|Check patient details (name, date, birth, hospital number).|||
|Check the date of the X-ray|||
|Identify the projection of the X-ray|||
|Assess technical quality of X-ray (rotation, inspiration, penetration)|||
|Describe any obvious abnormality|||
|Site (lung and zone/lobe)|||
|Size (if relevant)|||
|Shape (if relevant)|||
Systematic Review of the X-ray
|Position of trachea|||
|Assessment of lungs|||
|Size and appearance of hila|||
|Assess for cardiomegaly|||
|Assess cardiac and mediastinal borders and cardiophrenic angles|||
|Position and appearance of hemidiaphragms|||
|Evidence of pneumoperitoneum (free air under the diaphragm)|||
|Assess the imaged skeleton|||
|Assess the imaged soft tissues (e.g. surgical emphysema, mastectomy)|||
|Comment on iatrogenic abnormalities|||
|Look at review areas (apices, hila, behind the heart, costrophrenic angles, under the diaphragm)|||
|Review relevant previous imaging if appropriate|||
|Provide a differential diagnosis where appropriate|||
|Suggest further appropriate imaging/investigations if relevant|||
In Summary – This chest X-ray shows a largeright pneumothorax. There is no evidence of associated tension. There is no underlying cause discernible on this X-ray, suggesting that this is a primary spontaneous pneumothorax
Present Your Findings
“This is a PA chest X-ray of an adult.There are no identifying markings – I would like to ensure that this is the correct patient, and to check when the X-ray was taken.
The patient is slightly rotated; this is otherwise a technically adequate X-ray with adequate penetration and good inspiratory effort. No important areas are cut off at the edges of the film.
There is an obvious abnormality in the right hemithorax: a line can clearly be seen with absence of lung markings beyond it, in keeping with a lung edge.
The aerated right lung is otherwise normal in appearance.
The trachea and mediastinum are not deviated, and the right hemidiaphragm is not flattened.
Reviewing the rest of the film, the left lung is normal.
The heart is not enlarged, heartborders are clear, and there is no abnormality visible behind the heart.
There is minor blunting of the costophrenic angles which may represent small volumes of pleural effusion.
The hemidiaphragms are clear.
There is no free air under the diaphragm.
There are no soft tissue abnormalities or fractures; in particular, no rib fractures are visible.”
Questions for Candidate
- Which of the following are risk factors for a primary spontaneous pneumothorax?
- Male gender
- Marfan’s syndrome
- Which of the following clinical findings would be supportive of a large simple right sided pneumothorax?
- Central trachea. Dull percussion and reduced air entry on the right side of the chest
- Central trachea. Dull percussion with bronchial breathing and crackles on the right side of the chest
- Central trachea. Hyperresonant percussion and reduced air entry on the right side of the chest
- Central trachea. Hyperresonant percussion and reduced air entry onthe left side of the chest
- Trachea deviated to the left. Hyperresonant percussion and reduced air entry on the right side of the chest. Hypotensive, tachycardic
- Which of the following are appropriate differential diagnoses for a patient who presents with sudden breathlessness?
- Pulmonary embolus
- Heart failure