Reading a Chest X-Ray
- Patient Identification: Full name, DOB, address, NHS/hospital number.
- Type of Image (X-ray, CT etc, you must say this anyway as when given any image you must state what type it is)
- Anatomical area covered (in this case it'll be the chest)
- PA or AP (If scalpulae are visible x-ray is AP)
PA refers to prosterioranterior and is taken with the patient standing up, arms forward and breathing in (to move the scapulae and diaphragm from obscuring what you want to see). AP is taken anteroposterior, and can be performed with a portable machine. AP X-rays are only done when a patient cannot stand up, and often are worse as the shorter distance from the X-ray emitter to the film placed on the patient's back magnifies the images of organs such as the heart.
- Standing, sitting or supine
Firstly ensure that you can differentiate structures of different radiographic densities (can you see defined ribs?) if not then an incorrect amount of radiation may have been used (the film is over/underexposed). Also check that the whole of the chest is visible (can you see where the costophrenic angles should be along with the apexes of the lungs?). Then use this to clear up any other issues:
- R - Rotation (Are the spinous processes in the midline between the two medial heads of the clavicles)
- I - Inspiration (Is the patient inspiring fully? 5-7 anterior ribs should intersect the diaphragm in the mid-clavicular line)
- P - Penetration (The spine should be visible behind the heart)
Describe the Obvious Abnormality
- Tissue - Lungs, heart, aorta, bone etc.
- Side - Right, left, unilateral, bilateral.
- Number - Single or multiple.
- Distribution - Focal or widespread.
- Position - Lung zone, anterior or posterior.
- Shape - Round, cresent etc.
- Edge - Smooth, irregular, spiculated.
- Pattern - Nodular, reticular.
- Density - (Air, fat, soft tissue, bone, metal)
"There is a 3cm dense rounded lesion in the right upper zone of the lungs"
Systemic Check of Anatomy
- Trachea and bronchi - Visible, central, darker than surrounding area.
- Hilar structures - Major bronchi and pulmonary vessels. Left hilum is approx 1 cm higher. Size and density.
- Lung Zones - Upper, middle and lower zones (not lobes), any asymmetry.
- Pleura - Only visible with abnormality. Trace pleura starting at hila. Thickening means pneumothorax or effusion.
- Lobes and fissures - Help limit disease processes to specific lobes.
- Costophrenic angles - Should be sharp. Pleural effusion or hyperexpansion.
- Diaphragm - Should be domes, well defined. Can be a stomach bubble in left. Pneumoperitoneum.
- Heart - Size should be <50% of width of thorax (in PA).
- Mediastinum - Aortic knuckle thickening can show aneurysm. Aortic-pulmonary window can show lymphadenopathy, thickened paratracheal stripe can show lymphadenopathy.
- Soft tissue - Overlying fat or breast tissue can obscure the x-ray.
- Bones - Check all bones for signs of diffuse disease or metastatic cancer.
- The loss of a clear crisp contour between adjacent structures can indicate pathology.
- Left heart border - Lingula disease.
- Hemidiaphragm - Lower lobe lung disease.
- Paratracheal stripe - Paratracheal disease.
- Chest wall - Lung, pleural or rib disease.
- Aortic knuckle - Anterior mediastinal or left upper lobe disease.
- Paraspinal line - Posterior thorax disease.
- Right heart border - Middle lobe disease.
- Above horizontal fissure - Anterior segment of right upper lobe disease.
- A - Apices (Pneumothorax)
- B - Bones and soft tissues (Fractures or densities)
- C - Cardiac shadow (Consolidation or masses)
- D - Diaphragm (Pneumoperitoneum)
- E - Edge of image (Any unexpected findings?)