Category Archives: PA Student

Medical Musing of the Week: Atrial Fibrillation

Overview + Definitions

  • Most common arrhythmia
  • Increased risk with age
  • Irregularly, irregular rhythm and absent P waves on EKG
  • Valvular vs. non-valvular (valvular means that arrhythmia is being caused by some type of valve disease ie rheumatic fever or from a defect in a prosthetic valve)  Most cases are non-valvular A-Fib (you will hear that term frequently!)
  • A-Fib w/ RVR (stands for “rapid ventricular response”): This basically means that the person is not in rate controlled A-Fib and the ventricles are trying to keep up with all the beats being initiated by the atria.
  • The more days/weeks A-Fib persists the increasing likelihood that it will be permanent
  • Paroxysmal A-Fib: Self-terminating within 7 days onset.  Usually terminates <48 hours. Recurs with variable frequency.
  • Persistent A-Fib: Atrial fibrillation that fails to self-terminate within 7 days or requires medication for termination.
  • Permanent: Has persisted >12 months and cardioversion has usually been unsuccessful.  Focus shifts to rate control

Etiology + Risk Factors

  • Coronary Artery Disease
  • Congestive Heart Failure
  • Acute Coronary Syndrome
  • Hypertension
  • Pulmonary Disease (esp COPD flares)
  • Pneumonia/Infection
  • Etoh (“Holiday Heart”) –> Lots of patients will show up to the hospital around the holidays because of increase of alcohol use
  • Surgery or anything that will cause fluid shifts in the body either overload or dehydration
  • Has patient missed any doses of rate controlled medication?

Clinical Manifestations

  • Palpitations/Chest Pain
  • SOB (may have increased O2 requirement secondary to heart beating so fast patients are not perfusing appropriately and become SOB– once their HR slows the will perfuse better and O2 requirement likely subsides

Diagnosis

  • EKG
  • Troponin x3 + CKMB x1
  • CT PE study (for rule out–in hospitalized patients who have a new oxygen requirement
  • Telemetry Monitoring

Treatment

Steps to take/Questions to ask:

  • Calculate Cha2ds2 Vasc:
    • The “chads vasc” is a scale that determines an individual’s risk per year for stroke.  Based on their risk have a discussion with the patient about risks and benefits of oral anticoagulation
    • Scale includes:
      • Congestive Heart Failure
      • HTN
      • Age (2pts) >75, (1 pt) >65
      • Diabetes
      • Stroke/TIA history (2pts)
      • Vascular Disease
      • Sex (+1 if female)
  • Is the patient rate controlled?
  • New onset?
    • If rate controlled determine need for oral anticoagulation (watch providing with elderly who fall frequently)
    • If rate isn’t controlled do so with a BB
  • Is the patient rate controlled? (<110 BPM)
    • A-Fib RVR:
      • In a hospitalized patient options for treatment include IV Lopressor (may repeat for 3 doses, Cardizem 5mg +/- drip (may also repeat), Digoxin or Amiodarone bolus +/- drip
      • If low BP will want to hold off on Cardizem or Lopressor–cardizem will really drop the BP
      • Amiodarone is my go to when a patients BP is low 150mg bolus followed by a drip of 1mg/kg x6 hours, .5mg/kg for 6 hours, 400mg daily and then 200mg daily for maintenance
  • Are they hemodynamically stable?

Below is one of my favorite flow charts from UpToDate (love this source!)  This is a really good place to start to understand the treatment of A-Fib

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Prognosis + Complications

  • The longer a person remains in atrial fibrillation the greater the risk it will be a permanent rhythm
  • RVR (rapid ventricular response)
    • Frequently seen in the hospital especially with CHF exacerbation, surgery (because of fluid shifts)
  • CVA/TIA
    • Because of the irregular rhythm of the atria and valves individuals with a-fib are at increased risk of developing clots on their mitral valve and throwing ot through their aortic valve and to the brain
    • Calculate chads vasc as above to determine risk

 

Tearing off Training Wheels

PA school is super stressful and overwhelming.  Graduating and starting your first job and your first year out in the real medical word is equally stressful; but, in different ways.  I started my first job and felt like I had no idea what I was doing and like I hadn’t even prepared in the least to walk around a hospital.   Not because I didn’t get a good education at Pitt.

I believe there are several factors as to why I felt like I was attempting to ride a uni-cycle at first.  First, just as elementary and secondary schools are pushed toward performing for a test–so are PA students.  We spend 2 years obsessing about passing the PANCE and all of the horrific things that can happen if we fail.

Second, the PA profession was derived around filling the shortage of Family Physicians.  Thus the education model we follow although follows a general medical concept has a strong focus on family medicine. As I have talked to students who have gone through the same program as me I hear that they are adapting and learning different information and procedures to adapt to the ever diversifying role PA’s are filling.

Third, PA school is FAST.  There is only so much time to learn a lot of information.  I look at the doctors I work with or PA’s with  couple years more experience than me and I think damn “when will that be instinctive for me?”  I quickly decided I would treat my first couple of years in medicine as a resident would.   I do a lot of reading and ask A LOT of questions.

The next reasons are a bit more unique to me; but, perhaps others have experienced them as well.  Before PA school I did not obtain my HCE in a hospital or medical setting.  Even though I had a couple of rotations in hospitals they were pretty sub par despite my constant asking to learn ad do new things my preceptors weren’t particularly helpful in these settings.  So, when I started work I felt like I was still acclimating to a lot of things.  The job I took was also pretty low acuity patients with repetitive problems. The group I was with was great; but, once I got out doing hospitalist work I was like “holy shit”.  I worked basically taking care of post operative patients medical needs.  It got really repetitive pretty quick–every once in a while we had a unique case.  Usually it was standard post operative stuff surgeons didn’t want to handle.

So, when I started my position as a travel PA as a hospitalist at the largest medical resource between Pittsburgh and Philidelphia I felt really intimidated.  I remember my first night getting my first page I had to go and assess a patient.  I felt like I forgot to do a H&P and how to critical think.  it was a really weird feeling that I  can’t quite explain.  I look back at that day and I laugh to myself.  I’ve come a long way since then.  Practicing more independently and handling floor patients in the middle of the night pretty much independently (unless you have to push adenosine–then you call your Attending because–well that was above my pay grade to do that alone the first time on a patient who was a no code).  I’ve become more comfortable responding to RRT’s, even getting a system down as to what I would do to assess the patient and what questions I would ask the nurses.

I still feel like I’m losing my balance some days.  I partially think that is the nature of medicine and also being a PA–we’re expected to know about a lot of things in a short amount of time.  However, I think back a lot to my first day of PA school and my first clinical semester and first rotation, etc.  I realize I’ve come really far.  Even if some days I feel like I know nothing when it comes to a really complicated patient.  Then I remind myself that I would rather feel stupid temporarily and learn as opposed to feeling like I know everything all of the time.  First because that is dangerous and second that would mean I’m not being challenged.

The past can be evil, but it can also be our friend.  Make sure to realize how far you’ve come and everything you’ve learned!  Feel lost, ask questions and take things on before you think you are ready.  You will be ok and your medical knowledge and skills will advance. I sure as shit had never heard the term protein losing enteropathy before and I remember feeling super intimidated by trying to figure out how the hell to order sliding scale insulin.  I still don’t know much about protein losing enteropathies; but, I’m pretty sure I’ve gotten insulin and a lot of other things down since I was cut lose a year ago.  Always remember progress is always being made!!

 

Medical Musing of the Week: Behcet Disease

Overview

  • Disease marked by recurrent eye and genital lesions as well as ocular involvement.  Autoimmune/autoinflammatory disease with a hereditary component.

Etiology/Pathogenesis

  • Perivasculitis and early neutrophil infiltration w/ endothelial swelling
  • Association with HLA-B*51
  • Mediterranean descent/region, middle east and far east

Clinical Manifestations

  • Recurrent oral and genital ulcers
    • Painful with yellow necrotic base
    • Can occur alone or in clusters
    • Subside in 1-2 weeks w/o scarring
  • Integumentary Involvement
    • 80% of patients also have skin lesions
    • Folliculitis, Erythema Nodosum, Vasculitis (infrequent), sweet syndrome and pyoderma gangrenosum
  • Ocular Involvement
    • 50% of patients experience ocular symptoms
    • iritis, uveitis, retinal vain occlusions, optic neuritis
  • MSK
    • 50% have arthritis or arthralgia
    • Knees and ankles most common locations
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                                               Clinical Manifestations of Behcet’s Disease

Diagnosis

  • Clinical
  • Pathergy Test
    • Introducing a needle under the skin resulting in an abnormal healing and development of ulcers and raised erythematous area demonstrating irregular healing
Positive Pathergy Test.  Increase in inflammation and erythema represents impaired healing
Positive Pathergy Test. Increase in inflammation and erythema represents impaired healing

Treatment

  • Methylprednisilone 
    • 1 g administered intravenously for one to five days,  for progressive, severe, organ or life-threatening disease.
  • Colchicine
    • Effective for mucocutaneous involvement
    • Also associated with decrease in joint involvement for men and women and genital lesions and erythema nodosum in women
  • Azathioprine
    • Patients treatment with steroids and AZA demonstrated less vision deficits and blindness
  • Cyclophosphamide
    • 1 to 2.5 mg/kg per day, orally
    • 1 g or 0.75 to 1 g/m2 by monthly infusion IV
    • Effective for neurologic and vasculitis associated with Behcet’s

Complications

  • 30% develop DVT and PE is a rare complications
  • Blindness may ensue from Panuvitis
  • CNS Behcets: IL-6 is persistently raised in cerebrospinal fluid of these patients

 

 

 

 

My Journey

I’ve gotten a lot of questions recently about what my journey was like up until the point of getting my acceptance letter to PA school.  I also realized that I ask my clients (and patients) a lot of probing questions and there are a lot of things they don’t know about me!  Not because I’m unwilling to share; but, mostly because I focus on other people in my work.  Ok, enough chit-chat I’ll get down to it.

A brief background: I was pretty aimless academically in high school.  I was not your traditional straight A valedictorian type.  I worked hard and did above average; but, I don’t think anyone ever saw me as “smart”.  My mind had other areas of foci.  Mostly I was always an athlete first.  My mom was super sick with cancer most of my childhood and I think it probably took more of my mind then I realized or would ever be willing to admit.  I based college on where I would play softball and had no idea what in the hell I was doing when I went to college.  All I knew was that I was getting away from home and that made me happy.  Also that going to college was what everyone was supposed to do, so I did it.

If I had to do it over again, everything would be different.  Maybe not high school, but college for sure.  I would go to community college get whatever credits I could as cheap as possible.  I would have vacated the mid-west ASAP. I wouldn’t have majored in psychology and I wouldn’t have gotten a master’s degree around the same concentration.  WHAT WAS I THINKING. I was pretty hopeless and I think I suffered anywhere from a 4-7 year quarter life crisis. 

So, there I go proceeding with about 120k in student debt and a lot of people in my life cocking their heads at me wondering what the hell I was doing.  I didn’t know what the hell I was doing for the record. I was 24 years old working as a personal trainer and bartender.  I knew about half way through my Master’s it wasn’t right for me, but decided to finish. What the hell was I doing?

When I was working as a personal trainer a worked with a lot of medical professionals.  I talked to them a lot about what kind of work they did.  It interested me, medicine always interested me. As cliche as it sounds I was obsessed with all the typical medical shows–ER and Grey’s Anatomy (by the way as truthful as it is don’t put this in your personal statement 🙂 One day, a friend of mine who I was training brought in a brochure about Chatham’s Physician Assistant program.  I was like this is it.  I want to do this.  I sat down made a list of all the crap you guys know needs done to have a complete PA application, made a time line and never looked back.

I decided to stay in Pittsburgh if I could to avoid out of state tuition. Yea, I know good time to start worrying about that.  I also wasn’t interested in up rooting my life at this point.  So, I compiled a list of 5 schools wrote down all the classes, GRE, supplemental apps, letters of rec, etc that I needed–sent in my application to CASPA beginning of June, visited all the programs I was applying to, got an interview at Pitt, got accepted and the rest is history.

I realized not a lot of people agreed with my choice.  Of course no one vocalized anything. But you can always tell when people think you’re bat shit crazy. People did.  I didn’t particularly care.  As for why I didn’t really have much academic confidence when I was younger I’m not really sure.  The older I got and the more purpose I had in the science courses I was taking the better my performance became.

If you have a purpose you have a path.  Don’t let barriers stop you or others disapproval–or seeming disapproval.  Just bite the bullet and jump. I had a lot of reasons why I might not get an interview or get accepted.  I’ve also talked to a lot of people who focus on this detail.  Don’t let the don’ts come into your house and set up camp in your brain.  Don’t go down the don’t rabbit hole.  Remember you are unique and if you’re reading this you probably have your shit enough together to see how other people did it and that makes you a step ahead of a lot of people.  Always give yourself credit.  Smile. Be confident.  I’m convinced anything can be accomplished with these simple statements.  Good luck everyone!!  

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How to Choose an Elective Rotation in PA School

This is probably one of the vital mistakes I made in PA school.  We had to choose within our first six months of didactic year and I was on the clueless train as to what area I wanted to practice.  So, here is the advice I wish I knew when I chose my elective rotation.

 1. Play the Numbers for the PANCE.

Yep this means Cardiology.  Cards makes up 16% of content on the boards.  It’s also a huge part of practice no matter what area you go in to, especially if you are practicing in any type of medicine. Learn everything you need to know about treating STEMI’s, NSTEMI’s, CHF and A-Fib.

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2. Increase the Acuity

If you have any interest working in general medicine or in any specialty practicing in a hospital setting think about Critical Care.  I realize that the more rapid responses I’m involved in and forced to handle critical patient situations the more I advance as a provider.

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3. Future Job

Preceptors hire previous students, so think about what area of medicine you want to practice and where you might want to live.  Try and get a rotation based on where you want to live, or even just experience in an area of medicine regardless of location. For example rotating in dermatology would give you an edge over an applicant who did not complete a rotation in dermatology.

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4. Infectious Disease

Bugs and drugs people.  Everyone needs to know about antibiotic coverage.  I definitely wish I would have dug more into what antibiotics cover what types of bacteria in school. Although you probably don’t need a lot of this information for boards (you likely won’t get questions like what is the best drug to treat gram negative bacteria) it will help you when you graduate.

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5. Once in a lifetime

Some people take the opportunity to learn an area of medicine you may never practice or experience again.  For example neonatal medicine, maternal fetal medicine, specific area of oncology, pediatric neurosurgery, etc. You get the idea.

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Board Review Product Focus: Physician Assistant Study Guide

 

Physician Assistant Study Guide

By: National Physician Assistant Education

First, I would like to say that I love ALL of these products and if I were taking the boards I would definitely be purchasing from National Physician Assistant Education. They offer three products which include PANCE/PANRE Study Guide PDF, PANCE/PANRE Study Guide Paperback Book & PANCE/PANRE 2016: Online PA Board Review Program.

PANCE/PANRE Study Guide PDF

This is the most concise resource I’ve seen while still being able to maintain comprehension.  The readability of the product is wonderful, the PDF could not be better organized.  It is put together by organ system just as the PANCE/PANRE so you won’t miss a thing you need to be prepared for your exam.

Helpful Hint: Download to google drive on your iPad to have easy access on-the-go! (or whichever tablet of choice you may own :))

Access PANCE/PANRE Study Guide HERE.  Original price: $14.99.

Use “allthingspa15” for 15% off! 

Example of PDF presentation below:

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PANCE/PANRE Study Guide Paper Back Book

If you are old school like me and prefer having a physical book in front of you to jot down notes and make your own, this is a great option. What’s also wonderful about getting the paper back book is that you get a TON of bonus materials!  In addition to a printed version of the PDF, you also get access to the online PDF for quick on-the-go access, full length 300 question practice exam access, and a comprehensive review list.

Access the PANCE/PANRE Study Guide Paper Back Book HERE.

Use “allthingspa15” for 15% off

PANCE/PANRE 2016: Online PA Board Review Program

The whole she-bang. The online review program is honestly awesome.  It has everything you need to prepare and excel for the PANCE or PANRE. The whole program was developed through a website and App called Schoology so you can conveniently study whenever and wherever you want! The website, program and app are incredibly user friendly and well organized.  The content is beyond comprehensive.  Organized by organ system and the NCCPA blueprint. With each organ system you get the PDF, Audio review, several matching quizzes.

In total you get 2000+ practice questions, 10 hours of audio review, 100+ flash cards, 109 page PDF review, 13 progress quizzes and 5 full-length exams.  

For $199 this is an awesome deal.  I paid $400 for my Kaplan review course and ended up not even using it because I didn’t think it was worthwhile.  I would have much preferred the PANCE/PANRE Online PA Board Review Program.  

Access PANCE/PANRE Online PA Board Review Program HERE.

Use “allthingspa15” for 15% off

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5 EKG Resources for PA Students

EKG’s are a part of my daily life at work and also one aspect of clinical medicine I struggled with the most.  Below I’ve handpicked 5 EKG resources I wish I would have watched both before I started my first EKG lecture and throughout learning EKG’s. Disclaimer: By “BEFORE” I mean a few days prior to your first lecture when you have reviewed your classroom materials and want to have a deeper understanding before class.  Again, I also recommend using these tools throughout school to continue to learn!

1.How to Read an EKG: Khan-Academy Style Tutorial

If you let this continue to play to the next video it is actually a series of 10 videos that through your journey of learning EKG’s will be extremely helpful!  I recommend only watching until you don’t feel overwhelmed.  This may vary for individuals based on their background.  For instance I may have watched the first three videos; but, for someone with a paramedic background this would probably be too simple or they may watch all of them for a refresher!

 

 2. ECG Zone: Tutorials & Cases

These are case studies that help you learn how to interpret EKG’s. This may be too much for someone before in class lectures.  Definitely a great resource to have as you go along and learn!

 

3. The Rapid Interpretation of EKG’s

This is a comprehensive book of all the rhythms you need to know in PA school and clinical practice.  At times it is a bit slow and basic; but, I’m sure a review never hurt anyone.  I think I paid around $14.99 and I think you can get it cheaper on kindle/ibooks. Contains everything from physiology explanations, the different pacemakers of the heart, pictures of EKG strips, explanations of arrhythmias, etc. This is the resource that I used in PA school.  Click here to buy.  DISCLAIMER: The link is to the 5th edition.  There is now a 6th edition out; however, it costs about $50 dollars more.  If you want to purchase the 6th edition click here.

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4. EKG Interpretation: 24 Hours or Less to Easily Pass the ECG Portion of NCLEX

 

Made for nursing boards but also great for the PA student.  Again, if you were a paramedic to fulfill your health care experience hours this will probably be too simple for you (you could probably teach the EKG portion in PA school). Contains links to videos, explains basics of conduction and how it relates to the physiology of the heart.  Explains all of the arrhythmias and gives good picture examples.  The BEST part about this book is that if you have kindle unlimited with amazon ($9.99/month) it is FREE!.  If you don’t have a subscription you can buy for about $2.99.  Definitely a great buy for the dollar value.  Click here to buy!

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5. ECG Interpretation & Rhythm Recognition

Another great Amazon Kindle Unlimited find! This is a bit more in depth that the above option with more pictures and nitty gritty information on arrhythmias and how the are represented on EKG. I would read one of the more simple/basic resources such as #3 or #4 first before delving in to this book. Click here to buy!

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Top 7 Ways to Avoid Burnout in PA School

Let’s be honest, we all go in guns blazing thinking we can study 24/7 and survive on coffee alone. This could not be further from the truth, let me help you get a jump start on everyone in your class with some quick advise!

1. Exercise.

We do a lot of sitting in PA school, finding a way to blow off physical steam helps break up the study process and give yourself a mental break from the books!

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2. Go have fun.

See your friends, boyfriend, girlfriend and do whatever it is you do for fun.  Movies, drinks, dinner, etc. Make time for balance in your PA school career.  I promise a few hours a week will not make or break your GPA (btw as long as you are passing no one really cares about your GPA when you graduate unless you’re applying for a residency)

 

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3. Rest Days.

They aren’t just for your workout schedule anymore.  Just like muscle needs time to rest in order to re-build, so does your brain! Friday nights became my “rest days” from studying.  It gave me time to relax, see my friends and spend time away from my books! Let your brain recover and come back strong Saturday morning.

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4. A little bit goes a long way.

Chip away at your work each night.  Review the days lectures when you get home.  This prevents the need to cram which is stressful and stress contributes to burn out.

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5. One bad grade won’t kill you.

Listen, I hear you–we are all type A people and want to perform well in school. However, let me be real with you…in 5 years this will not matter.  No one will care that you bombed one of you Anatomy practicals.  In fact no one will likely even find out.  I am in no way advocating failing exams.  I’m just suggesting perspective.  Work hard and learn, but likely you will have one test that “gets you” in PA school and I’m here to tell you it will be ok.  In athletics I was always told: “The best athletes have the shortest memories”.  You had a bad performance.  Shake it off and kill it on the next exam 🙂

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6. Take one week at a time.

Concentrate on the week ahead of you, it gives you small goals to work towards and at the end of each week you can feel good about crossing part of the semester off your list!

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7. Enjoy the Journey

Not always the easiest thing to do I realize.  However, go back and read your personal statement.  Remember why you are doing this.  Remember how many people wanted to be in your shoes and you got lucky enough to be chosen!  Time flies so learn lots and have fun with it!

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How I Chose my Specialty

One of the biggest areas of concern for me while I was in PA school was what specialty I was going to enter after graduation. I remember sometime within the first week of PA school one of my professors asked for a survey by show of hands what specialty we wanted to practice medicine. I rasied my hand when she said Orthopedics. I had shadowed in ortho before school and was literally HELL BENT on definitely surgery and most likely ortho becuase of my athletic background.

Disclaimer: I don’t work in surgery or orthopedics. I honestly don’t think I ever will.

Here are the top 7 factors to consider when choosing your first specialty and job!

1. Medicine VS. Surgery

I think this is the first major decision. Do you like the OR or do you primarily like a medical based specialty? I did not have a great surgical roation and I think that definitely skewed my perception of PAs in surgery. Through rotations I learned that I liked the puzzle solving porition of medicine. I also did not want to deal with surgeon egos. The director of my program looked at me one day and told me I was not meant for surgery. I took this offensively at first, I now see the full picture (touche Dr. Opacic). Needless to say I am so happy I am in general medicine.

2. General vs. Specialty practice

Maybe you did a rotation in cardiology and loved it. Or you thought you would love your Nephrology elective and it made you miserable. Maybe you know that the OR is the place you want to be. Or emergency medicine is great for you because you love the idea of seeing a patient once, fixing the problem and saying peace out.

3. Work/Life Balance

Think about what hours you would like to work. Not that they always happen; but, in general what appeals to you? Days, nights, four 10 hour shifts, 7 on 7 off 12 hour shifts, 8-5 M-F, call/no call. Those are the basics. I think if I could have it my ideal way I would work two 16’s and 1 8 hour shift. That would be great (I’m not een sure that exists anywhere but I would jump on that opportunity!)

4. Who is hiring and Received Offers

Sometimes as a new grad you can’t seem to find EXACTLY what you want, and you need to take a job to get experience on your resume and that is ok. Don’t take just anything. However, taking a position slightly sub-optimal for a year or so is not a terrible idea. Obviously I would not express that thought process in an interview.

5. Collaborating Physicians and Co-workers.

If a company or group wants to offer you a job, ask to shadow for a few days and see what the work flow is like to make sure you like what you see on the inside. Everything can seem great superfically; but, when you shadow there are somethings that are less than appealing for whatever reason.

6. Salary

It is always going to be a factor. Areas of salary to consider/negotiate include: Overall salary, CME money, CME days off, vacation time, sick days, possibly maternity leave, sign on bonus, RVU/bonus incentives, non-compete clause (not exactly salary but something to be aware), raise policy/incentive. If you are between two job offers with all of the above you are pleased with and one job is offering you 5-8k more–it’s a no brainer. If you really want the other job–tell them. Maybe they will counter offer for more money.

7. Location

Do you want to stay in your home town or move to the beach, mountains, etc. What will your commute to work be? My first job ended up having a terrible commute. 45 minutes for 7 miles to and from work. Which to some may not seem bad but that was an hour and a half out of my day, everyday that I was basically contributing to work.

Disclaimer: The beautiful things about the PA profession… You can always pick something new 🙂

ABC’s of Interpreting Chest X-Rays!

I’m sure I wasn’t alone the first time someone showed me a chest x-ray and asked me to interpret.  I believe “FML” was the first thing to hit my brain.

So, let me help you not have the FML moment when it comes to looking at chest x-rays.  The picture below is quite detailed and can be overwhelming.  What I am going to review is much more simple; but, it doesn’t hurt to take a peak at the image below just so you have some orientation.

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ABC’s of Chest X-Rays

A: Airway/Assessment of Quality

I’ve seen both written for the letter “A”.

Airway: make sure the airway is patent and is not deviating to one side or the other which might indicate a tension pneumothorax.

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Obvious tracheal deviation.

Adequate Study: 

  • Position.  Make sure the study was not taken with the patient turned more to one side than the other.
  • Lung expansion.  10-11 ribs should be visible in each of the lung fields to be considered adequate.
  • Penetration (too dark/too light)  Can you see the spaces between vertebrae?  That means its a good study!
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Example of how to properly count ribs.  There are 8 visible.  Finding a study with 10 visible was proving difficult.

B: Bones

Don’t forget there are bones to look at in a CXR!  Although in most cases its secondary and in the background make sure there are no clavicle or rib fractures or shoulder dislocations.  You never know what you might find.  So take a quick glance at the bones.  Start from the top and work your way down to stay organized and on track.  There can be a lot going on in a CXR.

C: Cardiac

What does the patient’s cardiac silhouette look like? The size of the heart should be <50% of the PA film dimension.

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Outline of cardiac silhouette.

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D: Diaphragm

Look for position (right will always be slightly higher than the left due to liver), make sure there isn’t free air or maybe flattening due to emphysema. Make sure the costophrenic angles are both visible.

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Example of how the diaphragm should appear on each side of the lung fields with the right slightly higher.  Also visualized is the gastric air bubble (which is normal).

E: Effusions

Simple.  Presence or lack of pleural effusions.

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Obvious right pleural effusion with what looks like tracheal deviation to right likely due to the large effusion on right.

 

F: Fields & Fissures

I’m not going to pretend like I can appreciate a lung fissure on an x-ray.  I am definitely NO radiologist.  Fields stands for lung fields.  Basically what do you see in the lungs.  Take a look around for infiltrates, kerley B lines, pulmonary congestion, granulomas, pneumothorax, masses, etc.  Symmetry is your best friend in radiology–make sure both lung fields look roughly the same in vascular markings, etc.

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Potential findings when looking at the lung fields.

G: Great Vessels

The Aortic knob is probably the only thing I can really appreciate well on a chest x-ray.  Make sure the aorta in it’s entirety isn’t obviously out of proportion.

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H: Hila & Mediastinum

Look for widening of the mediastinum which is a pearl for Aortic Dissection or Hilar Lymphadenopathy as seen in Sarcoidosis. image

I: Instruments/Impression

Instruments stands for anything implanted in the patient such as pacemakers, etc.Summarize all of your findings as concisely as possible and to the best of your ability!

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ICD visualized on Chest X-Ray.