Start: Hold hands out (look for tremor + inspect) → Cap refill → Turn over → Clubbing → CO2 flap + HR + RR → Offer BP

• 1. Introduction
• 2. Postion & Exposure
• 3. General Inspection
• 4. Hands & Arms
• 5. Face
• 6. Neck
• 7. Chest Inspection
• 8. Chest Palpation
• 9. Chest Percussion
• 10. Chest Auscultation
• 11. Back
• 12. Completing Examination

• Mark Scheme

CXR Interpretation

• This is a PA/AP chest radiograph of Mr/Mrs XX, Date of Birth [X]. Taken on [This date and time].
• In terms of the quality of the film, there is minimal rotation, adequate inspiration, penetration and exposure.
  • Rotation = medial aspect of each clavicle should be equidistant from the spinous processes
  • Inspiration = 5-6 anterior ribs
  • Penetration = can see vertebral bodies behind heart
  • Exposure = left hemidiaphragm should be visible to the spine
• Comment on most obvious abnormality
• Looking at the airways, the trachea is central and not deviated
• The hilar region is normal (unilateral enlargement = malignancy, bilateral = sarcoidosis)
• Looking at the lung edges, there is no loss of lung markings or indication of a pneumothorax
• Looking at the lung fields they are clear (if abnormality - say which zone out of 3)
  • Alveolar/Interstitial Shadowing → heart failure (pulmonary oedema) or pneumonia
  • Reticulonodular Shadowing → pulmonary fibrosis
  • Homogenous Shadowing → pleural effusion or collapse
• Looking at the heart, the cardiothoracic ratio is normal (can only comment in PA film) and heart borders are clear (loss of right heart border = right middle lobe issue, loss of left heart border = left lingula issue)
• Looking at the diaphragm, there is no subdiaphragmatic free gas (abdo perforation) and no blunting of costophrenic angles (pleural effusion or consolidation)
• There are no soft tissue or bone abnormalities
• To complete my analysis, I would ideally examine previous films and take a full history

Consolidation = non-uniform soft tissue density (blotchy white)

Collapse = uniform soft tissue density (pure white), structures move towards empty space (ie. heart and trachea)

Effusion = uniform soft tissue density (pure white), meniscus sign, trachea and heart pushed away

Pneumothorax = uniform air density (black - loss of lung markings)

COPD → hyperinflation, flat hemi-diaphragms, bullae (black lesions)

Heart Failure → alveolar shadowing, kerley B-lines, cardiomegaly, diversion of blood to upper lobe, effusion (blunted costophrenic angles)

Most Common CXRs

Pneumonia = dense or patchy consolidation. Loss of borders can indicate lobes affected → diaphragm (left and right lower lobes), right heart border (right middle lobe), left heart border (left lingula).

• RML Pneumonia
• RLL Pneumonia

Pleural Effusion = loss of costophrenic angles, homogenous opacification, fluid level causes meniscus, push trachea away

• Pleural Effusion

Tension Pneumothorax = loss of lung markings, tension causes mediastinal/tracheal deviation away (Tx = needle decompression into 2nd ICS MCL)

• Tension Pneumothorax

Extras

• Left Lung Collapse (Pulls trachea towards)
• Bilateral Hilar Lymphadenopathy
• Heart Failure
• Interstitial Lung Disease (reticulo-nodular shadowing)
• Pneumoperitoneum