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Presents @BRITISHINDIANMEDICASSOCIATION @BIMA @BINDIANMEDICSMeghnaThakrar University of Birmingham Interested in gastroenterology, rheumatology and GP Enjoy travelling, dance and all things bollywood :)SessionAims 1. Go through how to interpret Chest X Rays 2. Recap the fundamentals of the Respiratory Examination 3. Practise some questions and casesChestXRaysMentimeter www.menti.com Code - 37 47 38 7Howtoanalysechestxrays DRSABCDE Confirm Patient Details ● Patient details: name, date of birth and unique identification number ● Date and time the film was taken ● Previous imaging: useful for comparison RIPE Airway Breathing CIrculation Diaphragm and disability ExtrasRIPE Rotation ● The medial aspect of each clavicle should be equidistant from the spinous processes ● The spinous processes should also be in vertically orientated against the vertebral bodies Inspiration ● The 5-6 anterior ribs or 10-11 posterior ribs, lung apices, both costophrenic angles and the lateral rib edges should be visible Position ● Supine or lateral. Note if the film is AP or PA: if there is no label, then assume it’s a PA film ● (if the scapulae are not projected within the chest, it’s PA) Exposure ● The left hemidiaphragm should be visible to the spine and the vertebrae should be visible behind the heartAirway Trachea ● Deviation towards ‘pulled’: lobar collapse, pneumonectomy,pulmonary fibrosis ● Deviation away from ‘pushed’: pleural effusion,tension pneumothorax ● Apparent tracheal deviation ● Inspect the clavicles to rule out the presence of rotationAirway Carina ● T4-T5 is where the trachea divides into the left and right main bronchus and should be visible ● site where nasogastric tubes should bisect into the gastrointestinal tract ● The right main bronchus is generally wider, shorter and more vertical than the left main bronchus and is a common site for foreign objects to become lodged Hilum T6-T7 ● Each hilar consists of lymph nodes, pulmonary vessels and the bronchi. Although the left hilum is slightly higher than the right, they should be similar in size so asymmetry is a sign of pathology ● The hilar point is also a very important landmark; anatomically it is where the descending pulmonary artery intersects the superior pulmonary vein. When this is lost, consider the possibility of a lesion here (e.g. lung tumour or enlarged lymph nodes). ● Hilar enlargement and position ● Bilateral ○ Sarcoidosis ● Causes of clubbing ● Unilateral ○ MalignancyBreathing Zones ● LL Three Zones ● RL Two Zones ● Look for consolidation which can indicate lung disease e.g. tumour, infection, pulmonary oedema, pneumonia (pus) and haemorrhage Look for fissure displacement which indicates zone collapse lung cavities ABSENCE OF LUNG MARKINGS INDICATES A PNEUMOTHORAX The pleura should not be visible Pleural thickening indicates a mesothelioma *TreatmentCirculation Heart size: measure cardiothoracic ratio. On a normal PA film the cardiothoracic ratio should not exceed 0.5 Heart borders – R) border is R) atrium, L) border is L) ventricle & atrium Heart shape Heart position - should be ⅓ to the right and ⅔ to the left Look at the hilar vessels again! ● Can you see them clearly on both sides? ○ are they at a similar height? ○ can you see a preserved hilar point bilaterally? Interesting case on this later!Disability Check for any bony pathology (fracture or metastasis). Trace along each posterior (horizontal) rib on one side of the chest. Repeat it on the other side and also look at the lateral and anterior ribs. Carefully look at the clavicles and shoulders and look for any fractures or bony anomalies. Check the vertebral bodies ○ are they all rectangular and of a similar height? ○ can you see 2 pedicles per vertebral body? ○ are there disc spaces? The right hemidiaphragm should be higher than the left Look for PNEUMOPERITONEUM which is where air accumulates under the dia[hragm and the presence of free air is visible. This is an emergency: always escalate Look for costophrenic blunting which can be caused by lung hyperinflation, consolidation and pleural effusions Gastric bubbleExtras ● Aortic knuckle Tubes, lines, artificial heart valves and pacemakers ● Nasogastric tube placement is something you’ll often be asked to assess on a chest X-ray to confirm safe placement for feeding. See our NG tube placement guide for more details. ● Various tubes and cables will be visible as radio-opaque lines on the chest X-ray (e.g. central line, ECG cables). ● Artificial heart valves typically appear as ring-shaped structures on a chest X-ray within the region of the heart (e.g. aortic valve replacement). ● Pacemakers typically appear as a radio-opaque disc or oval in the infraclavicular region connected to pacemaker wires which are positioned within the heart. ● ETT, CVP line, NG tube, PA catheters ● ECG electrodes, PICC line, chest tube ● PPM, AIDC, metalwork ● APICES ● Soft tissueCaseOne A 50 year old regular Emergency Department presenter with a history ETOH excess presents with a few weeks appendicectomyed and coughing up small amounts of blood. He has a past history of pancreatitis andCaseTwo Mrs Jones is a 72 year old lifelong non-smoker. She has recently been given a diagnosis of ovarian carcinoma which was discovered after a history of several months of vague abdominal symptoms. She has not yet received any active treatment. Over the last few days she has become progressively weak and complains of shortness of breath and is now unable to lie flat or to walk upstairs. On examination she has a tender and distended abdomen and reduced breath sounds on the right side of the chest. To confirm your clinical findings you have requested a chest X-ray which you will see on the next pageAfter a procedure, she develops a complication What has happened?CaseThree Lifelong smoker. A chronic cough and shortness of breath The lungs are hyperinflated Emphysematous changes in both upper lobesCaseFour He develops purulent sputum and experiences gradual weight lossECG. On examination the doctor reports a dull percussion note and increased vocal resonance A CXR is performed. What are the findings and likely diagnosis? How can this be managed?CaseFiveCaseFiveExamination Inspection Palpation Percussion AuscultationInspection General Inspection ● From the foot of the bed: cough, pallor, symmetrical chest movement ● Observe from the foot of the patient’s bed ● Do they look well/unwell? ● Consider if they are alert, comfortable, breathless ● Look for cachexic (malignancy, emphysema) or cushingoid (steroid use) ● Observe the patient’s breathing ○ Note any use of accessory muscles (COPD, pleural effusion, pneumothorax, severe asthma) ○ Pursed-lip breathing (prevents bronchial wall collapse by keeping airway pressure high in severe airway obstruction/emphysema) ● Listen for breathing noises ○ Speech abnormalities (e.g. in recurrent laryngeal nerve palsy) ○ Stridor (large airway obstruction e.g. mediastinal masses, bronchial carcinoma, retrosternal thyroid) ○ Wheeze ○ Cough (dry/productive/bovine) ○ Prolonged expiratory phase (asthma, COPD) ○ Clicks (bronchiectasis) ○ Gurgling (airway secretions) ● Around the bed: oxygen, medication (e.g. inhalers, nebulisers), sputum pots (look at sputum), cigarettesInspection General Inspection ● From the foot of the bed: cough, pallor, symmetrical chest movement ● Observe from the foot of the patient’s bed ● Do they look well/unwell? ● Consider if they are alert, comfortable, breathless ● Look for cachexic (malignancy, emphysema) or cushingoid (steroid use) ● Observe the patient’s breathing ○ Note any use of accessory muscles (COPD, pleural effusion, pneumothorax, severe asthma) ○ Pursed-lip breathing (prevents bronchial wall collapse by keeping airway pressure high in severe airway obstruction/emphysema) ● Listen for breathing noises ○ Speech abnormalities (e.g. in recurrent laryngeal nerve palsy) ○ Stridor (large airway obstruction e.g. mediastinal masses, bronchial carcinoma, retrosternal thyroid) ○ Wheeze ○ Cough (dry/productive/bovine) ○ Prolonged expiratory phase (asthma, COPD) ○ Clicks (bronchiectasis) ○ Gurgling (airway secretions) ● Around the bed: oxygen, medication (e.g. inhalers, nebulisers), sputum pots (look at sputum), cigarettesInspection General Inspection ● From the foot of the bed: cough, pallor, symmetrical chest movement ● Examine for tremors ○ Fine tremor: patient should hold arms out straight, with their fingers spread (fine tremor may be caused by β2 agonists) ○ Asterixis (flapping tremor): patient should hold their arms out straight, with their wrists ‘cocked bac2’ (flap = CO retention) ● Check perfusion ○ Look for peripheral cyanosis (hypoxia or hypoperfusion) ○ Check their capillary refill by pressing for 5 seconds then releasing the pressure and observe how long it takes for perfusion to return (>2 seconds is classed as hypoperfusion) ○ Are there hands sweaty/warm/clammy? (CO re2ention) ○ Look for small muscle wasting (Pancoast tumour) ● Nails ○ Look for clubbing by asking the patient to place their two index finger nails together – Schamroth window test (idiopathic pulmonary fibrosis, lung cancer, CF, bronchiectasis) ○ Check for tar-stained fingers (smoker) ● Radial pulse ○ Calculate rate over 30 seconds and also note rhythm (tachycardia may indicate: hypoxia in severe asthma or COPD, PE or infection) and bounding pulseInspection ○ Cushingoid features(steroid use) ○ Plethoric (secondary polycythaemia;Cushing’s syndrome; superior vena cava obstruction if facial swelling) ○ Features of autoimmune disease, e.g. telangiectasia/microstomia (systemic sclerosis), butterfly rash (SLE), lupus pernio (sarcoid), lupus vulgaris (TB) ● Eyes ○ Conjunctival pallor and horner’s syndrome ● Mouth: look for central cyanosis under tongue (hypoxia) ● Neck ○ JVP ○ Trachealdeviation: place your right hand’s index and ring fingers on each clavicle head. Roll your middle finger over the trachea in the sternal notch. (Pneumothorax pushes to contralateral side; collapsed lung pulls to ipsilateral side.) ○ Cricosternal distance and tracheal tug: place your right hand’s index on the inferior border of the cricoid. Now place subsequent fingers in the midline until you reach the sternal notch (<3 fingers = lung hyperinflation).Note reduction in inspiration (‘tracheal tug’). ● Inspect the chest closely, look at: ○ Chest wall ■ Scars (look under arms as well as on back), Skin changes, trauma and radiation tattoos ■ Deformities (pectus carinatum may be related to childhood respiratory disease; pectus excavatum may be related to connective tissue disease; barrel chest in emphysema or COPD) ■ Kyphosis/scoliosis (restrict chest movements) ○ Chest wall movements ■ Mainly upwards (emphysema) ■ Asymmetrical (fibrosis, collapsed lung, pneumonectomy,pleural effusion, pneumothorax) ○ Breathing ■ In-drawing of intercostal muscles (generalised = hyperinflation)Palpation ○ Supramammary and inframammary chest wall expansion: grip very hard around rib cage with thumbs in the air almost touching in expiration. Watch thumbs move away from each other during inspiration (normally ≥5cm). ○ Feel for RV heave by placing the heel of your right hand over the patient’s left lower parasternal edge with a straight elbow (pulmonary hypertension)Percussion ○ Compare left with right – start above clavicles and progress down to axilla ■ Normally resonant ■ Dull = consolidation or collapse ■ Stony dull = pleural effusion ■ Hyperresonant = increased air space, e.g. in pneumothorax or emphysemaAuscultationandrest ● Ask patient to breathe in and out deeply through their open mouth. Compare sides in turn, starting in supraclavicular area and ending in axillae. ● Vocal resonance: listen in all areas again while the patient repeats ‘ninety-nine’ (increased resonance = consolidation; decreased resonance = effusion/pneumothorax) ● Listen for loud S2 over pulmonary valve area (loud pulmonary S2 = pulmonary hypertension) ● Repeat all on back: now ask patient to sit over bedside with crossed arms and percuss, auscultate and assess vocal resonance again on the back ● Cervical lymph nodes: examine for cervical lymphadenopathy from posteriorly while the patient is still sitting forward (infection, carcinoma, lymphoma, sarcoidosis) ● Legs ○ Examine for peripheral oedema by pushing over the tibia for 10 seconds, then run finger over feeling for indent (cor pulmonale) ○ Feel calves (swollen/tender = DVT)ToComplete ● Thank patient and restore clothing ● ‘To complete my examination, I would like to review the observations chart (particularly to see oxygen saturations), and measure peak flow (if asthmatic).’ ● Summarise and suggest further investigations you would consider after a full historyResources ● OSCE Blogspot THANK YOU FOR LISTENING! 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