Review previous images (admission chest X-ray)

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Clinical information - Patient 1

  • 50-year-old female (never smoked)
  • 2 days ago presented with a fever and was swabbed
  • Returned with worsening shortness of breath
  • Bronchial breathing at the lung bases
  • O2 saturation of 75% on 4 litres of 2
  • COVID-19 swab positive prior to this X-ray

Review previous images (admission chest X-ray)

  • Anterior-Posterior (AP) image - too unwell to stand
  • Shadowing is typical for COVID-19 pneumonia - patchy, peripheral, bilateral and basal
  • Inspiration is suboptimal - the diaphragm should be intersected by the 5th to 7th anterior ribs in the mid-clavicular line - which may make the interpreter think the lung markings are exaggerated
  • Poor inspiration is common feature of COVID-19 pneumonia
  • Classification: Severe (see next page)

Review previous images (2017 chest X-ray)

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Clinical information - Patient 1

  • (Same patient as image above)
  • Chest X-ray acquired three years ago as part of a septic screen
  • The patient had no chest symptoms at the time

Review previous images (2017 chest X-ray)

  • Posterior-Anterior (PA) image - well enough to stand
  • Inspiration is only just adequate even though this is otherwise a good quality chest X-ray (the 5th rib crosses the diaphragm at the point of intersection with the mid-clavicular line)
  • Comparison with this previous image highlights the extent of lung shadowing at the time of admission
  • Review of the previous chest X-ray (if available) provides useful insight and is a mandatory part of chest X-ray interpretation

Assessing progress (admission chest X-ray)

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Clinical information - Patient 2

  • 60-year-old male
  • Ex-heavy smoker with COPD
  • Travel to Eastern Europe in March 2020
  • Productive cough and sweats
  • Crackles at right lung base

Assessing progress (admission chest X-ray)

  • PA chest
  • Shadowing is bilateral, peripheral and mainly affects the lower lungs
  • Shadowing extends more superiorly on the right
  • Classification: Mild (see next page)
  • Note: If shadowing due to COVID-19 pneumonia is asymmetric it is frequently more extensive on the right than on the left

Assessing progress (2 days later)

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Clinical information - Patient 2

  • Increasing shortness of breath
  • Maintaining O2 saturation of 95% on 15 litres of O2
  • Chest X-ray requested as part of consideration for admission to ITU
  • ITU was not required and the patient recovered and was discharged

Assessing progress - (2 days later)

  • AP chest X-ray
  • At first the shadowing appears worse on this chest X-ray when compared with the previous image
  • AP and PA images cannot be directly compared - an AP image can exaggerate lung markings
  • Careful assessment shows similar distribution and extent of shadowing
  • Shadowing is still classified as mild (see next page)

Page author: Salisbury NHS Foundation Trust UK (Read bio)

Last reviewed: May 2020