In this video, a third-year medical student explains how to read and interpret a chest x-ray. The student discusses the process step by step, starting with assessing the quality of the image (rotation, inspiration, projection, and exposure). Then, the student explains the clinical assessment, looking at the airway, breathing, cardiac shadow, diaphragm, and any other abnormalities. Finally, the student demonstrates how to summarize the findings and present them to a supervising doctor. This structured approach helps medical students gain confidence in reading chest x-rays and ensures a thorough evaluation of the image.
Key Insights:
- Reading and presenting a chest x-ray is a common task for medical students and can be intimidating if not practiced beforehand.
- Begin by checking the patient details, such as name, date of birth, and date of the x-ray.
- Assess the quality of the image using the mnemonic „RIPE“ (Rotation, Inspiration, Projection, Exposure).
- When clinically assessing the x-ray, use the ABCDE approach (Airway, Breathing, Cardiac, Diaphragm, Everything else).
- Analyze the trachea, bronchial, lung markings, pleura, heart size, and diaphragm for any abnormalities.
- Combine the information from the x-ray with patient history to come up with a diagnosis and management plan.
- Presentation skills should include summarizing findings and providing a suggested diagnosis based on the x-ray.
- Practice using the mnemonic „RIPE ABCDE“ to interpret any chest x-ray effectively.
Transcript
Now, this is one for all the medical students watching. Today, we’re going to learn how to read a chest x-ray and present it to your consultant on the ward round.
Hi everyone, Oli here. Welcome back to the channel. I’m a third-year medical student at Warwick Medical School in the UK on the Graduate Entry Program. So in this video, we are going to discuss how to read, interpret, and present a chest x-ray, which is one of the most common things you’ll be asked to do as a medical student. But it can be intimidating if you suddenly have to do it, put on the spot, and you’ve not done it before. So the purpose of this video is to go through a standardized, easy-to-remember process for reading and presenting your chest x-rays. And once you get this down, it’s sure to win you some brownie points on the wards and serve you when it comes up in your exams. So let’s just jump right in.
The first thing we’re going to check is the patient details. Are we looking at the right person? So you need to check their name, their date of birth, the date the x-ray was taken, potentially where it was taken. And you may also wish to note that you could compare the imaging you currently have in front of you to any previous images or other information that’s available. It’s also really important to remember before we move on that an x-ray is horizontally mirrored, with the person’s left side being on the right side of the image as you look at it.
So the first part of our process involves assessing the quality of the x-ray image we have, and for this, we use the mnemonic RIGHT. We’ll begin with our „R,“ which stands for rotation. Did the x-rays hit the patient straight on or at an angle of some sort? Ideally, they should have been as straight as possible. The way this is assessed is by looking for the medial parts of the two clavicles and checking that they’re equidistant from the spine. And the spinous processes should also be vertical when you’re looking at these images, or roughly vertical. In this case, it’s not perfect, but you are looking for something grossly abnormal to know that something is wrong.
So „R“ is for rotation. „I“ is for inspiration. How well did the patient breathe in when they were asked to? How good was their inspiratory effort? When we inspire, this stretches the thoracic cavity outwards, which separates all the vessels and soft tissues and things that we want to have a closer look at. An ideal x-ray, we should see at least five to six anterior ribs or nine posterior ribs. We should see the lateral edges of each rib ideally, as well as the costophrenic angle where the diaphragm meets the ribs at the bottom.
So „I“ is for inspiration. „P“ is for projection, and all that tells us is whether the x-ray was taken from anterior to posterior through the patient or posterior to anterior through their back. Most chest x-rays that you’ll see are PA. This is convention normally. And the only reason to think otherwise is if you see the scapula projected over the lung fields or the x-ray is labeled as being AP.
Lastly, „E“ is for exposure. Checking that we can see everything that we need to see. And the way we tell this is whether the vertebrae are visible behind the heart.
So running through our process quickly one more time, we have our „R“ for rotation, „I“ for inspiration, „P“ for projection, and „E“ for exposure. Now look at how much information there is to assess even before we’ve gotten onto any clinical findings.
So now that we’ve assessed the quality of the image, it’s time to actually think about our patient. And the approach we use for this is ABCDE. Now „A“ is for airway. Is the trachea visible, and is it central, or is it being moved away from the midline? If it’s deviated to either side, it stands to reason that it must either be being pushed or pulled by something significant. Pneumothorax or pleural effusion will exert a mass effect and push the trachea away from itself. But in the event of a collapsed lobe or part of the lung, the loss in volume will pull the trachea towards that side. We then need to check the Carina and the bronchi—all those airways. Remember that the right bronchus is more straight and wider than the left, which makes this side more likely for things to go down and cause an aspiration pneumonia. Lastly, we need to check the high-low regions on each side for the lymph nodes and the vascular structures that sit in that area. Bilateral lymphadenopathy in these areas might suggest something like TB or sarcoidosis, with a unilateral swelling of the lymph nodes being more likely to signify cancer.
„B“ is for breathing. So now it’s time to look at the lungs. Remember, normally, that we divide the lungs anatomically into different lobes on a chest x-ray. However, for the purposes of interpretation, we use zones, which divide the lungs into several parts. And this means that if we find any opacity or suspicious-looking thing, it means that we can easily report where it is. For example, here is an image showing a mass in the right middle zone, and here is one showing a left middle zone pneumonia. But if you can’t see any lung markings at all, this should make you highly suspicious of a pneumothorax. And also, it’s important to check the apices, the very tops of each lung before you move on.
Now, also under the breathing category come the pleura, which should not normally be visible. You just need to check the lung markings extend completely to the edges of the lung fields. Abnormally thick pleura layers can be due to things like mesothelioma, or blood might accumulate in that space in the event of something like a hemothorax.
Now, „C“ is for cardiac. And I know a lot of people think that chest x-rays are only to do with breathing problems, but the heart is one of the most important things to assess on a chest x-ray. The first and easiest thing to check about the heart is its size. So it should ideally be less than 50% of the entire thoracic window. If it’s more than that, we would clinically have a case of cardiomegaly, big heart. It’s important to remember that AP x-rays actually exaggerate the size of the heart. So you can only make these cardiomegaly decisions based on a PA x-ray. From here, we just need to check the right atrium and the left ventricle, which make up most of what we can see in the heart border. It would usually be consolidation that might cause some disturbance to these areas.
Nearly there now. „D“ is for the diaphragm. And you should remember that the diaphragm will be slightly higher for most people on the right side due to the presence of the liver directly underneath it. Now, normally, you shouldn’t be able to tell the diaphragm apart from the liver on the right side. But if you see a fluid level in there, you should probably tell someone that’s not ideal. So the first thing we need to check are the costophrenic angles when it comes to the diaphragm, where the diaphragm meets the ribs at the bottom of the image on both sides. This should be well-defined and acute. If this angle is lost or is obviously bigger, this is called costophrenic blunting and is usually a sign that fluid has settled in this space. For example, this might be due to hyperinflation of one or both of the lungs, which we would see in a condition like emphysema.
While we’re looking at the diaphragm, you can also look at the left side to check for the presence of the gastric fundus. And you might see a fluid or gas level there.
Now, „E“ is the catch-all, and „E“ is for everything else. The main things that you’re looking for here are damage to bony structures, such as rib fractures, dislocations of the long bones, lytic lesions, obvious soft tissue damage, or the presence of any extra features that might concern you. Some other completely circumstantial things you might see on a chest x-ray include the wires from a pacemaker, ECG leads, as well as potentially artificial heart valves.
And now we’ve got all our information. We’ve assessed the quality of the image, and we’ve clinically assessed the patient and interpreted the image. So at this point, it’s time to summarize our findings and present them back to our supervising doctor. You should combine any information from the x-ray with other information you already have or anything else you know about the patient that will help you come up with a diagnosis and a management plan.
Now, it’s really important when you’re doing this not to skip steps and not let any overwhelming idea you think you have of the diagnosis take you away from your structure. Your job, at least as far as the x-ray goes, is to say what you see. And even if you have absolutely no idea what’s going on, as many of us don’t, you can still do a good job of presenting the image, which will carry a lot of the marks available when you’re being assessed on this.
So now that we understand everything that we’re looking for, here’s one I prepared earlier, which I’m going to present to you in a way that would be acceptable on most ward rounds or in an MDT meeting. So I’ve got the image for you here. This is the x-ray of Steven Johnson, a 57-year-old male. It was taken on the 4th of November 2019. There are no previous x-rays available for Steven. So just looking at the quality of the image, there is minimal rotation. The clavicles seem equidistant from the midline. Inspiratory effort looks good. I count eight anterior ribs, potentially nine out of push, and the costophrenic angles are visible on both sides. This is a PA x-ray. The exposure is good. I can see vertebral bodies visible behind the heart.
So now we’re on to our clinical assessment. The trachea is deviated towards the right side. The bronchi are obscure and a bit difficult to visualize in this case. The left lung looks normal to me, no obvious consolidation or opacities. There is, however, a large, well-defined opacity in the apical zone of the right lung. The pleura looks normal. There is no evidence of thickening. The cardiac shadow is well-defined and of a normal size. I can visualize the arch of the aorta very easily. The left ventricle and the right atrium are visible as well. There does appear to be a small bulge in the diaphragm on the right side, but this doesn’t look necessarily pathological to me. This could be normal for this patient. It’s difficult to know with no previous imaging. There’s no costophrenic blunting or evidence of fluid in there. The fundus of the stomach, I can see on the left-hand side. So in terms of any other pathology, the only noticeable thing I can see is some erosion of the second and third ribs behind that mass in the apical right lung. Otherwise, the x-ray is unremarkable.
So, to conclude, I’ve reviewed this PA chest x-ray of Steven Johnson, a 57-year-old man taken on the 4th of November. My positive findings are tracheal deviation to the right, as well as a large mass in the apical zone of the right lung with some involvement from the right 2nd and 3rd ribs.
So just to show how you might combine this with a clinical vignette based on this patient, he’s a 40-pack-year smoker with a history and his exam findings of partial ptosis and constricted pupils. I would suggest a tentative diagnosis of a Pancoast tumor, which is an apical lung tumor with some involvement of the sympathetic chain. Other differentials might be a pulmonary met from elsewhere, mesothelioma, or something like primary tuberculosis.
So there you go. Now, I appreciate the way I did that can seem a little bit artificial, a little bit contrived. And it’s absolutely unlikely that you’d be asked to do all of that process at once, particularly when you’ve not done it before. But this is the general idea. Ideally, you would have taken a history from the patient and examined them yourself. And you could then combine any information gained from that with the imaging to inform a diagnosis. And notice that that wasn’t perfect either. I did omit some small details of what I was looking at. But the amount of detail and the things that they want you to go through will very much depend on the consultant or the attending that you’re with. A lot of the time, they’re only going to be interested in the key positive findings. „Well, do you see X? Where is it?“ „It’s in the right apical zone.“ „Okay, good.“ But you might have some who want you to go through that very formulaic approach to say what you see. And having that structure means that you don’t get lost and you don’t miss things, particularly when it comes to an exam.
So you only need to remember RIGHT + ABCDE, and that will get you through interpreting any chest x-ray that you come across.
So thanks very much for watching, guys. I really hope you enjoyed this video. If I can ask you to do me a huge favor, there’s a feedback form associated with this video that will let me know how good the teaching was. I’m really keen to get feedback from you guys and find out how I can improve these videos for the future. So if you fill that out, that will give you access to an Anki deck which you can add to your own study materials and use to test yourself on the basics of chest x-ray interpretation. And I’ll put a few sample diagnoses in there as well. The link to that is in the description below.
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