1. Review of Basic Chest X-Ray
Prepared and presented by
Marc Imhotep Cray, M.D.
2. REVIEW OF NORMAL CHEST
Next 9 slides are modified from using data from:
USUHS - Chest X-Ray Review
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)
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
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.
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
E. retrosternal clear space
REVIEW OF NORMAL CHEST (2)
5. REVIEW OF NORMAL CHEST (3)
8. Review hila:
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
a.fissures - major and minor - if seen
c.follow pleura around rib cage
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.
2.Date exam done (very
important if comparing prior
3.Check for position markers -
right vs. left, upright.
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.
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
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,
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.
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,
(5) BRIGHT WHITE - Man-made
46. Identify the lesion → localise the lesion →
describe the lesion → give DDx
Never stop looking, carry on with your
The following radiographic plateare scan ins from:
Felson, B., et al.: Principles of Chest Roentgenology. Philadelphia, W.B. Saunders
Fraser, R., et al.: Diagnosis of Diseases of the Chest, 3rd edition. Philadelphia,
W.B. Saunders Co., 1988.
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
Medical College of Wisconsin - Chorus
StudentBMJ - Introduction to Imaging
USUHS - Chest X-Ray Review