Interpreting Chest X-rays
/Before Tackling the Practice Cases Take a Look at this Brief Video on How to Interpret CXRs...
Practice Cases
Case 1 - The nurse contacts you about your patient with an SBO in whom you placed an NG tube because there has been no output yet, even on suction. You obtain the chest X-ray shown to the right.
Do you need to:
A.) Advance the NG tube
B.) Withdraw the NG tube
C.) Remove the NG tube
Case 2 - You recently intubated a patient who is now having decreased O2 saturations. You had a good view, visualized passage of the tube through the cords, and had confirmatory chest rise and end tidal reading. You obtain the following CXR.
What are the findings and what is your overall impression?
Do you need to:
A.) Advance the ETT
B.) Withdraw the ETT
C.) Remove the ETT
D.) Do nothing the ETT is not the problem
Case 3 - This patient was a unrestrained driver in MVC. He states he hit his chest on the steering wheel and is complaining of severe sternal chest pain. EKG and troponin are normal. His CXR is shown here.
The abnormal finding on this radiograph is also sometimes seen in patients with
A.) Asthma
B.) Pulmonary barotrauma
C.) Boerhaave syndrome
D.) All of the above
E.) None of the above
Case 4 - 63 yr old M with 3 days of fever, productive cough, shortness of breath, and chest pain. Physical exam reveals left sided crackles. WBC count is 14. You obtain the PA and lateral shown.
Where is the pathology located?
A.) Right Middle lobe
B.) Left Upper lobe
C.) Left Lower lobe
Case 5 - 80 yr old F with fever and altered mental status. She has a temp of 101°F and WBC count is 13. Physical exam is otherwise unrevealing. You obtain the PA and lateral shown.
Where is the pathology located?
A.) Right Middle lobe
B.) Left Upper lobe
C.) Left Lower lobe
Case 6 - 62 yo M with PMH of HTN, CAD, and DM presenting after a syncopal episode with sharp, tearing back pain. The patient is hemodynamically stable.
Which of the following should you do next?
A.) Needle thoracostomy
B.) Transthoracic echo
C.) Obtain lateral film
D.) Contrast CT of the chest
Practice Case Answers w/ Explanations
Case 1 - C.) Remove the NG tube
Remove the NG tube. The NG is in the RLL and needs to be removed and re-inserted in the GI tract. Always check NG tube position is correct with a confirmatory CXR.
Case 2 - B.) Withdraw the ETT
ETT located in the right main bronchus. There is associated complete atelectasis of the left lung with marked shift of the mediastinum towards the left. Nasogastric tube in situ.
Case 3 - D.) All of the Above
Pneumomediastinum can be seen blunt chest trauma, as well as conditions involving alveolar rupture, esophageal rupture, or barotrauma. Note the air density surrounding the cardiac silhouette .
Case 4 - C.) Left Lower Lobe
Airspace opacification in the apical segment of the LLL in keeping with pneumonia. The pleural spaces are clear. Cardiomediastinal contours are within normal limits. No PTX. Classic example of absent silhouette sign and using the lateral CXR to locate the consolidation to the apical segment of the LLL.
Case 5 - A.) Right Middle Lobe
Airspace opacification in the apical segment of the RML representing likely PNA. The pleural spaces are clear. Cardiomediastinal contours are within normal limits. No PTX. Classic example of absent silhouette sign and using the lateral CXR to locate the consolidation.
Case 6 - D.) Contrast CT of the Chest
Widened mediastinum is seen on CXR in up to 76% of aortic dissections. In the ED setting, a patient with this presentation and risk factors and a finding of widened mediastinum should haveconfirmatory diagnostic imaging. In the ED to most available modality is typically CT.
