Important Heart Murmurs

Austin Flint murmur : Austin Flint murmur is a mid-diastolic rumbling audible in subjects with severe aortic regurgitation that is best heard at the apex with little radiation. Several theories have been suggested for the origin of the murmur: (1) vibration of the anterior mitral valve leaflet due to the regurgitant jet, (2) collision of the jet with mitral inflow, (3) increased mitral inflow velocity due to narrowing of the valve orifice by the jet, and (4) vibration from the jet impinging on the myocardial wall. It differs from mitral stenosis murmur in that ,it occurs in the presence of a murmur of aortic valve insufficiency and in the absence of the rheumatic, mitral opening snap.

Carey Coombs murmur : Mitral valvulitis associated with acute rheumatic fever may cause a low-pitched mid-diastolic rumble. It can be differentiated from the diastolic murmur of Mitral stenosis by the absence of (1)an opening snap, (2)presystolic accentuation & (3)loud first heart sound.

Cruveilhier-Baumgarten murmur : Venous hum heard in epigastric region (on examination by stethoscope) due to collateral connections between portal system and the remnant of the umbilical vein in portal hypertension.

Duroziez’s murmur : Its a to & fro murmur heard over the femoral artery during both systole& diastole. It is elicited by applying gradual arterial compression with the diaphragm of the steth. This compression not only produces systolic murmur(which is the normal result of arterial compression) but also a diastolic murmur(which is pathologic &suggestive of aortic regurgitation).Sensitivity of 58-100%.False positives occur in high output states. In high output states the double murmur is due to forward flow. In Ar one murmur is due to forward flow& the other due to reverse flow.The two can be differnetiated by applying pressure first on the more cephalad edge of the diaphragm & then on its more caudal edge. The murmur of forward flow is enhanced by compressing the cephalad edge. Conversely the reverese flow murmur is enhanced by compressing the caudad edge.

Gibson murmur :The typical continuous “machinery-like” murmur of patent ductus arteriosus.train in tunnel murmur

Graham Steell’s murmur : Due to pulmonary regurgitation in patients with pulmonary hypertension and mitral stenosis. It is a high pitched early diastolic murmur heard best at the left sternal edge in the second intercostal space with the patient in full inspiration.

The murmur is heard due to a high velocity regurgitant flow across the pulmonary valve; this is usually a consequence of pulmonary hypertension. The Graham Steell murmur is often heard in patients with chronic cor pulmonale as a result of chronic obstructive pulmonary disease.

Means-Lerman “scratch” murmur: Increased flow across the pulmonary valve in Thyrotoxicosis may be associated with ejection systolic murmur.The ejection systolic murmur owing to hyperthyroidism may have a scratchy quality (Means-Lerman scratch), and, frequently, the intensity of P2 is increased because of mild to moderate pulmonary hypertension.

Roger’s Murmur:A loud pansystolic murmur caused by interventricular septal defect of the heart; maximal at the left sternal border.

Seagull murmur  a raucous murmur with musical qualities, such as that heard occasionally in aortic insufficiency.A “seagull’s cry murmur” is defined as a murmur imitating the cooing sound of a seagull. This type of murmur is typically characterized by a musical timbre and a high frequency, and may occur as a result of various valve diseases. It is usually described as a sign of tight calcific aortic stenosis, when the murmur’s high frequency components are transmitted to the lower left sternal border and the cardiac apex during most of systole (Gallavardin’s phenomenon). In this condition, the typical harsh timbre of the ejective murmur tends to assume a musical high pitched quality, resembling that of mitral regurgitation, which may be reminiscent of the cry of a seagull. A protodiastolic murmur with similar characteristics, typically in decrescendo, may occur in severe aortic valve regurgitation, particularly when the regurgitant flow presents high velocities. However, a seagull’s cry murmur may also be the sign of mitral regurgitation or prolapse. Similarly, the musical and holosystolic sound reflects the presence of high frequency components due to high velocities of reflow.
Still’s murmur An innocent musical murmur resembling the noise produced by a twanging string; almost exclusively in young children, of uncertain origin and ultimately disappearing.{There are five innocent murmurs of infancy and childhood: (i) pulmonary flow murmur, (ii) Still’s murmur, (iii) venous hum, (iv) carotid bruit, (v) physiologic pulmonary branch stenosis murmur of neonate}

Residency Interview Guide

Internal Med Residency 1


So you’re about to head off on your first interview. A little nervous, are we? Not to worry, we’re
here to help!
First, remember some of the personal and professional traits they are looking for: Enthusiasm,
motivation, initiative, communication skills, chemistry, energy, determination, confidence,
humility, reliability, honesty, integrity, pride, dedication, analytical skills, and listening skills.
Next, think of some of the questions that they might ask you – we’ve given you a head start by
listing over a hundred questions you might hear on your interview, so click on the link below to
download the list.
Now, what questions are you going to ask them? We’ve helped you out there too. Click on the
links below to download the lists.
There you go – you’re all set to impress!
Be sure to check out some of the other interview resources we have on our medical student home
page…and good luck!
Questions They Will Ask You
Questions to Ask Residents
Questions to Ask Faculty
Questions to Ask the Program Director
1. List three accomplishments of which you are most proud of and what each accomplishment
about you?
2. List three abilities you have that will make you valuable as a resident in this specialty?
3. What clinical experience have you had in this specialty?
4. Do you have any questions?
5. Tell me about yourself?
6. What three adjectives best describe you?
7. What might give me a better picture of you than I can get from your resume?
8. Tell me a story about yourself that best describes you?
9. If you were going to die in 5 minutes, what would you tell someone about yourself?
10. Of which accomplishments are you most proud?
11. Are there any hidden achievements or qualities that you are secretly proud of?
12. How have you changed since high school?
13. What are your strengths and weaknesses?
14. Tell me about your “secret identity” – The part of your personality that you don’t share with
15. Any skeletons in your closet you want to tell me about?
16. How well do you take criticism?
17. What’s your pet peeve?
18. If you could change one thing about your personality what would it be?
19. If you could be any cell in the human body, which would you be and why?
20. Do you see yourself as more relaxed/casual/informal or more serious/dedicated/committed?

21. Which is more important, the ability to organize, structure, and prioritize or to be flexible,
change and make do as needed?
22. Which is more important, knowledge or imagination?
23. Strangest Halloween costume you ever wore?
24. What do you value in your own life?
25. If you had unlimited money and (x amount of time) what would you do?
26. 3 wishes, what would they be?
27. What kinds of people are your friends?
28. Describe your best friend?
29. How are you similar and dissimilar to your best friend?
30. How would your friends or co-workers describe you?
31. Who are your heroes?
32. What is your favorite movie, book?
33. What is the last book you read?
34. What do success and failure mean to you?
35. What do you do in your spare time?
36. Favorite games/sports? Why?
37. Have you done any volunteer work?
38. How did you choose these outside activities?
39. If you had a completely free day, what would you do?
40. Describe for me your typical day?
41. What is the most bizarre thing you have ever done (in college, high school, etc)?
42. What is the most unusual occurrence in your life in the past (x amount of time)?
43. Which organizations do you belong to?
44. What are your plans for a family?
45. If could not be a physician, what career would you choose?
46. Why choose to be a doctor?
47. How do you make important decisions?
48. Are you a risk taker or safety minded?
49. What made you choose your undergraduate major?
50. How did you select undergraduate college and medical school?
51. What were the major deficiencies in your medical school training? How would you plan to
remedy this?
52. If you could begin your schooling again, what would you change?
53. Have you ever dropped a class, why?
54. Have you ever quit or been fired from a job?
55. Biggest failures in life and what have you done to ensure that they won’t happen again?
56. Have you always done the best work of which you are capable?
57. Which types of people do you have problems working with?
58. What qualities drive you crazy in colleagues?
59. Describe the best/worst attending with whom you have ever worked?
60. Do you prefer to work under supervision or on your own?
61. With which patients do you have trouble dealing?
62. How do you normally handle conflict?
63. How do you respond when you have problems with someone?
64. What do you do if someone senior tells you to do something you know is wrong?
65. With what subject/rotation did you have the most difficulty?
66. Why do you want to go into EM?
67. What would you be willing to sacrifice to become an emergency physician?
68. What is the greatest sacrifice you have already made to get to where you are?

69. If EM did not exist, what would you do?
70. How much did lifestyle considerations fit into your choice of specialty?
71. Why did you apply to this program?
72. What qualities are you looking for in a program?
73. What interests you most about this program?
74. What have you heard about our program that you don’t like?
75. Are you applying here because it is a familiar environment?
76. What will be the toughest aspect of this specialty for you?
77. How will you handle the least interesting or least pleasant parts of this specialty’s practice?
78. What qualities are most important in this specialty?
79. What kind of qualities does a person need to be an effective emergency physician?
80. Why should we take you over other applicants?
81. What can you add to our program?
82. What computer experience do you have?
83. Describe your ideal residency program?
84. What is your energy level like?
85. How many hours of sleep do you require each night?
86. How well do you function under pressure?
87. How do you handle stress?
88. Can you handle stress without the resources you are accustomed to relying on?
89. Tell me about the patient from who you learned the most?
90. Most memorable experience in medical school/college?
91. What errors have you made in patient care?
92. Greatest fear about practicing medicine?
93. Where do you see yourself in 5-10 years?
94. How do you see the delivery of health care evolving in the 21st century?
95. Is health care a right or a privilege?
96. What problems will our specialty face in the next 5-10 years?
97. What would you do if the house staff had a strike?
98. What do you think of what’s happening in mid east? Congress? Economy?
99. Teach me something non-medical in 5 minutes?
100. Where else have you interviewed?
101. What if you don’t match?
102. Can you think of anything else you would like to add?
103. How do you deal/cope with failure, give example?
104. What was your favorite course in medical school?
105. Describe a conflict you had with someone and how it was resolved?
106. Describe something that was very difficult in your life, how you dealt with it, and what you
learned from
107. What needs to be changed in our health care system?
108. How can you do your job more effectively?
109. What is the most pressing problem in medicine today?
110. What is the most rewarding thing you have ever done?
111. Tell me some of your successes?
112. Tell me some of your failures?
113. How do you show your commitment to medicine?
114. Who is the most influential in your life?
115. What is the worst thing that has ever happened to you?
116. What do you do for fun?
117. When did you decide you wanted to be a physician?

118. Where do you see yourself in 10 years?
119. What leadership roles have you held?
120. What are the biggest problems in medicine and EM?
121. What do you think of socialized medicine?
122. Do you know how hard residency is?
123. Do you want research to be a part of your career?
124. What is your most important accomplishment?
125. What makes you different from everyone else?
126. What do you expect out of EM?
127. What is your most important lesson learned from childhood?
128. What do you expect will be the hardest part of residency for you?
129. Who in your family are you closest to?
130. What makes you happy?
131. What makes you sad?
132. What makes you unique?
133. Is there anything else not in application that you want to tell me?
134. How do your friends describe you?
135. 3 people you would invite to dinner and why?
136. Describe important relationships you have had with people?
137. Anything else you want to tell me about yourself?
138. What was your most difficult challenge in life?
139. Why do you want to come here?
140. What are some challenges that will face this specialty?
141. What motivates you?
142. Why are you here?
1. What contact will I have with faculty and how often?
2. What is the faculty ED coverage? (Single, double, triple?)
3. What is the faculty per hour per patient ratio?
4. How often do you want faculty input but find it’s unavailable?
5. Who teaches – senior resident, attending, both? Do you feel you have the opportunity
to teach as a
senior resident?
6. How much didactic time is there? How much time is spent in lectures, seminars,
journal clubs?
7. What has higher priority: Attending conference or clinical duties?
8. What are the types of clinical experiences I can expect?
9. Are there struggles between services for procedures?
10. Is it difficult to obtain consults from other services?
11. Are you boarding lots of patients in the ED?
12. Have graduates felt comfortable performing all necessary procedures by the time they
13. What type of ultrasound and hyperbaric experience is there?
14. Will I have time to read?
15. What type of support staff is available? Who starts IV, blood draws, clerical work,
takes patient to x-ray? How often do you wheel patients to X-Ray?

16. What is the call schedule? Is it home call or hospital call?
17. What is the patient population like? (Indigent, insured, HIV, penetrating/blunt
18. Do the residents go out as a group? Are the events for all residents or just those in the
19. How often do social events occur? Any activities of special interest to residents?
20. Are the majority of residents here married or single, any with kids?
21. Where do people live?
22. Is parking a problem?
23. What if there is a problem, will the program stand up for the resident?
24. How are shifts done? What is their length? Advance from days to evenings to nights?
Time off?
25. Are there any away electives? Where?
26. Is there research time? How much and what is required?
27. What are the weaknesses of the program and how are they being improved?
28. What is the one thing you would improve at this program if you could?
29. Are you happy here?
1. What types of non-clinical responsibilities are there? (Research, projects, writing,
2. What research projects are the faculty and residents currently working on? How is
obtained? Who gets first authorship?
3. Is there time to do research? If you need to present at a national conference, will the
pay for your way there?
4. Is there training in administrative and legal aspects? Is there hands-on experience
dealing with
insurance, billing, contracts, hiring?
5. What are the population demographics? (Indigent, insured, etc)
6. Who does airway management and who does it in trauma? Does anesthesia come
7. Is there conference time? Is it protected time?
8. What is the pediatrics exposure and experience?
9. What is the underlying philosophy of the program? What is the mission statement for
the program?
10. Are there any required/provided certifications? (ACLS, ATLS, PALS/APLS)
11. Are there any skills labs?
12. How are procedures recorded and credentialed?
1. Where are your graduates? Geographic areas? Academic vs. community?
2. How have your graduates done on the board exam? Did all pass on the first time? How
did they do on oral exams?

3. How have residents done on in-service exams?
4. Any new faculty coming on? Any leaving?
5. Type of resident evaluations? How often? How is feedback supplied to residents?
6. What changes if any do you anticipate in the program’s curriculum? Why?
7. Have any residents left the program? Did they enter the same field elsewhere? Why did
they leave?
8. Do you help graduates find jobs? How do you accomplish this – counseling sessions,
contacts? Will faculty review job offers with residents?
9. What are the weaknesses of this program and how are they being improved?
10. What are the strengths of this program?
11. I am very interested in your program, what else can I do as an applicant?
12. What can I expect from you as a resident in your program?
13. What do you expect from me as a resident in your program?
14. What are your future plans and how long do you intend to stay here?
15. How are faculty chosen? What are their strengths, weaknesses, interests?
16. What is your accreditation status?
17. Has the program ever been on probation? If so, why?
18. How often are you reviewed by the RRC and when is the next review?
19. Do you support resident involvement in national associations?
20. How many national conferences do residents get to attend and when?
21. Does the program pay dues to ACEP/EMRA/SAEM?
22. What processes are in place to deal with issues for residents?
23. What is their policy on maternity/paternity leave?
24. How are the residents treated by the ancillary staff?


How to Read a Chest X-ray

X-ray-ChestReading a chest X-ray (CXR) requires a systematic approach. It is tempting to leap to the obvious but failure to be systematic can lead to missing “barn door” pathology, overlooking more subtle lesions, drawing false conclusions based on a film that is technically poor and, hence, misleading or even basing management on an inaccurate interpretation. There is not just one way to examine a chest X-ray but every doctor should develop his own technique. This article is not a tablet of stone but should be a good starting point to develop one’s own routine.

Traditionally, GPs rarely see X-rays. Connecting for Health has changed this and GPs should be able to peruse images as well as having access to radiologists’ reports via the Picture Archiving and Communications System (PACS).[1] Hence, learning to interpret X-rays is a skill learned as a junior hospital doctor that should not be lost. There may be occasions when a GP has to make decisions based on an unreported film.

This may sound pedantic, but it is very important. Check that the film bears the patient’s name. However, as names can be shared, check other features such as date of birth or hospital number too. The label may also tell of unusual but important features such as anteroposterior (AP) projection or supine position.

Having checked that it is the correct patient, check the date of the film to ascertain which one you are viewing.

Technical aspects should be considered briefly:

  • Check the position of the side marker (left or right) against features such as the apex of the heart and air bubble in the stomach. A misplaced marker is more common than dextrocardia or situs inversus.
  • Most films are a posteroanterior (PA) projection. The usual indication for AP is a patient who is confined to bed. It may be noted on the radiograph. If there is doubt, look at the relationship of the scapulae to the lung margins. A PA view shows the scapulae clear of the lungs whilst in AP projection they always overlap. Vertebral endplates are more clearly visible in AP and laminae in PA. This is important because the heart looks bigger on an AP view. The distance from the tube to the patient is also usually reduced in portable films and this also enlarges the shadow of the heart. X-rays are not so much like pictures as like shadows.
  • The normal posture for films is erect. Supine is usually for patients confined to bed. It should be clear from the label. In an erect film, the gastric air bubble is clearly in the fundus with a clear fluid level but, if supine, in the antrum. In a supine film, blood will flow more to the apices of the lungs than when erect. Failure to appreciate this will lead to a misdiagnosis of pulmonary congestion.
  • Rotation should be minimal. It can be assessed by comparing the medial ends of the clavicles to the margins of the vertebral body at the same level. Oblique chest films are requested to look for achalasia of the cardia or fractured ribs.
  • CXR should be taken with the patient in full inspiration but some people have difficulty holding full inspiration. The major exception is when seeking a small pneumothorax as this will show best on full expiration. A CXR in full inspiration should have the diaphragm at the level of the 6th rib anteriorly and the liver pushes it up a little higher in the right than on the left. Do not be unduly concerned about the exact degree of inflation.
  • Penetration is affected by both the duration of exposure and the power of the beam. More kV gives a more penetrating beam. A poorly penetrated film looks diffusely light (an x-ray is a negative) and soft tissue structures are readily obscured, especially those behind the heart. An over-penetrated film looks diffusely dark and features such as lung markings are poorly seen.
  • Note breast shadows in adult women.

So far you have checked that it is the right film for the right patient and that it is technically adequate.

Just as palpation of the abdomen and auscultation of the heart is the last part of that examination, so must the search for pathology be deferred until the preliminaries have been completed.

  • Have a brief look for obvious unusual opacities such a chest drain, a pacemaker or a foreign body. This is a two-dimensional picture and so a central opacity may not be something that was swallowed and is now impacted in the oesophagus. It might be a metal clip from a bra strap or a hair band on a plait.
  • Look at the mediastinal contours, first to the left and then to the right. The trachea should be central. The aortic arch is the first structure on the left, followed by the left pulmonary artery. The branches of the pulmonary artery fan out through the lung.
  • Check the cardio-thoracic ratio (CTR). The width of the heart should be no more than half the width of the chest. About a third of the heart should be to the right and two thirds to the left of centre. Note: the heart looks larger on an AP film and thus you cannot comment on the presence or absence of cardiomegaly on an AP film.
  • The left border of the heart consists of the left atrium above the left ventricle. The right border is only the right atrium alone and above it is the border of the superior vena cava. The right ventricle is anterior and so does not have a border on the PA chest X ray film. It may be visible on a lateral view.
  • The pulmonary arteries and main bronchi arise at the left and right hila. Enlarged lymph nodes or primary tumours make the hilum seem bulky. Know what is normal. Abnormality may be caused by lung cancer or enlarged nodes from causes includingsarcoidosis (bilateral hilar lymphadenopathy) and lymphoma.
  • Now look at the lungs. The pulmonary arteries and veins are lighter and air is black, as it is radiolucent. Check both lungs, starting at the apices and working down, comparing left with right at the same level. The lungs extend behind the heart, so try to look there too. Note the periphery of the lungs – there should be few lung markings here. Disease of the air spaces or interstitium increases opacity. Look for a pneumothorax which shows as a sharp line of the edge of the lung.
  • Ascertain that the surface of the hemidiaphragms curves downwards, and that the costophrenic and cardiophrenic angles are not blunted. Blunting suggests an effusion. Extensive effusion or collapse causes an upward curve. Check for free air under the hemidiaphragm – this occurs with perforation of the bowel but also after laparotomy or laparoscopy.
  • Finally look at the soft tissues and bones. Are both breast shadows present? Is there a fractured rib? If so, check again for a pneumothorax. Are the bones destroyed or sclerotic?

There are some areas where it is very easy to miss pathology and so it is worth repeating examination. Attention may be merited to apices, periphery of the lungs, under and behind the hemidiaphragms and behind the heart. The diaphragm slopes backwards and so some lung tissue is below the level of the highest part of the diaphragm on the film.

A lateral view may have been requested or performed on the initiative of the radiographer or radiologist. As an X-ray is a two-dimensional shadow, a lateral film helps to identify a lesion in 3 dimensions. The usual indication is to confirm a lesion seen on a PA film.

The heart lies in the anteroinferior field. Look at the area anterior and superior to the heart; this should be black because it contains aerated lung. Similarly, the area posterior to the heart should be black right down to the hemidiaphragms. The degree of blackness in these two areas should be similar, so compare one with the other. If the area anterior and superior to the heart is opacified, it suggests disease in the anterior mediastinum or upper lobes. If the area posterior to the heart is opacified there is probably collapse or consolidation in the lower lobes.

When observing an abnormal opacity, note:

  • Size and shape
  • Number and location
  • Clarity of structures and their margins
  • Homogeneity

If available, compare with an earlier film.

The common patterns of opacity are:

Collapse and consolidation

Collapse, also called atelectasis, and consolidation are caused by the presence of fluid instead of air in areas of the lung. An air bronchogram is where the airway is highlighted against denser consolidation and vascular patterns become obscured.

  • Confluent opacification of the hemithorax may be caused by consolidation, pleural effusion, complete lobar collapse, and after a pneumonectomy. Consolidation is usually interpreted as meaning infection but it is impossible to differentiate between infection and infarction on X-ray. The diagnosis of pulmonary embolism requires a high index of suspicion.
  • To find consolidation, look for absence or blurring of the border of the heart or hemidiaphragm. The lung volume of the affected segment is usually unaffected.
  • Collapse of a lobe (atelectasis) may be difficult to see. Look for a shift of the fissures, crowding of vessels and airways, and possible shadowing caused by a proximal obstruction like a foreign body or carcinoma.
  • A small pleural effusion will cause blunting of the costophrenic or cardiophrenic angles. A larger one will produce an angle that is concave upwards. A very large one will displace the heart and mediastinum away from it, whilst collapse draws those structures towards it. Collapse may also raise the hemidiaphragm.

Heart and mediastinum

  • The heart and mediastinum are deviated away from a pleural effusion or a pneumothorax, especially if it is a tension pneumothorax and towards collapse.
  • If the heart is enlarged, look for signs of heart failure with an unusually marked vascular pattern in the upper lobes, wide pulmonary veins and possible Kerley B lines. These are tiny horizontal lines from the pleural edge and are typical of fluid overload with fluid collecting in the interstitial space.
  • If the hilum is enlarged, look for structures at the hilum such as pulmonary artery, main bronchus and enlarged lymph nodes.

Children are not just small adults and this is important when interpreting a child’s X-ray. Such matters as identification of the patient are still important. A child, especially if small, is more likely to be unable to comply with instructions such as keeping still, not rotating and holding deep inspiration. Technical considerations such as rotation and under or over penetration of the film still merit attention and they are more likely to be unsatisfactory. A child is more likely to be laid down and have an AP film with the radiographer trying to catch the picture at full inspiration. This is even more difficult with tachypnoea.

Assess lung volume

Count down the anterior rib ends to the one that meets the middle of the hemidiaphragm. A good inspiratory film should have the anterior end of the 5th or 6th rib meeting the middle of the diaphragm. More than six anterior ribs shows hyperinflation. Fewer than five indicates an expiratory film or underinflation.

Tachypnoea in infants causes trapping of air. Expiration compresses the airways, increasing resistance and, especially under 18 months, air enters more easily than it leaves and is trapped, causing hyperinflation. Bronchiolitis, heart failure and fluid overload are all causes.

With underinflation, the 3rd or 4th anterior rib crosses the diaphragm. This makes normal lungs appear opaque and a normal heart appears enlarged.


Sick children, especially if small, may not be cooperative with being positioned. Check if the anterior ends of the ribs are equal distances from the spine. Rotation to the right makes the heart appear central, and rotation to the left makes the heart look large and can make the right heart border disappear.

Lung density

Divide the lungs into upper, middle, and lower zones and compare the two sides. Infection can cause consolidation, as in an adult. Collapse implies loss of volume and has various causes. The lung is dense because the air has been lost. In children, the cause is usually in the airway, such as an intraluminal foreign body or a mucous plug. Complete obstruction of the airway results in reabsorption of air in the affected lobe or segment. Collapse can also be due to extrinsic compression such as a mediastinal mass or a pneumothorax.

Differentiating between collapse and consolidation can be difficult or impossible, as both are denser. Collapse may pull across the mediastinum and deviate the trachea. This is important, as pneumonia is treated with antibiotics but collapse may require bronchoscopy to find and remove an obstruction.

Pleural effusion

The features of effusion have already been noted for adults. In children, unilateral effusion usually indicates infection whilst bilateral effusion occurs with hypoalbuminaemia as in nephrotic syndrome.

Bronchial wall thickening is a common finding on children’s X-rays. Look for “tram track” parallel lines around the hila. The usual causes are viral infection or asthma but this is a common finding with cystic fibrosis.

Heart and mediastinum

The anterior mediastinum, in front of the heart, contains the thymus gland. It appears largest at about 2 years old but it continues to grow into adolescence. It grows less fast than the rest of the body and so becomes relatively smaller. The right lobe of the lung can rest on the horizontal fissure, which is often called the sail sign.

Assessment of the heart includes assessment of size, shape, position and pulmonary circulation. The cardiothoracic ratio is usually about 50% but can be more in the first year of life and a large thymus can make assessment difficult, as will a film in poor inspiration. As with adults, one third should be to the left of centre and two thirds to the right. Assessment of pulmonary circulation can be important in congenital heart diseasebut can be very difficult in practice.

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