How to read a

Chest X-Ray
Dr. Felix Acosta
West Medical Review

Initial Checks
Make sure you have the right patient
Name, Surname
Age
Patient History
Date of the radiography
Optimize room lighting

Verify Technique
Orientation
Inspiration
Rotation
Penetration
Exposure

Orientation
PA
AP
Lateral
Supine
Low quality
Decubitus
Laying on your
side

When do you use an PA?

Gold Standard
If patient can stand up
Gravity pulls abdomen down
Better view of chest

When do you use an AP?

When patient is bed ridden
Distorts heart and mediastinum

When do you use a

lateral?
When you need to localize a lesion
See parts of the lung normally covered
Behind the heart, and bases (covered by
diaphram)
Fluids, but decubitus is better

When do you use supine?

Almost never
Only if patient is really deteriorated in bed

and cant be moved

Low quality
Abdomen compresses all chest structures

When do you use

decubitus?
To look at:
Fluids
Air
Obstruction

Inspiration or Expiration
Adequacy of inspiration
Nine pairs of ribs should be seen posteriorly
Expiration
Pneumothorax

Rotation
Distance from the medial end of each clavicle

to the spinous process of the vertebra at the

same level, should be equal

Penetration
One should barely see the thoracic vertebrae

behind the heart

Normal

Exposure (time based)

One needs to be able to identify both

costophrenic angles and lung apices

Radiological checklist
Airway
Bones
Cardiac
Diaphram
Effusions
Fields (Lung Fields)
Gastric Air bubble
Hilum

Airway (Trachea)
Pushed away
Pleural effusion,
Tension Pneumothorax
Pulled towards
Atelectasis (collapsed lung)
Tubes or foreign bodies

Tension Pneumothorax

Atelectasis (Loss of lung volume)

Bones
Check for fractures dislocation, subluxation,

osteoblastic or osteolytic lesions in clavicles,

ribs, thoracic

Cardiac
Check heart size
Cardiothoracic ratio
Less than 0.5

Cardiomegaly

Diaphram
Right hemidiaphragm
Should be higher than the left

Effusions
Look for blunting of the costophrenic angle

Fields
Check for infiltrates

Gastric Air bubble

Beware of hiatal hernia

Hilum
Enlarged lymph nodes
Calcified nodules
Mass lesions
Pulmonary arteries, if greater than 1.5cm

think about possible causes of enlargement

CT Scan

Case scenario: TB

Helical (Spiral) CT Scan

Think

pulmonary
embolism

Common Chest X-Rays

for USMLE
Lobar pneumonia
Bronchopneumonia
Interstitial pneumonia
Sarcoidosis
COPD

Lobar Pneumonia

Upper lobe pneumonia

Middle lobe pneumonia

Lower lobe Pneumonia

Bronchopneumonia

Interstitial pneumonia

Sarcoidosis
Bilateral hiliar

lymphadenopathy

COPD
Overexpanded/

hyperinflated
lungs
Flattened

diaphragm

COPD (emphysema)
Barrel chest
Flattening of the

diaphram
Increased

retrosternal
airspace

Normal vs COPD

Pneumothorax (low yield)