OSCE-Aid Revision Workshops: Data interpretation
Data Interpretation: Interpreting a Chest Radiograph
Example 1
Student instructions
To be read out loud by the student to the group
A 76 year old man presents to A&E after having had a fall at home. He is complaining of
pain over his right side, has a respiratory rate of 24 and saturations of 99% on room air. He
is haemodynamically stable. Please describe his chest radiograph, give your differential
diagnosis and then answer the questions below.
Questions;
1. How would you manage this condition?
2. What further information would you like to know about the history?
3. What further interventions would you advise?
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OSCE-Aid Revision Workshops: Data interpretation
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OSCE-Aid Revision Workshops: Data interpretation
Example 1
Model answer
This is a PA erect chest radiograph taken of John Jackson DOB, HN, on the from 5 January
2015.
View- adequate view showing the apices and CPAs.
Rotation- slightly rotated,
Inspiratory effort it poor.
Penetration adequate.
Most obvious abnormality: multiple right-sided rib fractures with increased lucency at the
right apex, but I will now go through this systematically.
A: The trachea is central
B: apices- on the right side there is increased lucency in the upper zone with absent lung
markings. The left lung field is normal, including the apex and behind the heart. There is no
pleural thickening. The costophrenic angle (CPA) appears blunted bilaterally. The hilar
appear normal and the cardiophrenic angles are clear.
C: The heart appears a normal size and there is no mediastinal widening.
D: The diaphragms are clear, at normal level and there is no free air under the diaphragm.
E:
 Bones: there appear to be multiple rib fractures on the right side- this involves ribs 3
to 7.
 Soft tissues: there is no abnormal soft tissue visible.
 Lines: And there are no lines visible.
Summary: In summary this is a PA chest radiograph taken of John Jackson on the 5/1/2015
with the main positive findings being that rib 3 to 7 are fractures on the right side, with a
probably resulting pneumothorax on the right side. There is additionally a small pleural
effusion or haemothorax on the left and right hand sides.
Answers to questions:
1. DR ABCDE, then full history and examination. Investigation would include bedside testsregular observations, bloods including FBC, UE and clotting, ABG if dyspnoeic and
investigation for falls including ECG and lying and standing BP. Management would
include analgesia, oxygen and definitive management for pneumothorax. This is a
traumatic pneumothorax and therefore is likely to require a chest drain, observation in
hospital and early involvement of cardiothoracic surgeons.
2. Important points in the history would include:



Full falls history including what happened before, during and after the fall eg
preceding symptoms, mechanism of fall, loss of consciousness (LOC), length of time
on the floor, how got to hospital and any other injuries particularly head injury, any
post ictal symptoms. Medication and previous falls history would be particularly
important.
Full medical history including diagnosis of lung disease and osteoporosis.
Determine capacity for recovery: AMTS, baseline function and full social history
including whether support at home.
3. OT/PT, falls clinic.
Example 2
Student instructions
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OSCE-Aid Revision Workshops: Data interpretation
To be read out loud by the student to the group
A 69 year old woman presents to A&E complaining of shortness of breath. Please describe
her chest radiograph, give your differential diagnosis and then answer the questions below.
Kylie Minogue, DOB 17/6/1950
HN: 45678789
Date of study: 3/1/2016 11am. PA erect.
Questions:
1. What further investigations would you order?
2. What treatment would you offer this patient?
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OSCE-Aid Revision Workshops: Data interpretation
Example 2
Model answer
This is a PA erect chest radiograph taken of Kylie Monogue, DOB 17/6/1950 HN 45678789,
on 3rd Jan 2016.
View: The radiograph shows an adequate view including the apices and CPAs.
R: the film is not rotated and shows a
I: good inspiratory effort.
P: the film is underpenetrated as it is not possible to see the spinous process behind the
cardiac shadow.
The most obvious abnormality is that there is cardiomegaly and there is bilateral
opacification in the middle and lower zones. However I will now review the radiograph
systematically.
A: trachea is central
B: the apices appear clear but there is patchy opacification in the middle and lower zones,
this appears denser towards the bases. It is possible to make our kerley B lines bilaterally.
Upper zone vasculature is prominent. There doesn’t appear to be blunting of the
costophrenic angles although I cannot fully make out the CPA on the left side. The hilar do
not appear bulky, there is not pleural thickening or absence of lung markings peripherally.
The cardiophrenic angles although hazy are visible.
C: there is cardiomegaly with the heart being > 50% of the cardiothoracic ratio.
D: diaphragms are visible bilaterally and at a normal level. There is no free air under the
diaphragm.
E:
- There are no obvious bony fractures.
- There are no abnormal soft tissue findings.
- There are no additional lines.
In summary, this is a PA chest radiograph of Kylie Minogue taken on the 3rd Jan 2016. The
main positive findings are cardiomegaly with mid to lower zone patchy pacification and
kerley B lines. This would be consistent with a diagnosis of pulmonary oedema due to heart
failure.
Questions:
1. I would manage this patient according to an ABCDE approach. I would then take a
history and do a full examination…
Bedside tests: observations, ECG, ABG, sputum sample, urine output (if diuresing),
daily weights
Bloods: FBC, U&Es, ?troponin, BNP, lipids, albumin
Imaging: ECHO for ejection fraction
2. DR ABCDE, fluid restriction
Acute treatment = LMNOP
Loop diuretics (Furosemide, Why does this work so quickly? Symptoms relief is
achieved before diuresis due to its vasodilatory effects)
Morphine (for respiratory distress and vasodilation)
Nitrates (GTN infusion)
Oxygen (high flow if not retaining CO2)
Position upright
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OSCE-Aid Revision Workshops: Data interpretation
Example 1 (large)- PA erect
Jackson, John 96443582 DOB 1/1/1960
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OSCE-Aid Revision Workshops: Data interpretation
Jackson, John 96443582
Study date 05/01/2015
PA erect
Study date 05/01/2016 12pm
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OSCE-Aid Revision Workshops: Data interpretation
Example 2 (large)- PA erect
Kylie Minogue, DOB 17/6/1950
HN: 45678789
Date of study: 3/1/2016 11am
Presenting and interpreting a CXR
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OSCE-Aid Revision Workshops: Data interpretation
Useful vocabulary: density, opacity, lucency, silhouette, shadow, reticular, nodular, irregular,
regular, patchy, uniform, heterogenous, wedge-shaped, circular, diffuse, consolidation
Acronyms: RIP ABCDE
Steps
Details of the radiograph
View: The radiograph should cover from the lung apices to the costophrenic angles.
Rotation: The medial borders of the clavicles should be equidistant from a spinous process.
Inspiration: With adequate inspiration, the diaphragm should be intersected by the 5th to
7th anterior rib in the mid-clavicular line. >7 ribs= hyperexpansion.
Penetration: Vertebral bodies should be visible behind the cardiac shadow. Too whiteunderpenetrated. Too black- over penetrated.
Obvious abnormality: a description not a diagnosis!
AIRWAY:
1. Trachea deviated? Which direction? Is it being pulled towards
collapse/consolidation, away from pneumothorax/effusion?
BREATHING:
1. Systematically report all areas of the lung fields using the
vocabulary above: apex; upper, middle and lower zones (NB different
to lobes); behind the heart. What borders are effaced:
hemidiaphragm? Right heart border?
2. Report the pleura: Do the lung markings go all the way to the edge
of the thoracic cavity? Are the costophrenic angles blunted? Is there
pleural thickening?
3. Report the hilum: bulky, bat wing
CARDIAC:
1. Heart size: Less than 50% of thoracic diameter on PA film
2. Heart position: displaced in effusion/collapse
3. Heart shape and borders: (right border = right atrium, left border =
left atrium left ventricle, angle of the carina = left atrium)
4. Mediastinal width should be <8cm on PA film. Enlarged in aortic
dissection/unfolded aortic arch
DIAPHRAGM:
1. Shape and position: flat in COPD, raised in diaphragmatic paralysis
2. Air under the diaphragm in perforation/post surgery
EXTRAS:
1. Bones: Check them all for fractures, decalcification, inferior rib
notching (coarctation of the aorta)
2. Soft tissue: surgical emphysema, swellings, calcification (esp.
breast), masses
3. Lines, pace-makers, ICDs etc
Summary: main positive findings (still as a description). This could be consistent with a
diagnosis of ….. A differential would include…
Further examples:
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OSCE-Aid Revision Workshops: Data interpretation
Remember with respect to densities, bone > soft tissue/blood/NG feed/lego > fat > air
Practice presenting the following CXRs with a systematic approach. The main findings and
diagnoses are listed as well as important descriptive terms that should be used.
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Demographics.
The view is adequate showing the apices and costophrenic angles on both sides
although the very tip of the right costophrenic angle has been cut off.
There is no rotation
There is a good inspiratory effort and
The image is slightly underpenetrated with the spinous processes behind the heart
shadow bwing obscured.
The main abnormality seen is tracheal deviation to the left and a double heart border,
however I will now go on to describe the radiograph systematically.
The trachea is deviated to the left.
The lung fields appear normal bilaterally, there is no blunting of the costophrenic
angles there is no hilar bulking, no pleural thickening and no absence of lung
markings.
The left heart border appears to have a double border and there may be mediastinal
shifting to the left. There does not appear to be cardiomegaly although it is difficult to
say with certainty due to the double heart border.
The diaphragms are visible on both sides although the left hemidiaphragm does not
appear to reach the spinous processes. They are not raised and there is no free air
under the diaphragm.
There are no clear bony injuries, damage to soft tissues and there are no lines or
devices.
In summary, this is a chest radiograph taken of …. On …. At…. The positive findings
are a deviated trachea, double heart border consistent with the ‘sail sign’ and left
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OSCE-Aid Revision Workshops: Data interpretation
hemidiaphragm that does not meet the spinous processes. Overall this is consistent
with a diagnosis of left lower lobe collapse.
COLLAPSE:
A uniform opacification. Pulls structures towards it because of volume loss
Right lobar collapses: Lower loses hemidiaphragm, middle loses right heart border, upper
causes wedge against SVC border
Left lobar collapses: Lower produces double left heart border or ‘sail sign’, upper lobe loss of
left heart border
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-
Demographics
View is adequate with apices and costohrenic angles visible.
Film is not rotated.
Inspiratory effort is difficult to determine although 5 anterior ribs are just visible on the
right side
The image is over penetrated making visualization of the lung markings difficult.
The obvious abnormality is a dense, homogenous opacification of the middle and
lower zones on the left side. There appears to be a fluid level at the top of this,
however I will now interpret the radiograph systematically.
The trachea appears deviated to the right side.
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OSCE-Aid Revision Workshops: Data interpretation
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The apices appear normal on both sides however there is the previously mentioned
dense homogenous opacification in the middle and lower zones on the left side. This
appears to have a fluid level at the upper borders and there is blunting of the
costophrenic angle on the left side. The lung fields on the right side appear normal
and the costophrenic angle is clear. The cardiophrenic angle on the right is clear but
obscured on the left, and the hilar do not appear bulky. There is no pleural thickening
and no clear loss of lung markings although the image is poor penetrated.
I am unable to interpret the size of the heart as the borders are obscured on the left
side.
The diaphragm on the left is obscured and on the right appears that is may be raised
although I am unable to ascertain this for certain as I cannot see the left
hemidiaphragm.
There are no obvious bony injuries, soft tissue abnormalities or lines.
In summary, this is a chest radiograph taken of ….. at…. On ….. The main positive
findings are homogenous opacification obscuring the middle and lower left lung
fields, with a meniscus, blunting of the left costophrenic angle and tracheal deviation
to the R. This is consistent with a diagnosis of L sided pleural effusion N.b.: know
your causes of unilateral and bilateral pleural effusions
Demographics
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OSCE-Aid Revision Workshops: Data interpretation
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View is inadequate with the tip of the costophrenic angle on the left being cut out,
however, I am able to visualise the apices, right costophrenic angle and most of the
left costophrenic angle.
There is some rotation of the film with the clavicles not equidistant from the spinous
processes
There is good inspiratory effort
The image appears slightly over penetrated.
The most obvious abnormalities is that the is heterogeneous opacification obscuring
the right heart border. However, I will now review the radiograph systematically.
The apices appear normal bilaterally. There is a focal heterogeneous opacification in
the right lower zone that is obscuring the right heart border and is demarcated
superiorly by the horizontal fissure The right hemidiaphram is also obscured where it
would be meeting the vertebral bodies. The left lung field appears normal throughout.
There is no blunting of the costophrenic angles, there may be hilar bulking on the
right although this is difficult to ascertain as the area is obscured by the opacification,
and there is no pleural thickening or loss of lung markings. There is blunting of the
cardiophrenic angle on the right.
The heart is normal in size.
The hemidiaphragms are not raised and there is no free air underneath them.
There is no obvious bony injury, abnormality of soft tissues or extra lines.
In summary this is a PA chest radiograph taken of…. On …. At…. Positive findings
are that there is a heterogeneous opacification in the right lower zone that is
obscuring the right heart border and demarcated superiorly by the horizontal fissure.
This picture would be consistent with a right middle lobe consolidation and diagnosis
of pneumonia.
CONSOLIDATION:
Area of increased density due to presence of pus/water/cells/blood/NG feed etc etc.
Can be diffuse (eg pulmonary oedema) or focal (eg pneumonia)
If focal, often with air bronchograms (patent bronchioles penetrating the affected area)
Right sided consolidation: Lower obscures right hemidiaphragm, middle obscures right heart
border, upper butts against horizontal fissure
Left sided consolidation (more diffuse than right): Lower lobe obscures left
hemidiaphragm/behind the heart, upper lobe spares the diaphragm
Look at www.radiologymasterclass.co.uk for more practice.
Images used from www.radiologymasterclass.co.uk
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