Making sense of clinical examination of the adult patient : hands-on guide


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Original Article: Is This Adult Patient Malnourished?

Breast shadows If you do not look specifically, sooner or later you will fail to remark on a mastectomy.

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Note also the loss of volume in right upper lobe with upward shift of right hilum and lesser fissure arrowed. Unhappily, an endobronchial secondary deposit had developed in right upper lobe bronchus. This was suspected radiographically after she presented acutely with cough and dyspnoea, and the diagnosis was subsequently confirmed at bronchoscopy. Also collapse of right upper lobe, due to an endobronchial secondary deposit. Radiotherapy resulted in excellent symptom improvement and the patient is alive three years after this CXR was performed.

Below the diaphragm Look specifically for air below the diaphragm Figs 1. This young man had a perforated duodenal ulcer. Very rarely, one can see calcification within the liver due to hydatid cyst or within the spleen, indicative of splenic infarction secondary to sickle-cell disease.

Bones Look at all bony structures very carefully — this includes the clavicles, upper arms, shoulder joints etc. Free air under the right hemidiaphragm is due to a perforated gastric ulcer. The left hilum looks suspicious. The ascending aorta was unfolded and not aneurysmal. Note the missing left fifth rib, the legacy of her lateral thoracotomy. It is easier to look at the ribs if you turn the image on its side with the relevant ribs uppermost.

Honestly, it works. Your systematic examination of the chest radiograph is now complete and it is time to move on to specific areas of interest. Mediastinal and hilar abnormalities offer a significant challenge. They may be difficult to see on a chest radiograph and it is vital to follow a system such as that outlined in Chapter 1.

The latter appear as narrow line shadows outlined on the one hand by the air contained within them and on the other by adjacent aerated lung. They can often be seen on a well-exposed radiograph and an intrabronchial obstructing lesion carcinoma or foreign body, for example can encroach on these line shadows — an appearance that is particularly helpful if there is associated lobar collapse. It is a useful exercise to take some simple measurements of the basal arteries when assessing the size of the hila Fig. Each basal artery tapers distally and, on the right, a convenient, though arbitrary, point to measure the artery is at its mid-point.

The measurement is taken from its lateral wall to the transradiancy of the intermediate bronchus medially. Apical Azygos Upper lobe artery vein artery Upper lobe Upper lobe vein maximum vein maximum diameter 6 mm diameter 6 mm. Basal Basal artery artery. Figure 2. Pulmonary arteries are shaded, pulmonary veins are unshaded. If this transradiant area at the medial wall of the right basal artery is lost on a well-centred radiograph it may suggest non-vascular pathology within, or adjacent to, the right hilum.

In normal adults this distance measures 18—32 mm mean 24 mm; Fig. It is also useful to have clear landmarks for identifying the normal position of each hilum. In Fig. If this point is taken as the centre of each hilum, on the right it will be opposite the horizontal fissure which meets the 6th rib in the axilla , or roughly at the level of the 3rd rib anteriorly on deep inspiration. On the left, the centre of the hilum is 0.


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Using these landmarks it becomes possible to determine movement of the hilar shadows in an objective way. A final word about measurement. The normal upper lobe pulmonary veins where they meet the upper border of their respective basal artery Fig. They are enlarged in pulmonary venous congestion due to heart failure or mitral valve disease. Continue to dissect the hilar structures in this way and then decide if you are left with any component of this shadow which cannot be explained on the basis of exaggerated vascular structures. Neither of these tips is infallible but they are a quick and easy evaluation unless the image is rotated, in which case interpretation may be impossible.

Using the principles just discussed we can be confident of the vascular nature of the huge hilar shadows.


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  5. This lady has pulmonary hypertension as a result of chronic obstructive pulmonary disease. Note also the abnormal shape of the right breast and the clips in the right axilla in Fig. There are healing fractures of ribs 3, 4, 5 and 6 and fortunately these were caused by trauma and were not metastatic.

    Only a systematic approach will ensure that all of these abnormalities are detected. This man had long-standing sarcoidosis. The hilar glands were very enlarged and preceded the intrapulmonary appearances. The primary carcinoma was in the breast. Chest radiography is diagnostic with the combination of a normal-sized or small lung, which is hyperlucent, and ipsilateral pulmonary vessels that are small and distributed sparsely throughout the lung field. In the majority, lymph node involvement is bilateral though asymmetric.

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    Unilateral node enlargement is unusual. Paratracheal and subcarinal nodes are involved as often as, or even more often than, hilar nodes.


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    Not surprisingly, leukaemic lymphadenopathy is far commoner in the lymphocytic forms of this disease. Metastatic lymph node enlargement Lymphomas are responsible for the majority of mediastinal lymph node malignancies but the second most common cause of lymph node enlargement is metastasis from solid tumours, especially from the lungs, upper gastrointestinal tract, prostate, kidneys and genitals.

    When the primary lesion is in the lung, nodal enlargement is almost always unilateral. Lymph node involvement in granulomatous diseases This category includes infective causes such as tuberculosis and histoplasmosis rare in this country but more common in the US as well as sarcoidosis. In the infectious granulomas, lymphadenopathy tends to be predominantly unilateral Fig. The hilar nodes are symmetrically enlarged.

    Hilar lymphadenopathy in sarcoidosis is usually bilateral Fig. Very importantly, mediastinal lymph node enlargement in sarcoidosis is almost invariably associated with hilar node involvement and this is an important differentiating feature from lymphoma. The X-ray appearance is of a solitary mass with a smooth or lobulated contour in any of the three mediastinal compartments and most commonly in the middle and posterior ones. Although these masses can grow very large, they seldom cause symptoms and the histological appearance is typical and non-malignant.

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    It has been suggested that the condition represents a hamartoma of lymphoid tissue. At least one Ghon focus can be seen arrowed as well as the calcified right hilar nodes. Potential hernia of Bochdalek. Posteriorly it abuts on the vertebral bodies and the paravertebral gutters and, inferiorly, it reaches the diaphragm. The division of the mediastinum into anterior, middle and posterior compartments in this way, together with consideration of the tumour masses, which may be expected in each one Table 2.

    Some examples of mediastinal masses Figure 2. The extent of the narrowing is shown dramatically in Fig. Figures 2.

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    Comparing this chest radiograph with Fig. The bronchogenic cyst illustrated in Figs 2. In all fairness, one could not reliably differentiate this from lymphoma on the chest radiograph alone, and the CT scan is more reassuring of its benign nature. The anterior mediastinal mass clearly seen in Fig. It is no surprise then that this proved to be a thymoma. The young man whose chest X-ray is shown in Fig. The posterior—anterior radiograph is fairly unimpressive but the CT scan Fig.

    Teratoma: Sometimes, unusual tissue elements including bone can be seen in these germinal cell tumours. The anterior mediastinal mass is difficult to see on chest radiograph but the area adjacent to the left hilum looks very suspicious. There are no prizes for diagnosing the cause of the anterior mediastinal mass shown on chest radiograph in Fig. There was an aortic diastolic murmur on auscultation and the clinical findings together with the chest radiograph secured the diagnosis of aortic dissection.

    Happily, he has made an excellent recovery following surgery and prompt diagnosis was crucial in ensuring this. Identifying posterior mediastinal masses can be difficult, particularly if the shadowing is behind the heart and I take you back to Figs 1. We are going to leave the mediastinum now and the next two chapters concentrate on aspects of abnormal intrapulmonary shadowing.

    This chapter discusses the radiographic patterns of pulmonary consolidation and illustrates the various pathological processes that can cause it. It also describes the features of partial and complete loss of volume of the major lobes of the lungs. We are all aware that it may be difficult to decide if there is abnormal parenchymal shadowing on a chest radiograph and most of us will have missed subtle changes of lobar collapse at some stage in our careers as well.

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    There is a systematic approach to the identification of both consolidation and collapse, however, and in this Chapter, I seek to share it. Before any of us reaches this stage of experience, however, it is vital to be obsessional about our systematic approach — but then this applies to all aspects of clinical medicine. I prefer the first of these because it is so descriptive and I use it preferentially in this chapter.

    Whatever the terminology, the radiographic appearances of consolidation are those of homogeneous shadowing in part of the lung field with little or no lobar shrinkage. The normal vascular pattern is lost because the alveolar-filling process denies the definition of lung markings by replacing the air in adjacent lung parenchyma. This loss of vascular pattern is a major clue when the appearances of consolidation are subtle.

    Making sense of clinical examination of the adult patient : hands-on guide Making sense of clinical examination of the adult patient : hands-on guide
    Making sense of clinical examination of the adult patient : hands-on guide Making sense of clinical examination of the adult patient : hands-on guide
    Making sense of clinical examination of the adult patient : hands-on guide Making sense of clinical examination of the adult patient : hands-on guide
    Making sense of clinical examination of the adult patient : hands-on guide Making sense of clinical examination of the adult patient : hands-on guide
    Making sense of clinical examination of the adult patient : hands-on guide Making sense of clinical examination of the adult patient : hands-on guide
    Making sense of clinical examination of the adult patient : hands-on guide Making sense of clinical examination of the adult patient : hands-on guide
    Making sense of clinical examination of the adult patient : hands-on guide Making sense of clinical examination of the adult patient : hands-on guide
    Making sense of clinical examination of the adult patient : hands-on guide Making sense of clinical examination of the adult patient : hands-on guide
    Making sense of clinical examination of the adult patient : hands-on guide

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