Reading CXRs

[username456789]

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is stupid. And I'm just talking about the very basics. I don't get how anyone sees that "oh that's the main pulmonary artery" or "there's the left main stem bronchus." Particularly the latter, I'm pretty sure people are just making up.

That is all. End mid-night rant.

 

[ShyRem]

You need more practice.

 

[sweetpotato]

I remember hearing my instructor say, "reading Chest X-Rays is more of an art than a science..."

That's when I knew that CXR interpretations could be iffy sometimes.

 

[engineeredout]

DOn't worry, I feel the same way. Someone looks at a CXR and goes "HAY THATS PULMONARY INFILTRATE" and I'm just thinking that it looks the same as every other one I've seen.

 

[dienekes88]

As it was explained to me...

Part of it is knowing where to look.

If you see something that looks like a Left Main Stem where the Left Main Stem is supposed to be... it's probably a Left Main Stem.

 

[Sol Rosenberg]

Just keep practicing and stick with it. I thought the same at first, but I felt real proud of myself (and very surprised) when I [correctly] picked out a visible azygous vein on one the other day. There is definitely valuable information to be found in CXRs.

 

[dikoerastenie]

I agree it's bull****.

 

[da8s0859q]

I agree it's bull****.

I did not know that CXRs are bull****.

 

[Rendar5]

yeah, totally BS, it never tells you if there's pneumonia, pulmonary fibrosis, dilated cardiomyopathy, lung Ca, septic emboli from endocarditis, COPD, pneumomediastinum, pneumoperitoneum, broken ribs or clavicles, history of sternotomy, pulmonary congestion, pleural effusions, etc.

Honestly, practice makes perfect, and you realize this when you start independently coming to the same reads as your colleagues.

 

[Forthegood]

Sounds like your anatomy needs some touching up. Cross sections are about you knowing the anatomy and then cutting a slice. If you can imagine it, then you will understand the cxr.

I learned it this way. For an unfamiliar cxr, first, find a big structure that is obvious to the point that nobody could screw it up. Then, move sideways and think, what is lateral to the descending aorta (or whatever). Then you continue to do that mediolaterally and anteroposteriorly. If you notice something that just shouldn't be there, or doesn't look like the surrounding tissue of the same sort, then that may be a pathology.

Bones, major arteries, lobes of the brain/lungs are good starting points if available.

What separates you from the resident who just posted above is PRACTICE. That person has seen thousands where you have seen dozens. After a while, if you practice finding structures on them, and you learn your anatomy (not just memorize it), then you will get good at them too. It is just tough when you are first learning the body in 3 dimensions in your mind, to apply that information by flipping it and slicing it.

 

[MossPoh]

There is an art to reading chest radiographs well, just like any other imaging study. It takes practices. When you look at eyetracking studies you get to see how disorganized a med student looks at the CXR compared to a family physician and how erratic that FP looks relative to a radiologist. There is even a difference between many radiologists and when they were trained. Watch a radiologist who has been reading these images since the mid-60s and you will be amazed at the speed and accuracy they can do it with.

Just like palpation, ausculatation and everything else, it takes practice.

 

[Podalarius]

You need more practice.

I know it's important, I honestly do but we're talking about practice. We're talking about practice man. We're talking about practice. We're talking about practice. We're not talking about the game. We're talking about practice. When you come to the arena, and you see me play, you've seen me play right, you've seen me give everything I've got, but we're talking about practice right now.

Happy New Year!

 

[rahulb]

i did a lecture on thoracic trauma recently. here are some images from my powerpoint:

of course a lot of the time you're going to be looking at crappy portable CXrs or over/underpenetrated films.

Systematic Method of Viewing
A systematic method should be used to examine
chest radiographs.
1. Soft tissues
2. Trachea
3. Bony thorax/ribs
4. Intercostal spaces
5. Diaphragm
6. Structures below diaphragm
7. Pleural surfaces
8. Mediastinum
9. Hila
10. Lung fields
11. Support catheters, tubes, wires, and lines

Following is the suggested order for viewing
lateral view structures,
1. Bones
2. Mediastinum
3. Hilum
4. Heart
5. Diaphragm/pleura
6. Lung fields
7. Support catheters, tubes, wires, and lines

 

[rahulb]

here are some more images. key is to practice as was stated before. when i have a patient i go to the imaging software and look at all their scans before i read the radio report.

i have a 30 page article with a ton of additional images if someone has a host for a pdf.

so yea CXrs can give you quite a bit of info

 

[username456789]

Fantastic series of posts, thank you. Obviously my recent post was made out of frustration (I'm an M2 and we were doing some CXR reading, nothing too advanced at all). What I think I have the most trouble with is identifying the bronchi and some of the pulmonary vessels.

For instance, in the images pointing to the carina, I really don't know that I see any identifiable difference in density . . . in fact, I'm not sure I even see the trachea down to the point, or the mainstem bronchi beyond that branch point (Figure 8).

And in Figure 9, to me it looks like the trachea is deviated to the right (patient's right), yet it says left, so I'm generally puzzled by CXRs I think.

 

[Rendar5]

Fantastic series of posts, thank you. Obviously my recent post was made out of frustration (I'm an M2 and we were doing some CXR reading, nothing too advanced at all). What I think I have the most trouble with is identifying the bronchi and some of the pulmonary vessels.

For instance, in the images pointing to the carina, I really don't know that I see any identifiable difference in density . . . in fact, I'm not sure I even see the trachea down to the point, or the mainstem bronchi beyond that branch point (Figure 8).

And in Figure 9, to me it looks like the trachea is deviated to the right (patient's right), yet it says left, so I'm generally puzzled by CXRs I think.

Figure 9 is a poor picture of leftward deviation. the trachea looks centered to me, until you realize that the patient is rotated to the right, sow hat looks centered is actually leftward. I'm sure a radiologist would be astute enough to call that shift, but it likely doesn't matter enough clinically on its own for you to care. a radiologist should care as it may allow him to provide you with more information when you request it. I would personally miss that and a couple of other signs on that CXR if it makes you feel better. If I miscall it, I have a radiologist to back me up.

 

[mjl1717]

Thanks for sharing rahulb!

 

[NTF]

I have to admit I identify a lot with the frustration of this thread. Sometimes I feel like such a total poser and think to myself, "Are people's lives seriously gonna depend on me?" People keep telling me that eventually it all coalesces in your head but it still drives me crazy when I forget stuff that I learned just a month ago.