The document provides guidance on evaluating a normal chest x-ray using a systematic approach. It outlines the key anatomical structures to examine, including the heart, lungs, bones, diaphragm and soft tissues. A normal chest x-ray should show the heart within normal size limits, clear lungs with uniform opacity in all zones, and sharp margins of the diaphragm and ribs. Recognizing what is normal serves as a baseline for identifying any abnormalities.

1. THE NORMAL CHEST
X-RAY
By saurabh gangwar

3. 1.Most of the chest x-rays you will see will
be normal
2.In order to recognise abnormality, you
need to know what a normal CXR looks
like
Introduction

5. General Principles
1.Havea systematic approachInterpret the CXR in
conjunction with the clinical findings
2.Always compare with previous CXR if available
to assess for change
3.Ask yourself “does my interpretation make sense

6. 1. Name/marker/rotation/
penetration
2. Lines/metal work
3. Heart
4. Mediastinum
5. Lungs
1. Zones
(upper/middle/lower)
6. Bones
7. Diaphragm
8. Soft Tissues
Systematic Approach

7. •Name/marker/rotation/
penetration
Systematic Approach
clavicles equidistant
from spinous
processes of thoracic
spine
can just see lower
thoracic spine

8. •Lines/metal work
Systematic Approach
Look for:
•Sternal wires (implies
previous thoracic
surgery)
•Tip of endotracheal
tube (2cm above
carina)

9. •Lines/metal work
Systematic Approach
Tip of central venous
lines at origin of
superior vena cava. See
tubes and lines
presentation.

10. •Heart
Systematic Approach
•Occupies up to 50% of
the maximum internal
thoracic diameter on a
standard PA erect view
•Cannot comment on
heart size on AP view
because of magnification
of heart

11. •Mediastinum
Systematic Approach
•Hilar vascular
structures should be
crisply defined
•No widening of
mediastinum
•Trachea should be
central

12. •Lungs
Systematic Approach
upper zone
lower zone
middle zone
•Compare upper, mid
and lower zones
•Look between ribs for
lung detail
•Remember to look
“behind” the heart

13. •Bones
Systematic Approach
•Look at each rib in turn
•Clavicles
•Scapulae and humeri if
visible
•Lower cervical and
thoracic spine

14. •Diaphragm
Systematic Approach
•Both diaphragms
should form a sharp
margin with the lateral
chest wall
•Both diaphragm
contours should be
clearly visible medially
to the spine
Position of stomach
gas bubble (not present
on this CXR)

15. •Soft Tissues
Systematic Approach
•Supraclavicular fossae
(enlarged nodes)
•Lateral chest wall
(surgical emphysema)
•Under diaphragm
(pneumoperitoneum)

16. How would you summarise this?

17. “This is an erect chest X-Ray of an adult male. The
heart is not enlarged, the mediastinal contours are
normal and the lungs are clear”