Xray

Superman has Xray vision. And thus can diagnose pneumonia as well as lift small buildings.

No one ever teaches people how to read X-Rays. And we aren't going to either. That takes a lot of hard work, and you have to look at about a million xrays. What we can tell you, is how to present one, and sound like you know what you are talking about.

The case

• Who - Bloggs, Joe. Date of Birth: 22/04/1946
• When - Taken Tuesday 18th March
• Where - Downstairs in the A&E department
• What - Its a Chest Xray...
• How - ...and its PA
• Why - It was taken because we were worried he had pneumonia

How and why can be difficult. PA means Posterior Anterior, which is the direction the xrays travel through the back to the front. AP means Anterior Posterior, where the plate is at the back, and the rays travel through the front to the back. Why is something to include only if you know why. Don't guess.

Penetration

The quality

You would say "The xray is well penetrated, not rotated and the patient is adequated inflated".

• Penetration - Is the plate had too much juice, or not enough. There are two ways to ensure this, is the trachea visible, and can individual vertebrae be clearly seen. Above right is a sample. The top section is well penetrated (note the trachea, and vertebrae), middle is under penetrated and the bottom over penetrated.
• Rotation - Has the patient been laying straight on when the plate was captured. Often in paediatrics they are off. There are several way to check this, but the main two are: can the bit where the ribs join the spine be seen more on one side than the other; and are the ends of the clavicles equal on each side. In the example on the right, you can see that in the top one, the clavicles are roughly equally visible. In the lower one, the body is clearly turned to the left.
• 

  Rotation
  Inflation - The patient must have inhaled to ensure there is air in the chest. The way you ensure this is to count the number of posterior ribs you can see. More than 7-9 means the patient's chest is adequately inflated. I don't have a picture for this.

The xray

• Tubes - Can you see any NG tubes or central lines, etc.
• Soft Tissues - Any obvious tissue abnormalities such as scars.
• Bones - Obviously misshapen, broken, dark patches, etc.
• Heart
  • Size - approximately 1/2 the total width of the chest is normal. In kids, its more like 60%.
  • Position - it should be one third on the right hand side, two thirds on the left. A shift may mean pneumothorax
  • Shape - is it the normal curvey triangle, or is it weird. For example, in coarctation of the aorta, the mediastinum is bigger and rounder.
• Lungs
  • Borders - Can you see anything around the edges. This can show hilar cancer, or pneumonia
  • Compare Sides - Comparing the sides with each other can show irregular shadowing on the lungs
  • Costophrenic angles - If these are gone, in an upright xray, that can indicate fluid on the lungs. However, check if the xray is supine, because if so that won't help.

Once you've done all that, they won't be that bothered if you don't have a diagnosis.