entry on auscultation of the right lung base. PNEUMONIA) A 56 year old women presents with a gradually worsening dyspnoea. Her blood pressure is 97/68mmHg. You notice a vessel in her neck is raCARDIAC On auscultation, you struggle to hear her heart sounds clearly. TAMPONADE (2 months ago). The ECG shows altering heights of the QRS complexes A 60 year old man presents with severe abdominal pain. On examination, there is rebound and percussion tenderness, guarding and BOWEL PERFORATION rigidity. Previous to this, his abdominal pain was less sever(SECONDARY TO LBO) not passed flatus or stool in 5 days. PMHx: Colorectal carcinoma A 26 year man presents to A&E by ambulance after a road traffic accident. He described a severe, sharp right sided pain. You notice thatURES when he inspires a part of his chest wall moves inwards. (FLAIL CHEST) PRESENTING A CHEST X-RAY AIRWA Y BREATHING PATIENNAME, DATE OF BIRTH, AGE, SEX, DETAILS: HOSPITAL NUMBER DATE OF SCAN OFFER TO COMPARE TO PREVIOUS IMAGING IMAGE RIPE: QUALITY:OTATION INSPIRATION PICTURE AREA / TYPE EXPOSURE EVER YTHING ELSE DIAPHRAGM CARDIAC REVIEW AREAS SUMMARISE YOUR FINDINGS ROTATION INSPIRATION 1 2 5-6 ANTERIOR RIBS MEDIAL BORDER OF 3 OR CLAVICLES MUST BE 8-10 POSTERIOR RIBS EQUIDISTANT TO SPINOUS 4 ABOVE THE DIAPHRAGM PROCESSES 5 BOTH LUNG APICES, BOTH VERTICLE SPINOUS COSTOPHRENIC ANGLES PROCESSES 6 AND ALL LATERAL RIB EDGES MUST BE VISIABLE PICTURE AREA / EXPOSURE TYPE VERTEBRAL BODIES SHOULD BE JUST VISIBLE THROUGH CARDIAC PA OR AP VIEW SHADOW SCAPULA OUT OF LUNG HEMIDIAPHRAGM FIELDS SHOULD BE VISIABLE ON THE EDGE OF THE SPINE PRESENTING A CHEST X-RAY AIRWA Y TRACHEA: DEVIATION PATIENT NAME, DATE OF BIRTH, AGE, SEX, DETAILS: HOSPITAL NUMBER DATE OF SCAN OFFER TO COMPARE TO PREVIOUS CARTILAGE AT DIVISION INTO 2 MAIN IMAGING CARINA: BRONCHI IMAGE RIPE: QUALITY: ROTATION BRONCHI: LEFT & RIGHT MAIN BRONCHUS INSPIRATION PICTURE AREA / TYPE HILA: UNILATERAL / BILATERAL ENLARGEMENT EXPOSURE TENSION PNEUMOTHORAX AIR WITHIN THE PLEURAL SPACE CAUSING MEDIASTINAL SHIFT CAUSE: THORACIC TRAUMA 1 WAY VALVE LETS AIR ENTER PLEURAL SPACE DURING INSPIRATION AIR IS TRAPPED DURING EXPIRATION INCREASING BUILD UP OF AIR IN PLEURAL SPACE CXR: TRACHIAL DEVIATION AWAYFROM PNEUMOTHORAX (MEDISTINAL SHIFT CONTRALATERALLY), HEMIDIAPHRAGM DEPRESSION DO NOT PERFORM A CXR IN TENSION PNEUMOTHORAX IMMEDIATE MANAGEMENT: INSERT A LARGE BORE CANNULA INTO THE 2ND INTERCOSTAL SPACE IN THE MIDCLAVICULAR LINE (URGENT NEEDLE THORACOCENTESIS) DEFINITIVE MANAGEMENT: CHEST DRAIN PNEUMOTHORAX (NON-TENSION) NO TRACHEAL DEVIATION OR MEDIASTINAL SHIFT CXR FINDINGS: LUNG MARKINGS DO NOT EXTEND TO THE PERIPHERIES PLEURAL LINE (EDGE OF THE LUNGS) MEASURING THE SIZE OF A PNEUMOTHORAX: AT THE LEVEL OF THE HILAR INHALED FOREIGN BODY COMMON IN YOUNG CHILDREN SIGNS & SYMPTOMS: COUGH, STRIDOR, CHOCKING, VOMITING, VOICE CHANGES, TACHYPNOEA, SOB INHALED FOREIGN BODIES ARE MORE LIKELY TO TRAVEL DOWN THE RIGHT MAIN BRONCHUS – WIDER, SHORTER & MORE VERTICAL UPPER AIRWAY OBSTRUCTION / CHOCKING MANAGEMENT: BACK SLAPS & ABDOMINAL THRUSTS LOWER AIRWA Y OBSTRUCTION / CHOCKING DEFINITIVE MANAGEMENT: BRONCHOSCOPY TUBES NASOGASTRIC (NG) TUBE PATH: NASAL CAVITY, OESOPHAGUS, STOMACH COMMON USES: FEEDING, ASPIRATON OF STOMACH CONTENTS NEEDS TO BE BELOW THE CARINA & DIAPHRAGM TO CONFIRM CORRECT FINAL POSITION IN STOMACH COMPLICATIONS OF INCORRECT PLACEMENT: ASPIRATION PNEUMONIA, DEATH TUBES ENDOTRACHIAL TUBE (ET) PATH: ORAL CAVITY, LARYNX, TRACHEA FUNCTIONS: OXYGENATION, AIRWAY PROTECTION NEEDS TO BE 5-7CM ABOVE THE CARINA TO CONFIRM CORRECT FINAL POSITION IN TRACHEA COMPLICATIONS OF INCORRECT PLACEMENT: ONLY 1 OXYGENATED LUNG & COLLAPSED CONTRALATERAL LUNG TUBES CHEST DRAIN FUNCTIONS: DRAINAGE OF PNEUMOTHORAX OR PLEURAL EFFUSION INSERTION SITE: TRIANGLE OF SAFETY • 5THINTERCOSTAL SPACE (INFERIOR NIPPLE LINE) • MID AXILLARY LINE 9LATERAL EDGE OF LATISSIMUS DORSI) • ANTERIOR AXILLARY LINE (LATERAL EDGE OF PECTORAIS MAJOR) INSERT NEEDLE JUST ABOVE A RIB TO AVOID DAMAGE TO NEUROVASCULAR BUNDLE DRAINING A PNEUMOTHORAX: TIP OF CHEST DRAIN TUBE POINTED SUPERIORLY IN PLEURAL CAVITY DRAINING A PLEURAL EFFUSON: TIP OF CHEST DRAIN TUBE POINTED INFERIORLY IN PLEURAL CAVITY SARCOIDOSIS A DISEASE CHARACTERISED BY THE GROWTH OF GRANULOMAS IN DIFFERENT PARTS OF THE BODY LUNGS & LYMPH NODES COMMONLY AFFECTED RESPIRATORY SYMPTOMS: SOB & NON-PRODUCTIVE COUGH OTHER SYMPTOMS: SWINGING FEVER, ERYTHEMA NODOSUM, LIVER CIRRHOSIS, HEART BLOCK, KIDNEY STONES, CNS INVOLVEMENT, ARTHRITIS, ETC. GOLD STANDARD DIAGNOSTIC INVESTIGATION: TISSUE HISTOLOGY AFTER BRONCHOSCOPY WITH ULTRASOUND GUIDED BIOPSY OF MEDIASTINAL LYMOH NODES → NON- CASEATING GRANULOMAS WITH EPITHELOID CELLS x FINDINGS ON CXR: • BILATERAL HILAR LYMPHADENOPATHY • PULMONARY FIBROSIS (UPPER LOBES) • PULMONARY NODULES (GRANULOMAS) CXR STAGING: STAGE 0 = NORMAL STAGE 1 = BILATERAL HILAR LYMPHADENOPATHY (BHL) STAGE 2 = BHL + INTERSTITIAL INFILTRATES STAGE 3 = DIFFUSE INTERSTITIAL INFILTRATES ONLY STAGE 4 = DIFFUSE FIBROSIS Mr Peter Pan (Male) DOB: 21.03.2001 (21) INTERPRET THIS CHEST X-RAY Date of Scan: 21.04.2022 PC: Acute SOB during This is the chest x-ray of Mr Peter Pan, a 21-year-old male taken on 21 April 2022. INTRO At this point, I would want to compare this image to any previous chest x-rays & RIPE available for this patient. Looking at the quality of the image: There is minimal rotation with the medial end of the clavicles equidistant from the spinous processes on the midline. There is adequate inspiration, with 6 anterior ribs visible above the diaphragm and all parts of the chest cavity are visible This is a PA projection There is adequate exposure to the image, as I can see the vertebral bodies behind the heart. The trachea is deviated to the right side. The carina & 2 main bronchi visible and A there is no hilar lymphadenopathy. In the left lung field, there is a pleural line, marking the edge of the left lung and B the lung marking on this side do not extend out to the lateral chest wall in all lung zones. The pleura are normal, with no evidence of thickening. The cardiac shadow is poorly defined and displaced to the right. There is no C evidence of cardiomegaly. The arch of the aorta is clearly visible. The left hemidiaphragm is depressed. There is no evidence of costophrenic angle D blunting or pneumoperitoneum. A normal gas bubble is seen on the left side. There is mediastinal shift towards the right side of the chest cavity.All soft tissues E & bone structures appear normal. To conclste, I have reviewed this PA chest x-ray of Mr Peter Pan , a 21-year-old male SUMMARY taken on 21pril 2022. My positive findings are tracheal deviation and mediastinal sshortness of breath, my top differential diagnosis is a tension pneumothorax.plaint of LET’S HA VE A BREA THER! HOPE YOU ARE ALL ENJOYING THE SESSION! UP NEXT  BREATHING, CIRCULATION @osceazyofficial Osceazy@outlook.com @OSCEazyOfficial OSCEazy PRESENTING A CHEST X-RAY AIRWA Y BREATHING TRACHEA: DEVIATION LUNG FIELDS: 3 ZONES – ASYMMETRY PATIENT NAME, DATE OF BIRTH, AGE, SEX, • ROTATION • CONSOLIDATION DETAILS: HOSPITAL NUMBER • PNEUMOTHORAX • FLUID DATE OF SCAN • PLEURAL EFFUSION • CONSOLIDATION • AIR OFFER TO COMPARE TO PREVIOUS CARINA: CARTILAGE AT DIVISION INTO 2 MAIN • COLLAPSE IMAGING BRONCHI • MASSESS • TUBE PLACEMENT (NG TUBE, ET TUBE) • SIZE OF LUNG FIELDS IMAGE RIPE: QUALITY: ROTATION BRONCHI: LEFT & RIGHT MAIN BRONCHUS PLEURA: THICKENING OR ABNORMAL POSITION INSPIRATION • INHALED FOREIGN OBJECT PICTURE AREA / TYPE HILA: UNILATERAL / BILATERAL ENLARGEMENT EXPOSURE • SARCOIDOSIS , TB (BILATERAL) • MALIGNANCY (UNILATERAL/ASSYMETRICAL) CONSOLIDATION ALVEOLAR AIRSPACES BECOME FILLED WITH DENSE MATERIAL IN INFECTION (PNEUMONIA), THE CONSOLIDATION IS TYPICALLY CONTAINED WITHIN 1 LOBE DIFFERENTIALS FOR CONSOLIDATION: • PNEUMONIA (MOST COMMON, EXUDATIVE PUS) • PULMONARY OEDEMA (TRANSUDATIVE FLUID) • LUNG CANCER (MALIGNANT CELLS) • PULMONARY HAEMORRHAGE (BLOOD) • FOREIGN BODY (CAUSING INFECTION) SIGN OF CONSOLIDATION: AIR BRONCHOGRAM, OPACIFICATION OF LUNG FIELD (WHITE) DESCRIBING THE SITE OF CONSOLIDATION RIGHT SUPERIOR LOBE LEFT SUPERIOR LOBE ASCENDING AORTA AORTIC KUCKLE UPPER RIGHT HEART BORDER LEFT HEART BORDER MAY OUTLINE HORIZONTAL FISSURE BELOW RIGHT MIDDLE LOBE RIGHT HEART BORDER LEFT INFERIOR LOBE MAY OUTLINE HORIZONTAL FISSURE ABOVE LEFT LATERAL HEMIDIAPHRAGM RIGHT INFERIOR LOBE RIGHT LATERAL HEMIDIAPHRAGM PNEUMONIA INVESTIGATIONS & MANAGEMENT ABCDE assessment Basic observations SITE OF CARE MEDICAL BEDSIDE Resp examination ECG CALCULATE CURB-65 COMMUNITY ACQUIRED SEPSIS 6 CONFUSION AMOXICILLIN UREA >7 CLARYTHROMYCIN FBC RESPIRATORY RATE ≥30 (DOXYCYCLINE FOR PENICILLIN ALLERGY) Calculate BLOOD PRESSURE SYSTOLIC ≤90 OR DISTOLIC ≤60 BLOODS U&Es CURB-65 ≥65 YEARS OLD HOSPITAL ACQUIRED ABG SCORE CO-AMOXICLAV CRP SITE OF CARE LOW RISK (0-1): Home-based care IMAGING INTERMEDIATE RISK (2): Hospital -based care HIGH RISK (3-5): Intensive care assessment & Sputum MC&S (ICU) Chest X-ray SPECIAL TESTS PLEURAL EFFUSION AN ABNORMAL COLLECTION OF FLUID BETWEEN THE 2 LAYERS OF THE PLEURAL (PARIETAL & VISCERAL) EXAMINATION FINDINGS: TRACHEAL DEVIATION AWAY FROM EFFUSION (LARGE) DISPLACED APEX BEAT (LARGE) REDUCED CHEST EXPANSION STONY DULLNESS TO PERCUSSION DECREASED TACTILE VOCAL FREMITUS / VOCAL RESONANCE REDUCED BREATH SOUNDS SIGNS OF PLEURAL EFFUSION ON CXR: COSTOPHRENIC ANGLE BLUNTING FLUID IN LUNG FISSURES MENISCUS SIGN MEDIASTINAL DEVIATION (LARGE & UNILATERAL) 2 CATEGORIES OF PLEURAL EFFUSION: TRANSUDATIVE COMMON CAUSES: HEART FAILURE, HYPOALBUMINAEMIA MORE LIKELY BILATERAL & EQUAL EXUDATIVE COMMON CAUSE: PNEUMONIA, OTHER INFECTIONS (TB, ABSCESSES), CONNECTIVE TISSUE DISEASE, MALIGNANCY, PE MORE LIKELY UNILATERAL OR UNEQUAL LOBAR COLLAPSE A COLLAPSE OF AN ENTIRE LOBE OF THE LUNG CAUSED BY OBSTRUCTION OF BRONCHI SUPPLYING THE AFFECTED LOBE COMMON CAUSES: LUNG MALIGNANCY ASTHMA ASPIRATED FOREIGN MATERAL MISPLACED ENDOTRACHEAL TUBE PNEUMONECTOMY SURGICAL REMOVAL OF A LUNG COMMON INDICATION: PRIMARY LUNG MALIGNANCY SIGNS ON CXR: TRACHEAL DEVIATION TOWARDS COLLAPSED LOBE MEDIASTINAL SHIFT TOWARDS COLLAPSED LOBE ELEVATION OF IPSILATERAL HEMIDIAPHRAGM VISIBLE COLLAPSED LOBE IS TRIANGULAR/PYRAMIDAL SHAPE – LOBE COLLAPSE CUT OFF BRONCHI - PNEUMONECTOMY PRIMARY LUNG CANCER SIGNS & SYMPTOMS: LUNG CANCER BY • PERSISTENT DRY COUGH • HAEMOPTYSIS LOCATION: • CHEST PAIN • SQUAMOUS CELL: LARGE, • SOB CENTRAL AIRWAYS • B SYMPTOMS: WEIGHT LOSS, FATIGUE, NIGHT SWEATS • ADENOCARCINOMA: • CLUBBING PERIPHERIES • SMALL CELL: CENTRAL • LYMHADENOPATHY • SWOLLEN FACE • HORNER’S SYNDROME (MYOSIS, ANHYDROSIS & PTOSIS) • HOARSE VOICE LUNG METASTASES CANCER THAT COMMONLY METASTASISE TO THE LUNGS: • BREAST CANNON-BALL • COLORECTAL • PROSTATE • BRONCHIAL LESIONS • HEAD & NECK • BLADDER • RENAL ADENOCARCINOMA SMALL CELL LUNG CANCER SQUAMOUS CELL CARCINOMA MOST COMMON SMOKERS SMOKERS CANCER IN THE UK UNDIFFERENTIATED, LOCATION: LARGE, NON-SMOKERS (MOST AGGRESSIVE, QUICKLY CENTRAL AIRWAYS WITH THIS ARE METASTASIZES (POOR SMOKERS) PROGNOSIS) ECTOPIC PTHrP  HYPERCALCAEMIA LOCATION: PERIPHERIES LOCATION: CENTRAL ECTOPIC TSH  GYNAECOMASTIA ECTOPIC ACTH  HYPERTHYROIDISM CUSHING’S SYNDROME SIADH LAMBER EATON SYNDROME WHITE SHADOWING DIFFERENTIALS PULMONARY OEDEMA COLLAPSE CONSOLIDATION EFFUSION MASS NON-UNIFORM UNIFORM SOFT TISSUE DENSITY NON-UNIFORM SOFT UNIFORM SOFT TISSUE DENSITY DEPENDANT ON DENSITY SMALLER PYRAMID/ TRIANGLE SHAPED TISSUE DENSITY MENISCUS SIGN AETIOLOGY BAT'S WING LOBE AIR BRONCHOGRAMS BLUNTING OF COSTOPHRENIC APPEARANCE OTHER STRUCTURE MOVE INTO THE ANGLE KERLEY B LINES EMPTY SPACE (MEDISTINAL SHIFT – FLUID IN LUNG FISSURES CARDIOMEGALY HEART, CONTRALATERAL LUNG, UPPER LOBE TRACHEA) ABNORMAL POSITIONS OF FISSURES DIVERSION PLEURAL EFFUSION ELEVATION OF IPSILATERAL DIAPHRAGM DIFFERENTIALS BASED ON TRACHEA POSITION TRACHEA DEVIATION TRACHEA DEVIATION CENTRAL TRACHEA AWAY FROM WHITE- TOWARDS WHITE- OUT OUT CONSOLIDATION PLEURAL EFFUSION COMPLETE LUNG COLLAPSE / PNEUMONECTOMY PULMONARY OEDEMA LARGE MASS SMALL MASS PULMONARY FIBROSIS AN EXCESS OF FIBROTIC TISSUE IN THE INTERSTITIUM BETWEEN THE LUNG PARENCHYMA CXR: INTERSTITAL SHADING (GROUND-GLASS APPEARANCE) CAUSES OF PULMONARY FIBROSIS UPPER ZONE FIBROSIS LOWER ZONE FIBROSIS COAL WORKER’S C PNEUMOCONIOSIS ASBESTOSIS A H HISTIOCYTOSIS TISSUE DISESES ANKYLOSING C (e.g. SLE) A SPONDYLITIS IDIOPATHIC I PULMONARY R RADIATION FIBROSIS D DRUG-INDUCED TB AMIODARONE T MBELOMYCINTE SARCOIDOSIS S ASBESTOS EXPOSURE PLEURAL PLAQUES PLEURAL THICKENING ASBESTOSIS MESOTHELIOMA LUNG CANCER Mr Donald Duck (Male) DOB: 11.11.1964 (57) INTERPRET THIS CHEST X-RAY Date of Scan: 21.04.2022 PC: 5 day hx of SOB, fever st& productive cough with INTRO This is the chest x-ray of Mr Donald Duck, a 57-year-old magreen sputum21 April 2022. At this point, I would want to compare this image to any & RIPE previous chest x-rays available for this patient. Looking at the quality of the image: There is minimal rotation with the medial end of the clavicles equidistant from the spinous processes on the midline. There is adequate inspiration, with 6 anterior ribs visible above the diaphragm and all parts of the chest cavity are visible This is a PA projection There is adequate exposure to the image, as I can see the vertebral bodies behind the heart. The trachea is deviated to the right side. The carina & 2 main bronchi A visible and there is no hilar lymphadenopathy. In the right lung field, there is non-uniform soft tissue density containing air bronchograms, indicative of an area of consolidation in the right upper B lobe. The pleura are normal, with no evidence of thickening. The cardiac shadow is well defined. There is no evidence of C cardiomegaly. The arch of the aorta is clearly visible. The two hemidiaphragm are of a normal shape. There is no evidence of D costophrenic angle blunting or pneumoperitoneum. A normal gas bubble is seen on the left side. There is no mediastinal shift. All soft tissues & bone structures appear E normal. To conclude, I have reviewed this PA chest x-ray of Mr Donald Duck, a 57-year-old male taken on 21April 2022. My positive findings are tracheal deviation to the right of the chest cavity SUMMARY and a right upper lobe consolidation. Based on this patient’s presenting complaint of shortness of breath, fever acommunity-acquired pneumonia.een sputum, my top differential diagnosis is a PRESENTING A CHEST X-RAY AIRWA Y BREATHING TRACHEA: DEVIATION LUNG FIELDS: 3 ZONES – ASYMMETRY PATIENT NAME, DATE OF BIRTH, AGE, SEX, • ROTATION • CONSOLIDATION DETAILS: HOSPITAL NUMBER • PNEUMOTHORAX • FLUID DATE OF SCAN • PLEURAL EFFUSION • CONSOLIDATION • AIR OFFER TO COMPARE TO PREVIOUS CARINA: CARTILAGE AT DIVISION INTO 2 MAIN • COLLAPSE IMAGING BRONCHI • MASSESS • TUBE PLACEMENT (NG TUBE, ET TUBE) • SIZE OF LUNG FIELDS IMAGE RIPE: QUALITY: ROTATION BRONCHI: LEFT & RIGHT MAIN BRONCHUS PLEURA: THICKENING OR ABNORMAL POSITION INSPIRATION • IHALED FOREIGN OBJECT • MESOTHELIOMA • TB PICTURE AREA / TYPE HILA: UNILATERAL / BILATERAL ENLARGEMENT • EMPYEMA EXPOSURE • SARCOIDOSIS (BILATERAL) • HAEMOTHORAX • MALIGNANCY (UNILATERAL/ASSYMETRICAL) • RADIATION CARDIAC HEART SIZE: HEART SIZE < 50% CARDIOTHORACIC RATIO • HEART FAILURE • VALVULAR PATHOLOGIES • CARDIOMYOPATHY • PULMONARY HTN • PERICARDIAL EFFUSION HEART BORDERS: WELL DEFINED Heart Failure (Pulmonary Oedema) A ALVEROLAR OEDEMA B KERLEY B-LINES C CARDIOMEGALY D DILATED UPPER LOBE VESSELS E PLEURAL EFFUSION Pericardial Effusion WATER BOTTLE SIGN EXCESS PERICARDIAL FLUID BUILDS UP BETWEEN THE HEART & THE PERICARDIUM CAUSES: PERICARDITIS, POST- CARDIAC SURGERY , TRAUMA, MALIGNANCY COMMONLY ASYMPTOMATIC Constrictive Pericarditis PERICARDIAL CALFICIATION CHRONIC INFLAMMATION OF THE PERICARDIUM, CAUSING IT TO THICKEN AND BECOME NON- COMPLIANT & FIBROSED SIGNS & SYMPTOMS: DYSPNOEA, RIGHT-SIDED HF FEATURES KUSSMAUL SIGN PERICARDIAL KNOCK S1 S2 PK S1 Mx: PERICARDIECTOMY Widened Mediastinum MOST COMMON CAUSE: XYRA TECHNICAL / ADEQUACY PROBLEMS CAUSES OF TRUE MEDISTINUM WIDENING: THORACIC AORTIC ANEURYSM AORTIC DISSECTION LYMPHOMA RETROSTERNAL GOITRE THYMUS TUMOUR TERATOMA Mr Carl Fredrickson (Male) DOB: 09.02.1945 (77) INTERPRET THIS CHEST X-RAY Date of Scan: 21.04.2022 PC: Increasing SOB on exertion INTRO Thst is the chest x-ray of Mr Car Fredrickson, a 77-year-old male taken on 21 April 2022. At this point, I would want to compare this image to any & RIPE previous chest x-rays available for this patient. Looking at the quality of the image: There is minimal rotation with the medial end of the clavicles equidistant from the spinous processes on the midline. There is adequate inspiration, with 6 anterior ribs visible above the diaphragm and all parts of the chest cavity are visible This is a PA projection There is adequate exposure to the image, as I can see the vertebral bodies behind the heart. The trachea is central. The carina & 2 main bronchi visible and there is A no hilar lymphadenopathy. There is opacification of lung tissue adjacent to the carina centrally. There are kerley B lines present on the peripheries, indicative of interstitial oedema. The upper lobe vessels are more prominent. The pleura are normal, with no B evidence of thickening. There is massive cardiomegaly, as the cardiac shadow is much greater than C 50% of the thoracic cavity width.The cardiac shadow is well defined. The arch of the aorta is clearly visible. There is mild costophrenic angle blunting on the right side. The two D hemidiaphragm are of a normal shape. There is no evidence of pneumoperitoneum. A normal gas bubble is seen on the left side. There is no mediastinal shift. All soft tissues & bone structures appear E normal. To conclude, I have reviewed this PA chest x-ray of Mr Carl Fredrickson, a 77-year-old male taken on 21il 2022. My positive findings are alveolar oedema, kerley B lines, SUMMARY cardiomegaly, upper lobe diversions and a small pleural effusion, suggestive of pulmonary increasing shortness of breath on exertion, my top differential diagnosis is heart failure. LET’S HA VE A BREA THER! HOPE YOU ARE ALL ENJOYING THE SESSION! UP NEXT  DIAPHRAGM, EVERYTHING ELSE, EXAMPLE CASES @osceazyofficial Osceazy@outlook.com @OSCEazyOfficial OSCEazy PRESENTING A CHEST X-RAY AIRWA Y BREATHING TRACHEA: DEVIATION • ROTATION LUNG FIELDS: 3 ZONES – ASYMMETRY PATIENT NAME, DATE OF BIRTH, AGE, SEX, • PNEUMOTHORAX • CONSOLIDATION DETAILS: HOSPITAL NUMBER • PLEURAL EFFUSION • FLUID DATE OF SCAN • CONSOLIDATION • AIR OFFER TO COMPARE TO PREVIOUS • COLLAPSE CARINA: CARTILAGE AT DIVISION INTO 2 MAIN IMAGING BRONCHI • MASSESS • TUBE PLACEMENT (NG TUBE, ET TUBE) • SIZE OF LUNG FIELDS IMAGE RIPE: QUALITY: ROTATION BRONCHI: LEFT & RIGHT MAIN BRONCHUS PLEURA: THICKENING OR ABNORMAL POSITION INSPIRATION • INHALED FOREIGN OBJECT • MESOTHELIOMA PICTURE AREA / TYPE • TB EXPOSURE HILA: UNILATERAL / BILATERAL ENLARGEMENT • EMPYEMA • SARCOIDOSIS (BILATERAL) • HAEMOTHORAX • MALIGNANCY • RADIATION (UNILATERAL/ASSYMETRICAL) DIAPHRAGM CARDIAC DIAPHRAGM SHAPE: FLATTENED HEART SIZE: 3HEART SIZE < 50% CARDIOTHORACIC RATIO • HEART FAILURE • VALVULAR UNDER THE DIAPHRAGM: FREE GAS / PATHOLOGIES PNEUMOPERITONEUM • CARDIOMYOPATHY • PULMONARY HTN • PERICARDIAL EFFUSION COSTOPHRENIC ANGLES: BLUNTING HEART BORDERS: WELL DEFINED COPD COPD CHRONIC BRONCHITIS EMPHYSEMA INFLAMMATION OF THE ALVEOLAR MEMBRANE BREAK MUCOUS MEMBRANES IN THE DOWN BRONCHIOLES & EXCESS MUCUS PRODUCTION CXR COPD FINDINGS: HYPERINFLATION (>8 ANTERIOR RIBS) FLAT HEMIDIAPHRAGMS DECREASED LUNG MARKINGS BULLAE PROMINENT HILA PNEUMOPERITONEUM FREE AIR UNDER THE HEMIDIAPHRAGM(S) ERECT CXR REQUIRED DIFFERENTIALS: PERFORATED PEPTIC ULCER PERFORATION AFTER BOWEL OBSTRUCTION PERFORATED APPENDIX PERFORATED DIVERTICULITIS ISCHAEMIC BOWEL NECROTISING ENTEROCOLITIS IBD MALIGNANCY AIR SUFFLATION DUE TO LAPAROSCOPY , TRAUMA SPREAD FROM PNEUMOMEDIASTINUM / PNEUMOTHORAX Miss Cruella de Vil (Female) DOB: 09.04.1954 (68) INTERPRET THIS CHEST X-RAY Date of Scan: 21.04.2022 PC: Progressively increasing This is the chest x-ray of Miss Cruella de Vil, a 68-year-old female taken on 21 Aprilum. INTRO 2022. At this point, I would want to compare this image to any previous chest x-rays & RIPE available for this patient. Looking at the quality of the image: There is minimal rotation with the medial end of the clavicles equidistant from the spinous processes on the midline. There is adequate inspiration, with 8 anterior ribs visible above the diaphragm and all parts of the chest cavity are visible This is a PA projection There is adequate exposure to the image, as I can see the vertebral bodies behind the heart. The trachea is central. The carina & 2 main bronchi visible.The hilar are prominent, A suggestive of hilar lymphadenopathy. There is hyperinflation of the lung fields bilaterally, with 8 anterior ribs visible. There are decreased lung markings in the peripheries The pleura are normal, with no B evidence of thickening. The cardiac shadow is well defined. There is no evidence of cardiomegaly. The arch C of the aorta is clearly visible. The two hemidiaphragm are flattened. There is no evidence of costophrenic angle D blunting or pneumoperitoneum. There is no mediastinal shift. All soft tissues & bone structures appear normal. E To conclude, I have reviewed this PA chest x-ray of Miss Cruella de Vil, a 68-year-old female taken on 21 April 2022. My positive findings are lung hyperinflation, decreased lung markings peripherally, flattened SUMMARY hemidiaphragms and hilar lymphadenopathy. Based on this patient’s presenting complaint of shortness of breath and a differential diagnosis is a natural progression of COPD.dical history of COPD, my top PRESENTING A CHEST X-RAY AIRWA Y BREATHING TRACHEA: DEVIATION • ROTATION LUNG FIELDS: 3 ZONES – ASYMMETRY PATIENT NAME, DATE OF BIRTH, AGE, SEX, • PENUMOTHORAX • CONSOLIDATION DETAILS: HOSPITAL NUMBER • PLEURAL EFFUSION • FLUID DATE OF SCAN • CONSOLIDATION • AIR OFFER TO COMPARE TO PREVIOUS • COLLAPSE CARINA: CARTILAGE AT DIVISION INTO 2 MAIN IMAGING BRONCHI • MASSESS • TUBE PLACEMENT (NG TUBE, ET TUBE) • SIZE OF LUNG FIELDS IMAGE RIPE: QUALITY: ROTATION BRONCHI: LEFT & RIGHT MAIN BRONCHUS PLEURA: THICKENING OR ABNORMAL POSITION INSPIRATION • INHALED FOREIGN OBJECT • MESOTHELIOMA PICTURE AREA / TYPE • TB EXPOSURE HILA: UNILATERAL / BILATERAL ENLARGEMENT • EMPYEMA • SARCOIDOSIS (BILATERAL) • HAEMOTHORAX • MALIGNANCY • RADIATION (UNILATERAL/ASSYMETRICAL) EVER YTHING ELSE DIAPHRAGM CARDIAC BONES: FRACTURE DIAPHRAGM SHAPE: FLATTENED HEART SIZE: 3HEART SIZE < 50% SOFT TISSUES: SWELLING • COPD CARDIOTHORACIC RATIO • PNEUMOTHORAX • HEART FAILURE MEDIASTINUM: WIDENING • VALVULAR UNDER THE DIAPHRAGM: FREE GAS / PATHOLOGIES PNEUMOPERITONEUM • CARDIOMYOPATHY DEVICES: NG TUBE, CENTRAL LINE, ECG • PULMONARY HTN CABLES, HEART VALVES, • PERICARDIAL EFFUSION PACEMAKERS/ICD COSTOPHRENIC ANGLES: BLUNTING • P LEURAL EFFUSION HEART BORDERS: WELL DEFINED • CONSOLIDATION BONY FRACTURE TRACE THE OUTER CORTEX OF ALL BONES TO LOOK FOR LOSS OF CONTINUITY CLAVICULAR FRACTURES MOST COMMON IN MIDDLE THIRD CAUSE: DIRECT TRAUMA TO SHOULDER / FOOSHMASTECTOMY PRESENTING A CHEST X-RAY AIRWA Y BREATHING TRACHEA: DEVIATION PATIENT NAME, DATE OF BIRTH, AGE, SEX, • ROTATION LUNG FIELDS: 3 ZONES – ASYMMETRY • PENUMOTHORAX • CONSOLIDATION DETAILS: HOSPITAL NUMBER • PLEURAL EFFUSION • FLUID DATE OF SCAN • CONSOLIDATION • AIR OFFER TO COMPARE TO PREVIOUS • COLLAPSE IMAGING CARINA: CARTILAGE AT DIVISION INTO 2 MAIN • MASSESS BRONCHI • SIZE OF LUNG FIELDS IMAGE RIPE: • TUBE PLACEMENT (NG TUBE, ET TUBE) QUALITY: ROTATION BRONCHI: LEFT & RIGHT MAIN BRONCHUS PLEURA: THICKENING OR ABNORMAL POSITION • INHALED FOREIGN OBJECT • MESOTHELIOMA INSPIRATION • TB PICTURE AREA / TYPE HILA: UNILATERAL / BILATERAL ENLARGEMENT • EMPYEMA EXPOSURE • SARCOIDOSIS (BILATERAL) • MALIGNANCY • HAEMOTHORAX (UNILATERAL/ASSYMETRICAL) • RADIATION EVER YTHING ELSE DIAPHRAGM CARDIAC BONES: FRACTURE DIAPHRAGM SHAPE: FLATTENED HEART SIZE: 3HEART SIZE < 50% • COPD CARDIOTHORACIC RATIO SOFT TISSUES: SWELLING • PNEUMOTHORAX MEDIASTINUM: WIDENING • HEART FAILURE • AORTIC DISSECTION UNDER THE DIAPHRAGM: FREE GAS / • VALVULAR PATHOLOGIES • AORTIC ANEURYSM PNEUMOPERITONEUM • CARDIOMYOPATHY DEVICES: NG TUBE, CENTRAL LINE, ECG • PULMONARY HTN CABLES, HEART VALVES, • PERICARDIAL EFFUSION PACEMAKERS/ICD COSTOPHRENIC ANGLES: BLUNTING REVIEW AREAS • PLEURAL EFFUSION HEART BORDERS: WELL DEFINED • CONSOLIDATION SUMMARISE YOUR FINDINGS CONDITION HISTORY CONDITION HISTORY CONDITION HISTORY - Pleuritic chest pain - Shortness of breath - Dry cough - Sudden onset - Shortness of breath - Peripheral oedema - Shortness of breath PNEUMOTHORAX PULMONARY - History of rheumatoid / SLE HEART FAILURE - Reduced exercise tolerance - Young teenage male FIBROSIS - Medications (e.g. amiodarone) - Elevated JVP - CXR: Pleural Line, Lung markings do not extend to peripheries, flattened - CXR: ’ground glass appearance’ - Bibasal crackles hemidiaphragm, - Productive cough - CXR: Alveolar oedema (bat- - Tension CXR: Tracheal deviation & - Shortness of Breath winging), Kerley B lines mediastinal shift to contralateral side COPD (interstitial oedema), - Expiratory wheeze - Smoker Cardiomegaly, Upper lobe - Pleuritic chest pain - CXR: hyperinflation, flat diversion, Pleural effusion - Productive cough hemidiaphragm, decreased lung - Asymptomatic PERICARDIAL - Green/blood-stained phlegm markings, bullae, prominent hila - CXR: Cardiomegaly (water bottle PNEUMONIA - Shortness of breath EFFUSION - Pleuritic chest pain sign) - Fever COPD - Productive cough with green/yellow AORTIC - Asymptomatic (until rupture) - History of viral illness EXCACERBATION - CXR: Consolidation (non-uniform soft sputum ANEURYSM - CXR: Widened mediastinum - Increasing shortness of breath tissue density opacification with air - Peritonism (generalised abdominal - Fever BOWEL bronchograms) PERFORATION pain, rebound tenderness, - Increased inhaler use - Shortness of Breath percussion tenderness, guarding - CXR: Consolidation - Non-productive cough and rigidity) PLEURAL - Chest pain - Smoking history - CXR: Pneumoperitoneum EFFUSION - CXR: costophrenic angle blunting, fluid LUNG CANCER - Weight loss in lung fissures, meniscus sign, - Asbestos Exposure - CXR: Disruption in outer cortex of mediastinal deviation - CXR: uniform soft tissue density BONE FRACTURE bones (fracture) Mr Li Shang (Male) DOB: 03.06.1989 (32) INTERPRET THIS CHEST X-RAY Date of Scan: 21.04.2022 PC: SOB, Trauma to the This is the chest x-ray of Mr Li Shang, a 32-year-old male taken on 21 April 2022. INTRO At this point, I would want to compare this image to any previous chest x-rays & RIPE available for this patient. Looking at the quality of the image: There is minimal rotation with the medial end of the clavicles equidistant from the spinous processes on the midline. There is adequate inspiration, with 6 anterior ribs visible above the diaphragm and all parts of the chest cavity are visible This is a AP projection There is adequate exposure to the image, as I can see the vertebral bodies behind the heart. The trachea is deviated to the right side. The carina & 2 main bronchi are difficult A to visualise. There is no hilar lymphadenopathy. Both lung fields appear smaller in size due to the large cardiac shadow.The lung markings appear normal. The pleura are normal, with no evidence of thickening. B There is massive cardiomegaly, as the cardiac shadow is much greater than 50% C of the thoracic cavity width, despite the AP view. It has a globular shape. The cardiac shadow is well defined. The arch of the aorta is clearly visible. There is evidence of bilateral costophrenic angle blunting, greater on the left side. D The left hemidiaphragm is indistinguishable from the heart shadow.There is no evidence of pneumoperitoneum. There is no mediastinal shift. All soft tissues & bone structures appear normal. E To conclude, I have reviewed this AP chest x-ray of Mr Li Shang, a 32-year-old male taken on 21 April 2022. My positive findings are tracheal deviation to the right of the chest cavity, bilateral pleural SUMMARY effusions and the globular-shaped cardiomegaly. Based on this patient’s presenting complaint of shortness of brpericardial effusion with bilateral pleural effusions.my top differential diagnosis is a Miss Luisa Madrigal (Female) DOB: 12.01.2000 (22) INTERPRET THIS CHEST X-RAY Date of Scan: 21.04.2022 PC: 2 day hx of fever, right iliac fossa pain, Rovsing’sign INTRO This istthe chest x-ray of Miss Luisa Madrigal, a 22-year-olpositive. Now, generalised on 21 April 2022. At this point, I would want to compare thabdominal pain & vomiting & RIPE any previous chest x-rays available for this patient. Looking at the quality of the image: There is minimal rotation with the medial end of the clavicles equidistant from the spinous processes on the midline. There is adequate inspiration, with 6 anterior ribs visible above the diaphragm and all parts of the chest cavity are visible This is a PA projection There is adequate exposure to the image, as I can see the vertebral bodies behind the heart. The trachea is central. The carina & 2 main bronchi visible and there is no A hilar lymphadenopathy. The lung fields are clear. The pleura are normal, with no evidence of thickening. B The cardiac shadow is well defined. There is no evidence of C cardiomegaly. The arch of the aorta is clearly visible. There is free air underneath the hemidiaphragms bilaterally, indicative of D pneumoperitoneum. The two hemidiaphragm are of a normal shape. There is no evidence of costophrenic angle blunting. A normal gas bubble is seen on the left side. There is no mediastinal shift. All soft tissues & bone structures appear E normal. To conclude, I have reviewed this PA chest x-ray of Miss Luisa Madrigal, a 22-year-old female taken on 21ril 2022. My positive findings are pneumoperitoneum bilaterally. Based on this SUMMARY patient’s presenting complaint of a 2 day history of fever, right iliac fossa pain and a positive Rovsing’sign fperforated appendix secondary to appendicitis. differential diagnosis is a a PLEASE FILL OUT THE FEEDBACK FORM FOLLOW OUR SOCIALS TO STA Y UP TO DATE WITH ALL EVENTS Image credits – Wikimedia Commons, Radiopaedia, Life in the Fast Lane @OSCEazyOfficial @osceazyofficial OSCEazy Osceazy@outlook.com