1. Review of Basic Chest X-Ray
Diagnostic Radiographs
Prepared and presented by
Marc Imhotep Cray, M.D.
BMS/CK Teacher
1

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. 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. 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. 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. 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. 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. 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. 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. Lecture Outline
•Densities
•Techniques
•Anatomy
•CXR Interpretation
•Common Pathologies
10

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. Techniques - Projection
P-A (relation of x-ray beam to patient)
12

13. Techniques - Projection (continued)
Lateral
13

14. Techniques - Projection (continued)
Lateral Decubitus
14

15. Rotation
15

16. Rotation (continued)
16

17. Penetration
17

18. Inspiration/Expiration
18

19. Anatomy
19

20. Anatomy
20

21. Anatomy
21

22. Lobes
Right upper lobe:
22

23. Lobes(continued)
Right middle lobe:
23

24. Lobes(continued)
Right lower lobe:
24

25. Lobes(continued)
Left lower lobe:
25

26. Lobes(continued)
Left upper lobe with Lingula:
26

27. Lobes(continued)
Lingula:
27

28. Lobes(continued)
Left upper lobe - upper division:
28

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. Heart(continued)
30

31. Heart(continued)
Valves
31

32. Mediastinum
32

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. Ribs
34

35. Lateral CXR
35

36. Lateral CXR(continued)
36

37. Lateral CXR(continued)
Tracheoesophageal Stripe
37

38. Lateral CXR(continued)
38

39. CXR Interpretation
39

40. Technical Details
• Type
• Orientation
• Rotation
• Inspiration/expiration
• Penetration
40

41. Lungs:
•Lungs
• Density
• Symmetry
• Lesions
41

42. Heart
Size:
42

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. Mediastinum:
• Width
• Contour
• AP window
• Size
• Location
44

45. Review areas:
• Apices
• Behind the heart
• CP angles
• Below the diaphragm
• Soft tissues ( breast, surgical emphysema)
• Ribs & clavicle
• Vertebrae
45

46. Identify the lesion → localise the lesion →
describe the lesion → give DDx
Never stop looking, carry on with your
systematic approach!!
46

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. RUL pneumonia 48

49. RML pneumonia 49

50. RLL pneumonia 50

51. LUL pneumonia 51

52. LLL pneumonia 52

53. • Consolidation on CT 53

54. Hilar mass 54

55. The Enlarged Hila
• Causes:
1. Adenopathies (neoplasia, infection)
2. Primary Tumor
3. Vascular
4. Sarcoidosis
55

56. • Multiple Masses 56

57. Hilar Lymphadenopathy - BL 57

58. 58Hilar Lymphadenopathy - BL

59. Pleural Effusion 59

60. Pulmonary Fibrosis 60

61. Heart failure 61

62. Pneumothorax 62

63. RUL collapse 63

64. LLL collapse 64

65. Air under the diaphragm 65

66. Emphysema 66

67. Cavitating lesion 67

68. Hiatus hernia 68

69. Miliary shadowing 69

70. Chest Tube, NG Tube, Pulm. artery cath
70

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