Simple Way to Interpreting CXR in Emergency Department

This morning during round, one medical student ask me how to simply read the radiograph in emergency department. Mmmm...i just smile to him, there is no simple way to interpret CXR in ED. I know they are waiting for my mnemonic to share with them. Maybe this mnemonics will help, i found this in the net. RIP ABCDEFG

Rotation: Check to see that the patient is not rotated. You can look at the clavicles and make sure the vertebral processes line up nicely in between them.
Inspiration: Check to see that you can see about 9 ribs on each side. Less than 8? It is likely poor inspiration.
Penetration: You should be able to see lucencies in the middle of the film representing the intervertebral discs. If there are none, the film is over-penetrated; if they are too well-defined, the film is under-penetrated.

Airway: Trace the lucency from the neck down towards the carina. It should be midline and you should be able to see two bronchi splitting from it.
Bones: Look at the shoulder joint and trace out each rib contour to check for fractures or other abnormalities.
Cardiac Silhouette: Check the right and left heart borders.
Diaphragms: These should be well-defined with no obscuration of their margins.
Empty Space =)
Fields: Look at the lung fields bilaterally and compare. Don't forget the apices.
Gastric Bubble: Check for a lucency in the left upper abdominal quadrant.
Hardware: Make sure the placement of any lines or other hardware is appropriate.

Click here for basic interpretation of the CXR

Healthfact 2009 - Download from KKM website

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APPROACH IN EMERGENCY MEDICINE

There were many approaches has been taught in dealing with patient presented to ED. Most of the emergency clinicians had their own way to approach certain cases. We have to understand that emergency department has their own environment which different with other disciplines. Some people said we are living in the fast lane...need quick thinking,quick decision & quick intervention within short of time. Here, i just want to share my practice that i got from my "guru" in approaching patient in ED. Only 5 steps...

step 1 : What are the chief complaints
step 2 : What are the life threatening condition
step 3 : What are the common causes
step 4 : Is it patient safe to be discharge or not
step 5 : if discharge need follow up or not

An example if patient come with the chest pain

step 1 : chief complaints chest pain
step 2 : what are the life threatening chest pain eg : AMI, Pulmonary embolism, aortic dissection
step 3 : after rule out life threatening can find the other causes of chest pain
step 4 : safe to be discharge or not
step 5 : need follow up or not.

Some clinicians used mnemonic 4C

1. complaints
2. condition
3. causes
4. complication

You can choose either one that comfortable/easy to use. I hope this sharing knowledge may help us in reducing misdiagnosis in our ED especially for young doctors.