The Normal Chest X-Ray: Reading Like the Pros

The keys to reading x-rays well are a good understanding of normal anatomy and an orderly search pattern. This chapter reacquaints you with the normal anatomy and helps you develop a search pattern that you can apply to every radiograph. By being systematic, you will miss fewer important findings—not that experienced hands don’t miss findings; they just miss fewer findings. Learn this ordered approach and then stick to it in case after case. You will look like a pro.

Now turn the page and do it with real images.

4 Test yourself by labeling the radiographs in Figures 3-2A and 3-2B . Figure 3-2A Figure 3-2B		4 A. gas in splenic flexure B. costophrenic sulcus (angle) C. heart D. descending aorta E. trachea F. carina G. hilum H. aortic knob J. ascending aorta K. right diaphragm
A. _____________ B. _____________ C. _____________ D. _____________ E. _____________ F. _____________ G. _____________ H. _____________ J. _____________ K. _____________	heart descending aorta costophrenic sulcus (angle) gas in splenic flexure right diaphragm aortic knob trachea carina hilum ascending aorta
To maximize your accuracy, you must have an organized search pattern. Start reading every radiograph—chest or otherwise—by scanning the areas of least interest first, working toward the more important areas. You are less likely to miss secondary but important findings this way. For the chest x-ray, start in the upper abdomen, then look at the thoracic cage (soft tissues and bones), then the mediastinal structures, and finally the lung. Look at each lung individually, then compare left lung and right lung. A helpful mnemonic is Are There Many Lung Lesions (ATMLL)?
5 Arrange the following in viewing sequence:		5 A. abdomen [A] B. thorax and soft tissue [T] C. mediastinum [M] D. lung—unilateral [L] E. lung—bilateral [L]
A. _____________ B. _____________ C. _____________ D. _____________ E. _____________	mediastinum lung—unilateral abdomen lung—bilateral thorax and soft tissue
*Abdomen: In* *Figure 3-3A* , start in the right upper quadrant (*) and scan across the upper abdomen several times. Normal gas-containing structures are the stomach and the splenic flexure of the colon. The liver is always visible. The hepatic flexure and the spleen may be visible.
6 Scan the abdomen in Figure 3-3B . Figure 3-3B		6 A. stomach bubble B. splenic flexure (colon) C. liver D. right diaphragm
A. The gas collection just below the heart = _____________. B. The gas collection lateral to A = _____________. C. The homogeneous density below the right diaphragm = _____________. D. The higher diaphragm is the _____________.	liver stomach bubble splenic flexure (colon) right diaphragm left diaphragm hepatic flexure
CLINICAL PEARL: Upper abdominal disease (subphrenic abscess, perforated viscus, pancreatitis, and cholecystitis) may mimic lung disease clinically. Similarly, basilar lung disease (pneumonia, pleurisy) may mimic upper abdominal disease. This is real! You’ll see!
Mediastinum: An organized search of the mediastinum is complicated because there are multiple overlapping structures. Start with a global look at the mediastinum for contour abnormalities (i.e., focal or diffuse widening). *Figures 3-4A* *and* *3-4B* *show three rapid searches of the mediastinum: A = for the trachea and carina; B = for the aorta and heart; C = for the hilum.*
7 Test yourself on Figure 3-4C by identifying the following structures: Figure 3-4C		7 1. trachea 2. carina 3. aortic knob (arch) 4. ascending aorta 5. descending aorta 6. heart 7. right hilum
1. _____________ 2. _____________ 3. _____________ 4. _____________ 5. _____________ 6. _____________ 7. _____________	aortic knob (arch) carina heart trachea right hilum ascending aorta descending aorta
*Note that the left hilum is normally slightly higher than the right. Just to confuse, the right diaphragm is normally slightly higher than the left.*

*Thorax: In* *Figure 3-5A* , start at the right base (), looking at the soft tissues (e.g., muscles, breast) of the chest wall, the ribs, and the shoulder girdle in sequence. Finish by reversing the order down the left side. These structures are represented in Figure 3-5B* *. Note that the posterior ribs (B) tend to be horizontal, while the anterior ribs descend from lateral to medial (E).*
8 Test yourself on Figure 3-5B by identifying the following structures:		8 A. breast B. posterior rib C. scapula D. clavicle E. anterior rib F. stomach bubble G. liver
A. _____________ B. _____________ C. _____________ D. _____________ E. _____________ F. _____________ G. _____________	liver clavicle breast anterior rib posterior rib stomach bubble scapula
Lungs: Most chest x-rays are ordered to evaluate lung disease, so the lungs are examined last. The lungs are so important that we search them twice. Start in the right costophrenic angle () as outlined in Figure 3-6A* *, examining the right and then left lung. The second look involves a side-by-side comparison of the lungs (* *Figure 3-6B* *). This also should give you a second look at costophrenic angles and the hilum. Practice this search pattern in* *Figure 3-7A* *. Are There Many Lung Lesions?*
9 See anything abnormal in Figure 3-7A ? The abnormality is subtle. Compare side to side. The change should be obvious (it is to me anyway). There is a nodule in the _____________.		9 right midlung laterally, over fourth anterior rib (Who said this would be easy?)
CLINICAL PEARL: The old x-ray is your best friend. Radiologists always look at old films when available. You should, too. They help you detect new disease and evaluate for change in preexisting disease. In *Figure 3-7B* *, obtained 1 year earlier than the x-ray in* *Figure 3-7A* , the nodule was barely visible ( arrows ).
10 For the novice, subtle and not so subtle abnormalities are easy to miss. In searching the lungs, three helpful strategies to minimize oversights are (1) searching the lungs individually, (2) searching the lungs _____________, and (3) taking advantage of _____________, if available.		10 2. side to side 3. old radiographs
*The lateral is a valuable but often ignored radiograph. Don’t ignore it! The search pattern is identical (ATMLL). In* *Figure 3-8A* , start by searching below the diaphragm (A). Continue up the lower spine (B), searching the soft tissues and bones posteriorly, then anteriorly (C). Return to the trachea and work your way down the mediastinum (D). In *Figure 3-8B* *, crisscross the superimposed lungs and costophrenic angles (E).*
11 Search in Figure 3-9 . This patient is complaining of _____________. A. dyspnea B. cough C. back pain Only gold members can continue reading. Log In or Register to continue Share this: Click to share on Twitter (Opens in new window) Click to share on Facebook (Opens in new window) Related posts: Cross-Sectional Imaging Techniques The Radiographic Examination: The Basics Signs of Lung and Lobar Collapse Cardiovascular Disease Computed Tomography: The Fleischner Society Glossary of Terms Interstitial Lung Disease: A Picture Book Stay updated, free articles. Join our Telegram channel Tags: Felson's Principles of Chest Roentgenology Mar 3, 2019 \| Posted by drzezo in CARDIOVASCULAR IMAGING \| Comments Off on The Normal Chest X-Ray: Reading Like the Pros Full access? Get Clinical Tree Get Clinical Tree app for offline access Get Clinical Tree app for offline access