s noor .

p gela

scrubbingup

chest x-ray survival

www.scrubbingup.com
copyright 2006

scrubbingup

chest x-ray survival

www.scrubbingup.com
copyright 2006

s noor
bmbs

p gela
bmbs
First edition 2006
The right of the author to be identified as the Author of this Work has been asserted in accordance
to the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or
transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without prior permission from the publisher.
Disclaimer: Although the authors do their utmost to ensure the reliability of all information contained within, no responsibility is held for the material's accuracy or for any actions taken based on
this information. Readers are encouraged to confirm that all information is correct, up to date, and
in keeping with current medical practice.

contents
Preface

Introduction

Identify the structures

A systematic approach

10

The normal chest x-ray

27

Clinical cases:
Dextrocardia
Pneumothorax
Pneumonia
Pneumoperitoneum
Pleural effusions
Tumours
Lobar collapse
Pneumonectomy
Pulmonary oedema
Cardiomegaly
Cardiac failure
Interstitial fibrosis
Cavitations
Fractures
Mastectomy

30
31
34
39
41
44
50
52
54
56
57
58
59
60
63

Presenting your findings & passing

the exam

www.scrubbingup.com
3

64

preface
This chest x-ray guide was written with only one purpose: to get you competent enough
and confident enough to interpret a chest x-ray and discuss your findings with examiners.
By doing so, we hope this guide helps you to pass any up coming examinations you may
have. This guide does not include lateral chest x-ray films, often not required for medical
students teaching.
We assume (probably correctly) you are all beginners; a few of the easy going students
may not have even seen a chest x-ray before. We know most of you have missed clinical
teaching sessions in radiology because it was just too boring or you slept through it because the dark radiologists room was too warm and comfortable.
We assume you are panicking because finals are soon around the corner.
We know time is a major factor and that all you want is the important need to know
facts. No time wasting! We want to help you to pass, even if it means scraping through by
the skin of your teeth (like most of us did in the past).
Also note, this chest x-ray guide was not written to make you overnight radiologists, experts in your field or even make the list of top ten geeks in your medical school. It is not
designed to teach you abstract theory or every delicate intricacy about the exciting world
of chest x-rays. This, we will happily leave to those big boring textbooks, those long tedious lectures but more importantly, we can leave all that fun until after you have successfully passed finals.

S. NOOR
P.GELA

www.scrubbingup.com
4

introduction: 1
The chest x-ray is one of the most common and valuable investigations requested by doctors. Most patients who are admitted to the hospital seem to have one, whether they really
needed it or not is another question altogether! You will inevitably review at least one
chest x-ray every day in your early career as a doctor - how very depressing, get used to it.
Before you begin to interpret the x-ray, you first must know what a chest x-ray is. It is basic information but there is always one radiologist who takes a disproportionate amount of
pleasure in asking simple questions that makes every one look stupid. So here is a very
brief summary (skip this if time is limited).

X-rays are a form of electromagnetic radiation. They have a wavelength in the

range of 10 to 0.01 nanometres.

A tungsten anode receives this radiation from a cathode after it passes through the
patients body converting the image into a plain film.

On an x-ray:
White = Bone / Calcified tissue
Black = Air
Anything in between = everything else!

A chest x-ray is a radiological image of the thorax taken using x-rays. The effective
radiation dose from this procedure is about 0.1 mSv (millisievert). This is about the
same as the average person receives from background radiation in 10 days. A chest
x-ray is considered a low dose of radiation.

The chap most associated with x-rays is Wilhelm Conrad Rontgen (German physicist, born 1845, died 1923). He won the first nobel prize for physics, 1901. Radiologists love this guy! Go Conrad!

www.scrubbingup.com
5

introduction: 2
What are the different views? (A summary of the important ones)
1. Posteroanterior (PA)
This is the standard view for chest radiographs. This means the front of the patients chest
is against the film, the x-rays come through from the back and out the front. Just imagine
being shot with a bullet from the back (posterior) and out through your front (anterior).
2. Anteroposterior (AP)
This is used for unwell patients. Sick patients are difficult to get out of bed so the x-rays
need to be shot from the front of the chest and come out the back. The anterior structures
of the chest (e.g. heart) are magnified on this view and therefore difficult to assess accurate
heart size.
3. Lateral
This is shot from side to side. It helps localize any abnormality identified on the PA view.
It is not used all that commonly in the exam setting so we are ignoring it.
4. Supine
The supine position is a position of the body is lying down with the face up. This is more
practical for infants and ill patients. Again the heart size cannot be accurately assessed.
5. Erect
Erect and semi-erect is with the patient standing / sitting up. It makes air under the diaphragm or fluid within the lungs more prominent.
6. Expiratory
With the patient breathing out, a pneumothorax becomes more apparent.

www.scrubbingup.com
6

identify the structures: 1

To fully appreciate a chest x-ray, you must and identify the anatomy. The following labeled x-rays should help (some ribs on the left have been outlinedobviously!):
The bones:

1st Rib

Clavicle
Head of humerus

3rd Rib

Scapula
5th Rib

Thoracic vertebra
7th Rib

Lumbar vertebra

Remember: There are 12 Thoracic vertebra and then towards the bottom of the film you
may see 1 or 2 lumbar vertebra.
Note: It is often difficult to count the ribs. Remember you can see the front and the back of
each rib, so trace them round with care. If necessary outline them with your finger but it
does look rather unprofessional. Try to visualize them in 3D if possible!

www.scrubbingup.com
7

identify the structures: 2

The mediastinum, heart and diaphragm:
It is important to recognize the midline structures:

Trachea

Arch of aorta
Left hilum
Right hilum
Right atrium

Left atrium
1/3

2/3
Left ventricle

Right
hemidiaphragm
Costophrenic
angle

Stomach gas

Note: The heart should take up no more than half of the width of the thoracic cavity. One
third of the heart should be on the right of midline, two thirds on the left. The contours of
the right ventricle (it is the most anterior chamber of the heart).
Around the hila are branching pulmonary vessels, the main bronchus and lymph nodes.

www.scrubbingup.com
8

identify the structures: 3

The lungs:

Lung apex
Right upper
lobe

Left upper
lobe

Right middle
lobe

Right lower
lobe

Left lower
lobe

Note: There are three lobes on the right, two on the left. The lobes are divided by the horizontal fissure (between right upper and right middle lobe) and the oblique fissures
(between right lower and right middle, between left upper and left lower lobes). These fissures are difficult to identify on an AP film unless there is fluid within the fissures. It is
therefore often difficult to assess the lobes individually and it is best to describe your findings in zones (upper, middle and lower zones) .
The white arrows highlight the vascular markings which fan out across the lungs (these are
the smaller pulmonary vessels).

www.scrubbingup.com
9

a systematic approach: 1
For beginners and for students taking exams, a systematic approach is essential for successful interpretation of an x-ray. In reality (not in the secluded life of medical students),
no self respecting doctor requires such a system, nor do we have the endless time to review
one x-ray in such detail. You guys, however, need to learn a system before reaching the
same immense level as us!
Every radiologist will teach their own perfect system on how to interpret a chest radiograph. They insist you learn it and if you do not use their system, they snigger at you and
dismiss you as worthless. However, contrary to the radiologists belief, no method is perfect. All have their merits and flaws. The key to success is to develop a system you are
confident and familiar with, something you can rely on when you are faced in an exam
situation, sweating like a dog.
We will describe one such method to review a chest x-ray, step by step. These steps will be
described in detail. Feel free to adapt the technique to your own personal preference when
you are confident enough.

1. Identify the patients age, sex and the x-ray type

2. Is the chest x-ray satisfactory?
3. Any foreign bodies/objects?
4. The trachea, mediastinum and heart
5. The diaphragm
6. The lung fields
7. Soft tissues
8. The bones

www.scrubbingup.com
10

a systematic approach: 2
1. Identify the patients age, sex and the x-ray type
The best way to start interpreting a chest film is to try to gain as much information about
the patient as possible from the markings on the film itself. This will allow you time to set
the clinical scene and gather your thoughts.
Firstly, identify if the film is PA or AP, erect, supine, portable etc. Usually there will be
markings on the film suggesting what view it is. If there are no markings, presume it is a
PA. If you identify an AP film for example, you can presume you are looking at an ill patient who was to sick for a PA. This will aid you in your eventual interpretation.
The patients age may give you a huge clue about the diagnosis. For example, a young person is unlikely to have lung cancer. Usually the date of birth is printed on the film, so look
for it and work out the age or at least if they are young, middle aged, or elderly.
It is useful although not essential to figure out if its a film of a male or a female. The easiest way to do this is to look for the breast of course (if there is no name present on the
film)!
So before you even start the difficult task of interpretation, you already have some vital
clues. You could have a twenty year old male with a standard PA film, or an 87 year old
female taken as a portable AP film. Your mind should already be racing of possible diagnoses! Voila, you are on your way to reading your first x-ray! Well done!

www.scrubbingup.com
11

a systematic approach: 3
2. Is the chest x-ray satisfactory?
You will hear lots of doctors mumble to themselves: Its such a poor chest x-ray, how can
I possibly interpret it. Often is it just an excuse for not being able to make a confident diagnosis, but there are such things as poor films. It is important for you to identify the good
from the bad. Look for the following criteria:
Is the chest x-ray complete?
You cant fully interpret an x-ray is half of it is missing! The x-ray must include all the
relevant body parts for it to be complete. You need to be able to see the clavicles, all the
ribs, the diaphragm, the costophrenic angles, the apices of the lungs etc. If half the lung is
missing, or the diaphragm is absent, you may miss the important diagnosis. So if the film
is incomplete, it is important to comment on this.
Is there adequate penetration?
Good penetration is a key aspect of the chest x-ray. Under penetrated or over penetrated
films make it difficult to interpret. A good way of assessing penetration is being able to
see the lower thoracic vertebral bodies through the heart.
Is the film rotated?
A rotated film gives you a distorted view of the anatomy and can lead you to make misinterpretations of normal structures or missing abnormal structures. The easiest way of identifying rotation is to view the spinous processes of the thoracic vertebrae midway between
the medial ends of the clavicles.

www.scrubbingup.com
12

a systematic approach: 4
An example of an incomplete x-ray:

This is a rather unremarkable looking radiograph. Only trouble is the costophrenic angles are
missing. How do you know there is not a pleural effusion at the bases for example?

www.scrubbingup.com
13

a systematic approach: 5
An example of an under penetrated x-ray:

This is obviously a rubbish x-ray. It is under penetrated because there is too much of
the white stuff, and you cant see the thoracic vertebra behind the mediastinum or
heart.

www.scrubbingup.com
14

a systematic approach: 6
An example of an over penetrated x-ray:

Here there is probably some over penetration meaning too much x-rays are getting
though the body. The lung fields perhaps looking a little hollow an the thoracic vertebra too prominent behind the mediastinum. Any low density lesion could easily be
missed as the x-rays may have over penetrated right though it.
Also note the hand on the left! This film is of a child who obviously needed encouragement!

www.scrubbingup.com
15

a systematic approach: 7
An example of a rotated film:

Descending
aorta

Wow what is going on here? Well clearly this radiograph is not straight! The medial
ends of the clavicles should be well aligned with the thoracic vertebra behind it. This
chap is clearly rotated! Note how the mediastinal contours distorted and you can view
the descending aorta coming form the arch of aorta. Poor film really!

www.scrubbingup.com
16

a systematic approach: 8
3. Any foreign bodies/objects?
Foreign bodies within or on the patient are usually the first thing noticed when viewing an
x-ray. You need to be able to recognize the obvious otherwise you will look like an idiot in
front of the examiner. It is a good idea to identify them early as it may give you a clue to
the clinical scenario. Examples include ECG leads, oxygen masks, endotracheal tubes, NG
tubes, central lines, swallowed objects, pacemakers, jewelry, nipple piercing etc!
Here are some examples:

Wow! What is that? Dont worry, its only a pacemaker! If the pacemaker has two wires
going into the heart it is a dual chamber pacemaker. This one is a single.

www.scrubbingup.com
17

a systematic approach: 9
Commonly a chest x-ray is performed to ensure a feeding NG (nasogastric) tube is in
the right place:

The NG tube is radio-opaque so that it can be visualized with an x-ray to confirm its
position. Here you can see it clearly passing below the level of the diaphragm and into
the stomach.

www.scrubbingup.com
18

a systematic approach: 10
Now take a look at this NG tube:

Oh dear, where is this NG tube going? The right main bronchus! Yikes, let us hope
they did not commence feeding!

www.scrubbingup.com
19

a systematic approach: 11
Here are a few more common objects to look out for and important to recognize:

Two items of note here. Firstly, there is a line entering the internal right jugular vein,
presumably for central IV access. Secondly is an ECG lead on the right chest wall with
the obvious lead attached.

www.scrubbingup.com
20

a systematic approach: 12
When faced with an object you are unclear about, try to use all the limited knowledge
you have to solve it. Firstly, work out where it is, where it starts, where it ends and
identify any structures it involves.

Ok so this is a short tube like structure, descending from the neck area downwards. It is
in the same area of the trachea! So folks, what is it? A tracheostomy! Very good, simple isnt it?

www.scrubbingup.com
21

a systematic approach: 13
More examples of foreign objects

Yes objects can be inside or outside the patient. Some structures are obviously recognizable;
some are not and cause you grief unless you can think on your feet.

www.scrubbingup.com
22

a systematic approach: 14
Another interesting example:

Mmm, very fashionable. Bilateral pierced nipples! Painful!

www.scrubbingup.com
23

a systematic approach: 15
What the hell is this? Is this patient impaled on a fence or something? Help! Come on, use
your imagination

Well, I have only ever seen one x-ray like this. This is a corset! Try to think lateral boys and
girls, it may get you out of a spot of bother.

www.scrubbingup.com
24

a systematic approach: 16
4. The trachea, mediastinum and heart
Ok enough of the foreign bodies, lets get down to business. Start at the trachea. It
should be central. Any deviation from the center may indicate pathology.
From the trachea, work your way downwards on both sides along the mediastinal contours. Ensure the mediastinum is also central and it should not be too wide (wide = approximately over 8cm), this may indicate pathology including aortic aneurysm or mediastinal lymphadenopathy.
Continuing downwards, the first structure you should come to is the aortic arch on the
left. This is often calcified in the elderly and usually an incidental finding.
The next structures are the pulmonary vessels and lymph nodes around the hila. Look
for any enlarged nodes or lesions here; you may pick up a tumour.
Then take a look at the heart. Two thirds should lie on the left side of the chest, one
third on the right. The left border is made up of the left atrium and ventricle, the right
made up of the right atrium. The right ventricle is anterior and therefore its contours
are not visualized.
Assess the size of the heart; it should be no more then half of the width of the thorax.
Note, the heart and mediastinal width cannot be accurately assessed using AP films.
5. The Diaphragm
Now trace from the heart along the diaphragm. Look at the cardiophrenic and costophrenic angles. Ensure they are crisp and clean. Blunting here may indicate an effusion.
Look for air under the right side of the diaphragm (air under the left is usually the
stomach!). The right diaphragm is often higher than the left, the liver pushing it upwards.

www.scrubbingup.com
25

a systematic approach: 17
6. The lung fields
Now examine the lung fields. The lungs should be black (containing air of course) but not
totally black! There should be vascular markings extending throughout to the peripheries.
Start by outlining the contour of the lung fields, ensuring you can see these marking. If the
contours are black (lucent), it may indicate a pneumothorax. In particular concentrate on
the apices of the lung, a common place to miss a pneumothorax.
Work your way inwards and look for any obvious abnormal white areas - shadowing or
lesions.
7. Soft tissues
Take a peek at any of the soft tissues. Look for the breast shadows; make sure one breast is
not missing. Glance up at the neck; are there any swellings that shouldnt be there? Is there
any air within the tissue? Could there be surgical emphysema?

8. The bones
Examine the bones thoroughly. It is very easy to miss obvious abnormalities because you
are concentrating on the lungs. Outline the bones, ensure there are no fractures. Remember
the clavicles and humerus as well as the ribs. Assess the bone quality; are there any transparencies within the bone structure? Could these be bony lesions?

www.scrubbingup.com
26

the normal chest x-ray: 1

Chest x-rays, like people, are slightly different. No two chest x-rays are the same. You have
to be confident identifying what is normal before it becomes easy to identify the abnormal.
Radiologists always show us films of small abnormalities and are surprised we can not spot
it. Students are inexperienced and unfamiliar with subtle variations of the chest x-ray. It is all
about repetitive training for your eyes and mind!
So feast your eyes on the following normal radiographs and if you are very keen, go through
them all with the systematic approach you have just learnt! Geeks!

This is a normal chest radiograph. Notice however the size of the breasts! This is obviously a
female or a male with severe gynaecomastia (man boobs)!

www.scrubbingup.com
27

the normal chest x-ray: 2

This is an AP portable film. It was probably taken because the patient was acutely unwell.
However there is nothing abnormal on this radiograph to suggest a cause for being unwell.
Remember, the heart appears to be larger but this an illusion as it is an AP film. Overall, we
can conclude this film as having normal appearances

www.scrubbingup.com
28

the normal chest x-ray: 3

Again, a rather unremarkable radiograph! Remember that the air under the left hemidiaphragm is usually the stomach!

www.scrubbingup.com
29

clinical cases: dextrocardia

Ok, this is arguably a normal chest x-ray. However, in an exam situation, it is not. Stay sharp
and on your toes! Always look for the markings on the film saying which side is which. On
this film, the heart is clearly on the right side of the patient. This can either mean the radiograph has been put up in the light box incorrectly or there is a dextrocardia. It is present in
present in 0.01% of the population and is a potential examination banana skin! Watch out!
How to present: This is a satisfactory PA chest film of a man. With the correct annotation
noted, the heart border appears on the right hand side. There are no other major abnormalities detected. This patient has dextrocardia.

www.scrubbingup.com
30

clinical cases: pneumothorax

As you are all aware (Im sure), a pneumothorax is air within the pleural space resulting in
collapse of the lung on the affected side. However, please beware! Failure to diagnose a
pneumothorax in an exam is a potential automatic fail. It is a possible life threatening condition and medical students are expected to recognize it. So all of you slackers, concentrate
now. First look at the following film and then we will discuss it.

How to present: This is an AP portable film. There is air within the right pleural cavity and
a clear outline of a collapsed right lung. The mediastinal structures are possibly deviated to
the left but there is some rotation. I can see no obvious rib fractures or evidence of any iatrogenic procedures. The findings are consistent with a pneumothorax.

www.scrubbingup.com
31

clinical cases: pneumothorax

A pneumothorax can either be a simple or a tension pneumothorax. Not going into too much
detail but any doctor ordering an x-ray of a tension pneumothorax will likely see the patient
dead before the radiographer arrive! A tension pneumothorax is an immediate life threatening condition - it requires a clinical diagnosis and urgent treatment. So technically, you
should never see an x-ray of a tension pneumothorax but I am sure it is has happened.
A simple pneumothorax is pretty straight forward to diagnose on a radiograph. When assessing the lung fields, look for any obvious well defined radiolucent (black) areas surrounding
the edge of one side. If in doubt, look towards the peripheries and see if the vascular markings extend towards the edges. If vascular markings are present, you can rule out a pneumothorax. However if they seem to be significantly missing, there may well be a pneumothorax with a collapsed lung.
Associated with a tension pneumothorax include mediastinal shift away from the affected
side (as the increasing air is pushing the midline structures away). That is all you need to
know to successfully diagnose a pneumothorax. If you want to look really smart, look for
any possible causes. Pneumothoracies are often spontaneous with no cause but also look for
traumatic or iatrogenic causes.
The radiologist may ask how you would treat this. Simply respond with:
In the case of tension pneumothorax, I would insert a large bore cannula into the second
intercostal space, mid-clavicular line on the affected side. Following this, I would insert a
chest drain into the fifth intercostal space in the mid-axillary line! Thats good enough for
the pass, you are the man!
Tips:

Look for a black outline on the periphery of the lung field. Ensure you examine the apices of the lung carefully as a small pneumothorax can be missed.

Assess for mediastinal shift, this may indicate a tension pneumothorax

Look for causes

Remember the life saving treatment.

If in doubt if a true pneumothorax is present, suggest to the examiner an expiratory film

may help clarify.

www.scrubbingup.com
32

clinical cases: pneumothorax

This is the same patient as the case above. Wow look, the pneumothorax has resolved. The
lung is inflated, look at the vascular markings now. Also note at the bottom, a cheeky chest
drain within the pleural cavity! Yes my friends, your expert management has saved him, I
have taught you well! There is lots of other problems with this chest x-ray but at least the
pneumothorax is treated!

www.scrubbingup.com
33

clinical cases: pneumonia

Pneumonia is an infection or inflammation of the lung parenchyma (lung tissue). It is a very
common exam case so you must get used to recognizing it. Pneumonia, although easily identifiable on a plain film, is quite frustrating for the budding medical student. This is because
pneumonia comes in all shapes and sizes and is quite frustrating to describe accurately. Anyhow let us try to go through it systematically. Peek at the following film:

How to present: This is a supine chest film with some slight rotation. There is a large confluent opacity in the lower and mid zones of the right lung. The mediastinal structures appear
to be in the midline. The right hemidiaphragm is raised. Overall this film represents consolidation in the right lung, consistent with a lobar pneumonia

www.scrubbingup.com
34

clinical cases: pneumonia

There are many causes of pneumonia with different infecting organisms and different presentations. Unfortunately a chest x-ray can not often distinguish between them.
The only value of the chest x-ray is to identify and localize the pneumonia and perhaps assess the severity. However even the severity of a pneumonia on a chest x-ray may not even
correspond fully with the clinical picture as the radiological changes remain for some time
even after the episode has resolved. Likewise a patient may have severe pneumonia and
there maybe no x-ray changes at all! How annoying!
The x-ray changes

The lung tissue is involved so obviously we are looking within the lung fields to
diagnose a pneumonia

With inflammation, infection and exudates, classically the areas involved appear
more densely white.

Consolidation on a chest x-ray often implies opacification due to the above.

Consolidation can be described as patchy, diffuse, or confluent.

When consolidation on the x-ray begins to distort the borders of the normal structures (heart and diaphragm) we get a silhouette sign.

Air within areas of consolidation are often due to air remaining in the affected
bronchi. This appears as lucent areas within the density and is called an air bronchogram

There are two patterns of pneumonia to look out forlobar and bronchopneumonia.

www.scrubbingup.com
35

clinical cases: pneumonia

Lobar pneumonia:

The inflammatory changes are confined to a single lobe.

Each loch lobar pneumonia has a different x-ray appearances
.More than one segment involved is called multilobular pneumonia obviously!

Bronchopneumonia:

This causes a more diffuse widespread pneumonia

There are irregular areas of bilateral opacification

Observe the following set of radiographs and learn!

There is patchy consolidation in the left lower zone and the right mid zone

www.scrubbingup.com
36

clinical cases: pneumonia

How to present: This is a rotated AP erect portable film. There is extensive confluent
opacities in both the right and left mid and lower zones. This is consistent with a widespread
pneumonia
Alsonotice the patients teeth! Dont they look funny! Some are missing!

www.scrubbingup.com
37

clinical cases: pneumonia

Spot the pneumonia!

www.scrubbingup.com
38

clinical cases: pneumoperitoneum

Pneumonia is an infection or inflammation of the lung parenchyma (lung tissue). It is a very
common exam case so you must get used to recognizing it. Pneumonia, although easily identifiable on a plain film, is quite frustrating for the budding medical student. This is because
pneumonia comes in all shapes and sizes and is quite frustrating to describe accurately. Anyhow let us try to go through it systematically. Peek at the following film:

How to present: This is a satisfactory AP erect film of a male. The most obvious abnormality is air under the diaphragm. There are no other abnormalities. This case would be consistent with a perforated viscus.

www.scrubbingup.com
39

clinical cases: pneumoperitoneum

A pneumoperitoneum literally means air within the peritoneum (abdominal cavity). Although the symptoms of the patient are predominantly within the abdomen, the chest x-ray is
often crucial to the diagnosis. A perforated viscus (hollow organ) is a surgical emergency,
and you medical students need to recognize the chest x-ray findings. Again this is a potential
automatic fail if you blunder on this! Pay attention!
The chest film is taken with the patient in an erect position so that any air within the abdomen rises to the diaphragms. The air can then be recognized under the right hemidiaphragm
with a clear outline of the diaghragm above. The left hemidiaphragm can also have air under
it but with the stomach in this region, it is more difficult. Therefore just concentrate on the
right side.
A pneumoperitoneum is pretty easy to diagnose but only if you spot it. The pitfall is concentrating on looking for abnormalities within the chest and forgetting to fully assess the diaphragm.
Here are some tips:

Look for the ERECT label on the film. This will trigger you into remembering the
reason for an erect chest x-ray

If you are struggling to find any abnormalities in your exam, before you say I can
find no obvious abnormality, just glance again at the diaphragm. It is acceptable
if you miss a small lesion within the lung, but its a disaster if you miss a pneumoperitoneum in the exam!

Remember other causes of a pneumoperitoneum include recent abdominal surgery

(laparotomy or laparosocopy). However this should not last for more then 24 to 48
hours post surgery.

www.scrubbingup.com
40

clinical cases: pleural effusion

A pleural effusion is an abnormal collection of fluid within the pleural space. Just like a
pneumothorax contains air within this space, an effusion contains liquid. There are many
causes for an effusion. Effusions can be described as small, medium and large (obviously!)

How to present: This is an AP chest radiograph of a female. There is a large concave homogenous opacity with a meniscus on the left. It occupies over half of the pleural cavity.
There is a smaller similar opacity on the right with blunting of the costophrenic angle. The
heart borders are lost. There are bilateral pleural effusions here.

www.scrubbingup.com
41

clinical cases: pleural effusion

Pleural effusions are pretty easy to diagnose.
Here are some tips:

Think of fluid within a container, it will all sink to the bottom. The opacity will be
evenly distributed in its density.

Remember it is like glass in water, there will be a meniscus at the edges. This is
called the meniscus sign.

Large ones are very obvious and can be really concave in shape!

Smaller ones can be detected by looking for blunting of the costophrenic angles.
Blunting may not occur until about 200-400ml of fluid is present.

Large ones can cause the lung to collapse and / or he mediastinum to shift.

A common exam question from the evil examiner is to list the causes of a pleural effusion
so be prepared to answer it! Here is a quick tutorial:
There are many causes of a pleural effusion so instead of remembering a list, have a structured answer by splitting them into transudates and exudates.

Transudate

Exudate

- Low protein content (<30g/l)

- High protein content (>30g/l)

- Formed by increased hydrostatic pressure

or reduced oncotic pressure

- Formed by increased capillary permeability

Remember the failures of other organs:

Think of the nasty stuff:

Congestive cardiac failure

Malignancy

Liver cirrhosis (liver failure)

Infection

Nephrotic syndrome (renal failure)

Pulmonary infarction

www.scrubbingup.com
42

clinical cases: pleural effusion

Here is another obvious example of an effusion

How to present: This is a satisfactory AP chest radiograph. There is a dense homogonous

opacity within the right lung filed with a meniscus (arrow). This appears to be a moderately
sized pleural effusion. There is also some blunting of the lest costophrenic angle. The heart
appears large.

www.scrubbingup.com
43

clinical cases: tumours

A chest x-ray is very good at picking up discrete opacities within the lung fields and assessing their shape, size and distribution. This often gives clues to the underlying cause of the
lesionbenign or malignant. For your purposes, all you need is to presume any sinister
looking lesion is malignant. However it is useful to have a list of differential diagnoses if the
examiner asks you what else your findings could be.

How to present: This is an AP erect chest radiograph. There is a small opacity within the
left lower lobe. It is circular with an irregular outline. I can see no other similar lesions or
any other abnormalities. This is a solitary nodule. It may represent a neoplasm.

www.scrubbingup.com
44

clinical cases: tumours

Tumours can either be really obvious, with a film full of metastases or just one discrete
solitary nodule all ready to be missed by the untrained eye. It is important not to miss anything within the lung fields but also remember that tumours may also be present in other
structures, not just the lung. In particular look for any sinister lesions within the bones.
Tips:

Describe any lesion you see in terms of size, density, shape and outline.

Remember a few differential diagnosis for a solitary nodule other than malignancy: hamartoma (benign tumour), granuloma (inflammatory post infection), AV
malformation, lung cyst. This will make you look pretty smart that you have
thought of other possibilities.

If you have multiple metastases, always consider where the primary cancer is. A
common question is which tumours metastasize to the lung?
Theoretically any tumour can spread anywhere but breast, kidney, testicular, gastrointestinal, lymphomas is a good list to remember.

www.scrubbingup.com
45

clinical cases: tumours

Some more examples:

How to present: This is a PA film. There are at least three large opacities on this film. Two
within the right lung field and one on the left. They have the density of a soft tissue mass.
They are of similar size. They all have an irregular outline. Unfortunately these lesions may
represent pulmonary metastases.

www.scrubbingup.com
46

clinical cases: tumours

Another example:

How to present: This is a standard chest film. There are multiple lesions throughout the
lung fields or differing size and shape. There is also diffuse shadowing spanning centrally
towards the peripheries. This is a case of pulmonary metastasis.

www.scrubbingup.com
47

clinical cases: tumours

Oh dear, this is such a sad radiograph. I am sure by now you can come to the diagnosis.

www.scrubbingup.com
48

clinical cases: tumours

A hilar mass:

How to present: This is a PA chest film. There is an obvious mass within the right hilum.
It has an irregular outline and seems to extend outward to the periphery. It has the density of
soft tissue. There maybe an old fracture of the left clavicle but otherwise there are no other
abnormalities. Overall, this film may represent a malignant lesion, lymphadenopathy or an
infective source. I would suggest a lateral plain film or a CT scan may help us here.

www.scrubbingup.com
49

clinical cases: lobar collapse

When a lobe of a lung fails to get any air, it collapses. It is usually caused by an obstruction proximally which prevents the lung from being aerated (for example a tumour or foreign body). The lung can also collapse from outside pressurelike when a pneumothorax
compresses it. The collapse causes a loss of volume in the lung fields and there are characteristic radiological changes of each lobe when it collapses on a chest x-ray. Observe:

How to present: This is a plain PA chest radiograph. There is reduced size of the right lung
field with the right lower lobe entirely collapsed. There is some reticular shadowing in the
left lower zone but otherwise there are no other major abnormalities.

www.scrubbingup.com
50

clinical cases: lobar collapse

Again when identifying a collapsed lung, it is useful trying to identify which lobe has collapsed and also for a cause of the collapse.
Here are some tips:
Right upper lobe collapse:

The horizontal fissure will be pulled upwards

The hilum maybe lifted upwards
The right apex will have an increased density with sharp outline
The mediastinum will shift to the right

Right middle lobe collapse:

The middle lobe is difficult to see on a PA view as it is small.
There is increased density lateral to the heart, producing a possibly silhouette
sign
Suggest a lateral view may help to clarify.

Left upper lobe collapse:

Similar to the right upper lobe but remember the left is bigger than the right
It is the oblique fissure moving superiorly (there is no horizontal).
The increased density will therefore be in the upper and mid-zones.

Right and left lower lobe collapse:

The oblique fissure becomes more steep.

There is a triangle wedge shape behind the heart shadow.
The hilum maybe pulled downwards

www.scrubbingup.com
51

clinical cases: pneumonectomy

Pneumonectomy (surgical excision of the lung) provides an interesting chest film. It is one
of the causes of complete white out of the removed lung. It is always interesting to see medical students struggle with a compete white out of the lung field. They just gape and point it
is white and then make some unintelligible sounds.

How to present: A standard chest radiograph is shown. There is a complete white out of
the left lung field. The trachea is deviated to the left and the left hemidiaphragm is raised
(look how high the stomach bubble is). The right lung field is unremarkable. This case
would indicate a complete collapse of the left lung or complete removal of the lung with a
pneumonectomy.

www.scrubbingup.com
52

clinical cases: pneumonectomy

A pneumonectomy is not the only cause of a complete white out of the lung field (opaque
hemithorax). You must have a differential diagnosis when faced with such a picture in the
exam. The most important feature again is the mediastinum.
The mediastinum deviating towards the white out

Complete lung collapseif the main bronchus becomes occluded, the entire lung
becomes devoid of air, and like a brown paper bag, just collapses. No air = no
black on the x-ray!

PneumonectomyRemoving the lung means removing the air to that side! Obviously!

The mediastinum central

Severe pneumoniathis spells bad news for the patient unfortunately if their entire hemithorax is consolidated.

The mediastinum deviated away from the white out

Large plural effusions, massive haemothoraxAny fluid building up on one side

of the lung will push all the other contents of the thorax to one side if it gets big
enough. Similar to a tension pneumothorax but with fluid (and therefore white, not
black on an x-ray).

www.scrubbingup.com
53

clinical cases: pulmonary oedema

Pulmonary oedema occurs when fluid from within the pulmonary vessels enters the interstitium alveoli. The most common causes of acute pulmonary oedema are cardiogenic but it
can also be precipitated by other causes. Examples of this include infections, allergic reactions, toxins (inhaled or circulatory), disseminated intravascular coagulation and over aggressive fluid management. Here is an example of pulmonary oedema on a chest film:

How to present: This is a supine portable chest film. The film is inadequate as the costophrenic angles are absent. There is increased vascularity throughout the lung fields with
batswing shadowing (black arrows) around the hila. There is fluid in the horizontal fissure
(white arrows). The heart is within normal limits. I am unable to fully assess for a pleural
effusion but certainly there is no gross one. The findings are overall consistent with pulmonary oedema

www.scrubbingup.com
54

clinical cases: pulmonary oedema

Pulmonary oedema has some classical x-ray findings. It is a common question to list the
findings so here you go:

Kerley B lines (early signs of pulmonary edema) - 1-2cm horizontal lines seen in
the lower zones on the periphery of the lung field at the lung edge.

Butterfly or Batswing shadowingcentral prominence of the vasculature around

the hilum to look like a batswingapparently!

Fluid within the fissureslook closely at the horizontal and oblique fissures to
see if you can see them. They are straight long white lines

Upper lobe diversionthe superior pulmonary vessels seem to be far more predominant on the x-rays to appear all the blood vessels are diverting to the upper
lobes.

Pleural effusionsthere maybe small pleural effusions bilaterally

Cardiomegalyan enlarged heart would suggest a cardiac cause for the oedema

www.scrubbingup.com
55

clinical cases: cardiomegaly

Cardiomegaly on an x-ray is defined when the width of the heart is more then half the size of
the thoracic diameter. It is a simple diagnosis but it is important not to forget that AP or supine films falsely enlarges the heart and therefore an accurate assessment can not be made.

How to present: This is a standard chest film. It appears slightly over penetrated. The obvious abnormality is an enlarged heart. There also appears to increased central shadowing, upper lobe diversion and very small pleural effusions. This is appears to be a case of congestive
cardiac failure.

www.scrubbingup.com
56

clinical cases: cardiac failure

Congestive cardiac failure is failure of the heart to adequately pump around the blood. This
leads to congestion and fluid seeping out into the tissues. At its worst in can cause severe
pulmonary oedema.
Here is another example of congestive cardiac failure on an x-ray:

How to present: This is a PA film. The heart is significantly enlarged. There is increased
haziness within the lung fields. There are small bilateral pleural effusions. There is also a
mass within the pleura of the left lateral lung field. The appearances suggest cardiac failure
with pleural thickening of an unknown origin.

www.scrubbingup.com
57

clinical cases: idiopathic fibrosis

Idiopathic pulmonary fibrosis is a progressive interstitial lung disorder of unknown origin.
X-ray changes are non-specific but tend to be abnormal in these patients. There is usually a
diffuse shadowing bilaterally at the bases and at the peripheries of the lung fields.
Observe the following x-ray:

How to present: This is an AP erect film. Although an AP film, the mediastinum looks
widened. There is diffuse bilateral reticular (intricate, resembles a net) infiltrates at the lower
zones and peripheries. The findings would be consistent with an interstitial fibrosis.

www.scrubbingup.com
58

clinical cases: cavitations

Cavitating lung lesions are often quite weird to view on a chest x-ray. They just do not look
right. It is like the lungs have eyes staring at you! Anyhow, there are many causes of cavities, the most common being an abscess, either developing from a pneumonia or from septic
emboli. Other causes include TB (infection), Wegeners granulomatosis, pulmonary infarction, infected bullae and neoplasms.

How to present: This is a portable AP semi-erect film. There are two large cavities with
thick walls on each side of the lung field. The largest is on the left measuring 10 by 10 cm
and on the right approximately 5 x 5 cm. Furthermore there is consolidation of the right
lower zone. The trachea is deviated to the right. This picture certainly seems to have infective source, possibly a pneumonia with associated abscesses. I can see no fluid level but a
fully erect film may help us here.
Note: A fluid level within the cavity almost certainly suggests an abscess and is best obtained with the patient erect.

www.scrubbingup.com
59

clinical cases: fractures

Fractures are easily missed on chest x-rays. This is either because they are not looked for or
simply that they are too difficult to see. Anyway, browse the following x-rays and spot the
fractures.

How to present: This is an AP erect film. It is satisfactory. There are no abnormalities

within the mediastinum, heart, diaphragms or lung fields. There is however a fracture of the
right clavicle.

www.scrubbingup.com
60

clinical cases: fractures

Spot the fracture:

How to present: This is a PA radiograph. It is satisfactory. There are no abnormalities

within the mediastinum, heart, diaphragms or lung fields. There is however fractures of the
6th, 7th and 8th ribs on the left hand side.
Look at the next page for the arrows to show you where the fractures are!

www.scrubbingup.com
61

clinical cases: fractures

The fractures:

Rib fractures are often difficult to spot immediately. Some people advocate turning the xray onto the side so it is easier to identify each ribs outline. It certainly does make it easier
but looks a little unprofessional!

www.scrubbingup.com
62

clinical cases: mastectomy

Sometimes even the subtlest features are the only abnormality in a chest x-ray. Observe:

There is only one breast shadow! The right breast is present, the left is missing. Otherwise
there is nothing too exciting about this x-ray (apart from half of it is missing!)

www.scrubbingup.com
63

present your findingspass the exam: 1

Presenting your findings is just as an important skill as reading the chest x-ray in the first
place. There is no point making the perfect diagnosis if you are going to stutter your way
through your findings.
Here are some tips of how to go through your presentation:
1. Be confident, look confident, not arrogant
You have to fool the examiner into thinking you have seen hundreds if not thousands of xrays before. You have to show him you are not afraid of what he has to show. Already by
reading this book you have seen quite a few x-rays, you should be pretty confident.
2. Careful with the word x-ray
Some examiners are very pedantic. They dislike the world x-ray when describing the chest
film. Be careful. When presenting, use the term radiograph or plain film. It will make
you sound good too! You will notice this book as interchanged radiograph, plain film and xray. That is because we are not pedantic fools!
3. A good reliable start
An examiner often makes a quick impression of his prey, so you should have a reliable start
to support you. Always start with a presentation of the actual patient and film you are looking at.
- This is an erect chest radiograph of a 23 year old lady, Mrs Bloggs
- This is standard PA chest radiograph of Mr Jackass, a 100 year old.
This buys you time, and you have made an impressive start already.
.

www.scrubbingup.com
64

present your findingspass the exam: 2

4. Dont waste your time and his with the obvious
Do not spend too long on the basics. Quickly assess whether the film is adequately exposed
or rotated. Dont put your face next to the film to measure the distance between the medial
sides of the clavicles and dont spend ages deciding whether you can see the thoracic vertebra. It is unlikely you will get a poor film to assess in an exam so make a quick decision;
otherwise youll just annoy the man who is looking to fail you. Say for example:
- It is well exposed and well aligned
- It is satisfactory
- It is clearly overexposed
- Half the lung is missing from this film but I will assess what is available!
5. The most obvious abnormality
If you are confident that you have spotted an obvious abnormality, go straight for the money
shot. This is risky but rewarding. If you get it right, youre a hero, if you actually miss the
obvious abnormality, youre in trouble. One possibility is saying the following:
-

The most obvious abnormality is . . I will also go through the rest of

the film systematically to identify any other abnormalities.

If you cant see a clear abnormality, do not panic. Stick to your system. Say:
-

There is no obvious abnormality. I will examine systematically to identify any

6. Dont come out with the diagnosis until the end

Be careful; try not to be too much of a hero. Do not say This is obviously lung cancer and
say nothing else. Describe your findings first, then at the end say the potential diagnosis.
For example:
-

There is patchy consolidation in the right upper lobe, possibly consistent with
pneumonia.
There is free air under the right hemi diaphragm consistent with a perforated viscus

www.scrubbingup.com
65

present your findingspass the exam: 3

7. Be familiar with the lingo
You have to show the examiner you have presented a billion times. Show him you are familiar with his language. Do not say:
-

There is white stuff in the top corner

There is a circular thing in the middle
The heart is big
The trachea has moved!

Use terms like opaque, lucent, patchy, confluent, lesion, mass, deviated etc. It will make you
look good. Look at the clinical cases above for good terms to use!
8. Suggest further investigations
If you are doing really well or believe further investigations may help your uncertain diagnosis, by all means suggest them along with your reasons. The examiner may well tell you that
these investigations may not help, but it shows you are thinking. Please please only do this at
the end! Do not walk in and say A CT would be more beneficial! You will get thrown out!
9. Good luck
We hope with the above information, you will pass your clinical exam easily! All of us lazy
medical students need luck to scrape through. We hope your examiners are kind, good mannered and light hearted. May all the nasty examiners fall into a ditch and sustain a fractured
rib with a pneumothorax! GOOD LUCK SCRUBS!

www.scrubbingup.com
66