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Review of Basic Chest X-Ray
Diagnostic Radiographs
Prepared and presented by
Marc Imhotep Cray, M.D.
BMS/CK Teacher
1
REVIEW OF NORMAL CHEST
ADMINISTRATIVE
INITIAL SURVEY
Introduction
Next 9 slides are modified from using data from:
USUHS -...
REVIEW OF NORMAL CHEST
A systematic approach to film review and is therefore, designed such
that the major areas of the ch...
1.Check patient name, position, technical quality.
2.Soft tissue including breast, chest wall, companion shadow.
3.Review ...
REVIEW OF NORMAL CHEST (3)
Sequenced Checklist
8. Review hila:
A.normal relationships
B.size
9. Review lungs and pleura:
A...
ADMINISTRATIVE
Get in the habit of always
checking the following items
before anything else. It takes a
few seconds and is...
Other items to check before commencing with clinical review of the film include:
1.Type of film (although this is a chest ...
A basic principle to adopt is going from general observations to specific
details. Sometimes a change may be so major that...
The Chest X-Ray
The following radiographic plates are scan ins from:
Felson, B., et al.: Principles of Chest Roentgenology...
Lecture Outline
•Densities
•Techniques
•Anatomy
•CXR Interpretation
•Common Pathologies
10
Densities
The big two densities are:
(1) WHITE - Bone
(2) BLACK - Air
The others are:
(3) DARK GREY- Fat
(4) GREY- Soft ti...
Techniques - Projection
P-A (relation of x-ray beam to patient)
12
Techniques - Projection (continued)
Lateral
13
Techniques - Projection (continued)
Lateral Decubitus
14
Rotation
15
Rotation (continued)
16
Penetration
17
Inspiration/Expiration
18
Anatomy
19
Anatomy
20
Anatomy
21
Lobes
Right upper lobe:
22
Lobes(continued)
Right middle lobe:
23
Lobes(continued)
Right lower lobe:
24
Lobes(continued)
Left lower lobe:
25
Lobes(continued)
Left upper lobe with Lingula:
26
Lobes(continued)
Lingula:
27
Lobes(continued)
Left upper lobe - upper division:
28
Heart(continued)
Right border: Edge of (r) Atrium
2. Left border: (l) Ventricle + Atrium
3. Posterior border: Left Ventric...
Heart(continued)
30
Heart(continued)
Valves
31
Mediastinum
32
Hilum
Made of:
1. Pulmonary Art.+Veins
2. The Bronchi
Left Hilus higher (max 1-2,5
cm)
Identical: size, shape, density
33
Ribs
34
Lateral CXR
35
Lateral CXR(continued)
36
Lateral CXR(continued)
Tracheoesophageal Stripe
37
Lateral CXR(continued)
38
CXR Interpretation
39
Technical Details
• Type
• Orientation
• Rotation
• Inspiration/expiration
• Penetration
40
Lungs:
•Lungs
• Density
• Symmetry
• Lesions
41
Heart
Size:
42
Heart
• Size of heart
• Size of individual
chambers of heart
• Size of pulmonary vessels
• Evidence of stents, clips,
wire...
Mediastinum:
• Width
• Contour
• AP window
• Size
• Location
44
Review areas:
• Apices
• Behind the heart
• CP angles
• Below the diaphragm
• Soft tissues ( breast, surgical emphysema)
•...
Identify the lesion → localise the lesion →
describe the lesion → give DDx
Never stop looking, carry on with your
systemat...
Pathology
47
The following radiographic plateare scan ins from:
Felson, B., et al.: Principles of Chest Roentgenology. Phi...
RUL pneumonia 48
RML pneumonia 49
RLL pneumonia 50
LUL pneumonia 51
LLL pneumonia 52
• Consolidation on CT 53
Hilar mass 54
The Enlarged Hila
• Causes:
1. Adenopathies (neoplasia, infection)
2. Primary Tumor
3. Vascular
4. Sarcoidosis
55
• Multiple Masses 56
Hilar Lymphadenopathy - BL 57
58Hilar Lymphadenopathy - BL
Pleural Effusion 59
Pulmonary Fibrosis 60
Heart failure 61
Pneumothorax 62
RUL collapse 63
LLL collapse 64
Air under the diaphragm 65
Emphysema 66
Cavitating lesion 67
Hiatus hernia 68
Miliary shadowing 69
Chest Tube, NG Tube, Pulm. artery cath
70
71
Radiology Online Study Resources:
Albert Einstein Medical Center – Learning Radiology
eMedicine - Radiology
GE - Medcyc...
Basic CXR Interpretation_Diagnostic Radiography
Basic CXR Interpretation_Diagnostic Radiography
Basic CXR Interpretation_Diagnostic Radiography
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Basic CXR Interpretation_Diagnostic Radiography Slide 1 Basic CXR Interpretation_Diagnostic Radiography Slide 2 Basic CXR Interpretation_Diagnostic Radiography Slide 3 Basic CXR Interpretation_Diagnostic Radiography Slide 4 Basic CXR Interpretation_Diagnostic Radiography Slide 5 Basic CXR Interpretation_Diagnostic Radiography Slide 6 Basic CXR Interpretation_Diagnostic Radiography Slide 7 Basic CXR Interpretation_Diagnostic Radiography Slide 8 Basic CXR Interpretation_Diagnostic Radiography Slide 9 Basic CXR Interpretation_Diagnostic Radiography Slide 10 Basic CXR Interpretation_Diagnostic Radiography Slide 11 Basic CXR Interpretation_Diagnostic Radiography Slide 12 Basic CXR Interpretation_Diagnostic Radiography Slide 13 Basic CXR Interpretation_Diagnostic Radiography Slide 14 Basic CXR Interpretation_Diagnostic Radiography Slide 15 Basic CXR Interpretation_Diagnostic Radiography Slide 16 Basic CXR Interpretation_Diagnostic Radiography Slide 17 Basic CXR Interpretation_Diagnostic Radiography Slide 18 Basic CXR Interpretation_Diagnostic Radiography Slide 19 Basic CXR Interpretation_Diagnostic Radiography Slide 20 Basic CXR Interpretation_Diagnostic Radiography Slide 21 Basic CXR Interpretation_Diagnostic Radiography Slide 22 Basic CXR Interpretation_Diagnostic Radiography Slide 23 Basic CXR Interpretation_Diagnostic Radiography Slide 24 Basic CXR Interpretation_Diagnostic Radiography Slide 25 Basic CXR Interpretation_Diagnostic Radiography Slide 26 Basic CXR Interpretation_Diagnostic Radiography Slide 27 Basic CXR Interpretation_Diagnostic Radiography Slide 28 Basic CXR Interpretation_Diagnostic Radiography Slide 29 Basic CXR Interpretation_Diagnostic Radiography Slide 30 Basic CXR Interpretation_Diagnostic Radiography Slide 31 Basic CXR Interpretation_Diagnostic Radiography Slide 32 Basic CXR Interpretation_Diagnostic Radiography Slide 33 Basic CXR Interpretation_Diagnostic Radiography Slide 34 Basic CXR Interpretation_Diagnostic Radiography Slide 35 Basic CXR Interpretation_Diagnostic Radiography Slide 36 Basic CXR Interpretation_Diagnostic Radiography Slide 37 Basic CXR Interpretation_Diagnostic Radiography Slide 38 Basic CXR Interpretation_Diagnostic Radiography Slide 39 Basic CXR Interpretation_Diagnostic Radiography Slide 40 Basic CXR Interpretation_Diagnostic Radiography Slide 41 Basic CXR Interpretation_Diagnostic Radiography Slide 42 Basic CXR Interpretation_Diagnostic Radiography Slide 43 Basic CXR Interpretation_Diagnostic Radiography Slide 44 Basic CXR Interpretation_Diagnostic Radiography Slide 45 Basic CXR Interpretation_Diagnostic Radiography Slide 46 Basic CXR Interpretation_Diagnostic Radiography Slide 47 Basic CXR Interpretation_Diagnostic Radiography Slide 48 Basic CXR Interpretation_Diagnostic Radiography Slide 49 Basic CXR Interpretation_Diagnostic Radiography Slide 50 Basic CXR Interpretation_Diagnostic Radiography Slide 51 Basic CXR Interpretation_Diagnostic Radiography Slide 52 Basic CXR Interpretation_Diagnostic Radiography Slide 53 Basic CXR Interpretation_Diagnostic Radiography Slide 54 Basic CXR Interpretation_Diagnostic Radiography Slide 55 Basic CXR Interpretation_Diagnostic Radiography Slide 56 Basic CXR Interpretation_Diagnostic Radiography Slide 57 Basic CXR Interpretation_Diagnostic Radiography Slide 58 Basic CXR Interpretation_Diagnostic Radiography Slide 59 Basic CXR Interpretation_Diagnostic Radiography Slide 60 Basic CXR Interpretation_Diagnostic Radiography Slide 61 Basic CXR Interpretation_Diagnostic Radiography Slide 62 Basic CXR Interpretation_Diagnostic Radiography Slide 63 Basic CXR Interpretation_Diagnostic Radiography Slide 64 Basic CXR Interpretation_Diagnostic Radiography Slide 65 Basic CXR Interpretation_Diagnostic Radiography Slide 66 Basic CXR Interpretation_Diagnostic Radiography Slide 67 Basic CXR Interpretation_Diagnostic Radiography Slide 68 Basic CXR Interpretation_Diagnostic Radiography Slide 69 Basic CXR Interpretation_Diagnostic Radiography Slide 70 Basic CXR Interpretation_Diagnostic Radiography Slide 71 Basic CXR Interpretation_Diagnostic Radiography Slide 72 Basic CXR Interpretation_Diagnostic Radiography Slide 73 Basic CXR Interpretation_Diagnostic Radiography Slide 74
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Basic CXR Interpretation_Diagnostic Radiography

  1. 1. Review of Basic Chest X-Ray Diagnostic Radiographs Prepared and presented by Marc Imhotep Cray, M.D. BMS/CK Teacher 1
  2. 2. REVIEW OF NORMAL CHEST ADMINISTRATIVE INITIAL SURVEY Introduction Next 9 slides are modified from using data from: USUHS - Chest X-Ray Review 2
  3. 3. REVIEW OF NORMAL CHEST A systematic approach to film review and is therefore, designed such that the major areas of the chest should be viewed in the sequential order (see next slide for checklist) 3
  4. 4. 1.Check patient name, position, technical quality. 2.Soft tissue including breast, chest wall, companion shadow. 3.Review soft tissues and skeletal structures of shoulder girdles and chest wall. 4.Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc. 5.Review soft tissues and spine of neck. 6.Review spine and rib cage: check alignment, disc space narrowing, lytic or blastic regions, etc. 7.Review mediastinum: A. overall size and shape B. trachea: position C. margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle D. lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic E. retrosternal clear space REVIEW OF NORMAL CHEST (2) Sequenced Checklist 4
  5. 5. REVIEW OF NORMAL CHEST (3) Sequenced Checklist 8. Review hila: A.normal relationships B.size 9. Review lungs and pleura: A.compare lung sizes B.evaluate pulmonary vascular pattern: compare upper to lower lobe, right to left, normal tapering to periphery C.pulmonary parenchyma D.pleural surfaces a.fissures - major and minor - if seen b.compare hemidiaphragms c.follow pleura around rib cage 5
  6. 6. ADMINISTRATIVE Get in the habit of always checking the following items before anything else. It takes a few seconds and is an important legal safe guard as well. 1.Patient's name. 2.Date exam done (very important if comparing prior exams). 3.Check for position markers - right vs. left, upright. 6
  7. 7. Other items to check before commencing with clinical review of the film include: 1.Type of film (although this is a chest program, practice noticing if it is a plain film, CT, angio, MRI, etc.) 2.Patients position - supine, upright, lateral, decubitus. 3.Technical quality of exam - learn what are the acceptable limits for the exam. You can't find a subtle pneumothorax if there is patient motion or the film is overexposed. ADMINISTRATIVE (2) 7
  8. 8. A basic principle to adopt is going from general observations to specific details. Sometimes a change may be so major that the old saying about missing the forest for the trees comes true. For instance, an absent breast shadow on a film of a patient after a mastectomy. After completing your administrative housekeeping, get a general overview of the film before zooming in on tiny detail. Notice the following because it may change the baseline normals you use as reference points, and you may be sensitized to look for specific findings. 1.General Body Size, Shape, and Symmetry 2.Male vs. Female 3.Is this an infant, child, young adult, elderly person? 4.Survey for foreign objects - tubes, IV lines, EKG leads, surgical drains, prosthesis, etc., as well as non-medical objects, bullets, shrapnel, glass, etc. ADMINISTRATIVE (3) 8
  9. 9. The Chest X-Ray The following radiographic plates are scan ins from: Felson, B., et al.: Principles of Chest Roentgenology. Philadelphia, W.B. Saunders Co., 1973. Fraser, R., et al.: Diagnosis of Diseases of the Chest, 3rd edition. Philadelphia, W.B. Saunders Co., 1988. 9
  10. 10. Lecture Outline •Densities •Techniques •Anatomy •CXR Interpretation •Common Pathologies 10
  11. 11. Densities The big two densities are: (1) WHITE - Bone (2) BLACK - Air The others are: (3) DARK GREY- Fat (4) GREY- Soft tissue/water And if anything Man-made is on the film, it is: (5) BRIGHT WHITE - Man-made 11
  12. 12. Techniques - Projection P-A (relation of x-ray beam to patient) 12
  13. 13. Techniques - Projection (continued) Lateral 13
  14. 14. Techniques - Projection (continued) Lateral Decubitus 14
  15. 15. Rotation 15
  16. 16. Rotation (continued) 16
  17. 17. Penetration 17
  18. 18. Inspiration/Expiration 18
  19. 19. Anatomy 19
  20. 20. Anatomy 20
  21. 21. Anatomy 21
  22. 22. Lobes Right upper lobe: 22
  23. 23. Lobes(continued) Right middle lobe: 23
  24. 24. Lobes(continued) Right lower lobe: 24
  25. 25. Lobes(continued) Left lower lobe: 25
  26. 26. Lobes(continued) Left upper lobe with Lingula: 26
  27. 27. Lobes(continued) Lingula: 27
  28. 28. Lobes(continued) Left upper lobe - upper division: 28
  29. 29. Heart(continued) Right border: Edge of (r) Atrium 2. Left border: (l) Ventricle + Atrium 3. Posterior border: Left Ventricle 4. Anterior border: Right Ventricle 29
  30. 30. Heart(continued) 30
  31. 31. Heart(continued) Valves 31
  32. 32. Mediastinum 32
  33. 33. Hilum Made of: 1. Pulmonary Art.+Veins 2. The Bronchi Left Hilus higher (max 1-2,5 cm) Identical: size, shape, density 33
  34. 34. Ribs 34
  35. 35. Lateral CXR 35
  36. 36. Lateral CXR(continued) 36
  37. 37. Lateral CXR(continued) Tracheoesophageal Stripe 37
  38. 38. Lateral CXR(continued) 38
  39. 39. CXR Interpretation 39
  40. 40. Technical Details • Type • Orientation • Rotation • Inspiration/expiration • Penetration 40
  41. 41. Lungs: •Lungs • Density • Symmetry • Lesions 41
  42. 42. Heart Size: 42
  43. 43. Heart • Size of heart • Size of individual chambers of heart • Size of pulmonary vessels • Evidence of stents, clips, wires and valves • Outline of aorta and IVC and SVC 43
  44. 44. Mediastinum: • Width • Contour • AP window • Size • Location 44
  45. 45. Review areas: • Apices • Behind the heart • CP angles • Below the diaphragm • Soft tissues ( breast, surgical emphysema) • Ribs & clavicle • Vertebrae 45
  46. 46. Identify the lesion → localise the lesion → describe the lesion → give DDx Never stop looking, carry on with your systematic approach!! 46
  47. 47. Pathology 47 The following radiographic plateare scan ins from: Felson, B., et al.: Principles of Chest Roentgenology. Philadelphia, W.B. Saunders Co., 1973. Fraser, R., et al.: Diagnosis of Diseases of the Chest, 3rd edition. Philadelphia, W.B. Saunders Co., 1988.
  48. 48. RUL pneumonia 48
  49. 49. RML pneumonia 49
  50. 50. RLL pneumonia 50
  51. 51. LUL pneumonia 51
  52. 52. LLL pneumonia 52
  53. 53. • Consolidation on CT 53
  54. 54. Hilar mass 54
  55. 55. The Enlarged Hila • Causes: 1. Adenopathies (neoplasia, infection) 2. Primary Tumor 3. Vascular 4. Sarcoidosis 55
  56. 56. • Multiple Masses 56
  57. 57. Hilar Lymphadenopathy - BL 57
  58. 58. 58Hilar Lymphadenopathy - BL
  59. 59. Pleural Effusion 59
  60. 60. Pulmonary Fibrosis 60
  61. 61. Heart failure 61
  62. 62. Pneumothorax 62
  63. 63. RUL collapse 63
  64. 64. LLL collapse 64
  65. 65. Air under the diaphragm 65
  66. 66. Emphysema 66
  67. 67. Cavitating lesion 67
  68. 68. Hiatus hernia 68
  69. 69. Miliary shadowing 69
  70. 70. Chest Tube, NG Tube, Pulm. artery cath 70
  71. 71. 71 Radiology Online Study Resources: Albert Einstein Medical Center – Learning Radiology eMedicine - Radiology GE - Medcyclopaedia McGill University - Basic Radiology Primer: An Introduction to Problem-Oriented Imaging Algorithms Medical College of Wisconsin - Chorus RadiologyEducation.com SearchingRadiology.com StudentBMJ - Introduction to Imaging USUHS - Chest X-Ray Review
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