Megan Lung Pulmonology W3D4

Today marked my last day in pulmonology. Dr. Huang went over chest x-rays with us and showed us systematic ways to review CXRs so that we do not miss any possible lesions.

First, we have to evaluate the quality of the CXR.

• Make sure the CXR is big enough and that the peripheral parts are not cropped out, such as the neck or diaphragm.
• CXR should be done on inspiration. You can check by looking at what rib the diaphragm is located at. The diaphragm should be located at the end of anterior rib 6 and posterior rib 10. For obese patients this might be an inaccurate way to assess if the patient is inspiring.
• Make sure the position of the patient is not rotated or uneven. You can do this by looking at the spine processes to make sure they are straight and lined up.
• Exposure level: should be able to see the trachea and carina, should be able to see lung markings behind the heart and diaphragm. This is important because you can find lesions present there and if you are unable to locate these lung markings, you may miss the lesion. Lung markings should expand throughout the lung in a normal CXR, if not it may be under exposed.

There are many ways to look at a CXR. Some like to go from peripheral to to medial. Dr. Huang's systemic scan goes like this:

1. Check if left and right label, may be situs inversus! Check for the breasts if a female pt.

2. Airway, air, apex. For the airway there could be a foreign body, and endobronchial lesion, or cuff herniation. For abnormalities in air, there could be a pneumothorax or pneumomediastinum. In the apex there could be a pancoast tumor or an azygous fissure.

3. Bone, breast.  Check for any fractures. For the spine, check for bamboo spine, TB spine, at the thoracolumbar region for any protruding mass. For the breast, check for masectomy or augmentation.

4. Cardiac

5. Diaphragm

6. Extrapulmonary.  

ABCDE! 

Once a lesion is identified you will try to identify it through

• Hemodynamic, congenital
• Infection
• Inflammation, occupation, exposure, or through some systemic disease
• Neoplasm

In general, when looking at an X-Ray, it is mostly to look for signs and patterns to compare to the clinical symptoms. One cannot diagnose solely with an X-Ray, it is usually one consideration among lab tests and symptoms. I hope to get more practice reading X-rays in the upcoming year!