Chest X-ray
Systematic approach
Review areas
After a systematic look at the whole chest X-ray, it is worth re-checking areas that may conceal important pathology.
It is always worth double checking for pneumothorax or pneumoperitoneum. In an OSCE/viva this is seen as good practice, and a mark may be granted for mentioning the absence of these entities.
A pneumothorax is most easily seen at the apices on a Posterior-Anterior (PA) X-ray. Pneumoperitoneum (free gas below the diaphragm) is only seen on a chest X-ray if acquired when the patient is positioned erect.
Other review areas include the soft-tissues and bones, the area behind the heart, and the edges of the image.
Key points - Review areas
- Apices - Pneumothorax?
- Bones/soft-tissues - Fractures/density?
- Cardiac shadow- Consolidation/mass?
- Diaphragm - Pneumoperitoneum?
- Edge of the image - Unexpected findings?
Mnemonic - ABCDE
Hover over image to show findings
Review areas - Apices
There is a small (<2cm depth) pneumothorax on the right.
A pneumothorax is often a very subtle finding, and may only be seen on a second review of each lung apex.
You should also check the lung apices for tumours.
Hover over image to show findings
Review areas - Bones
Bone abnormalities can be very subtle on chest X-rays. Here the first right rib is destroyed by a metastatic bone lesion(?).
Compare this poorly defined area of increased soft tissue density with the normal first left rib (highlighted).
Hover over image to show findings
Review areas - Cardiac shadow
The area behind the heart is too dense (red ring) and the left hemidiaphragm is not well-defined to the midline. This is evidence of consolidation affecting the left lower lobe.
There is also a reactive effusion (arrow).
Hover over image to show findings
Review areas - Diaphragm
Check every chest X-ray for pneumoperitoneum (arrowheads).
Occasionally lung pathology is visible through the 'window' of the gastric bubble(*), which is normal in this case.
Hover over image to show findings
Review areas - Edge of the image
Well done if you noticed the small left pleural effusion (arrow).
Did you spot the missing right humerus?!
This patient had a history of a previous malignant bone lesion of the right humerus which had been resected (red area). Note the surgical clips (white).