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The Normal Chest X-Ray
Introduction
• Most of the chest x-rays you will see will be normal
• In order to recognise abnormality, you need to know what a normal CXR looks like
The CXR on the next slide is normal. How would you interpret it?
General Principles
• Have a systematic approach• Interpret the CXR in conjunction
with the clinical findings• Always compare with previous CXR
if available to assess for change• Ask yourself “does my
interpretation make sense?”
•Name/marker/rotation/ penetration
•Lines/metal work
•Heart
•Mediastinum
•Lungs•Zones (upper/middle/lower)
•Bones
•Diaphragm
•Soft Tissues
Systematic Approach
•Name/marker/rotation/ penetration
Systematic Approach
clavicles equidistant from
spinous processes of thoracic spine
can just see lower thoracic spine
•Lines/metal work
Systematic Approach
Look for:
•Sternal wires (implies previous thoracic surgery)•Tip of endotracheal tube (2cm above carina)
•Lines/metal work
Systematic Approach
Tip of central venous lines at
origin of superior vena cava. See tubes and lines presentation.
•Heart
Systematic Approach
•Occupies up to 50% of the maximum internal thoracic diameter on a standard PA erect view•Cannot comment on heart size on AP view because of magnification of heart
•Mediastinum
Systematic Approach
•Hilar vascular structures should be crisply defined•No widening of mediastinum•Trachea should be central
•Lungs
Systematic Approach
upper zone
lower zone
middle zone
•Compare upper, mid and lower zones•Look between ribs for lung detail•Remember to look “behind” the heart
•Bones
Systematic Approach
•Look at each rib in turn•Clavicles•Scapulae and humeri if visible•Lower cervical and thoracic spine
•Diaphragm
Systematic Approach
•Both diaphragms should form a sharp margin with the lateral chest wall•Both diaphragm contours should be clearly visible medially to the spine
Position of stomach gas bubble (not present on this CXR)
•Soft Tissues
Systematic Approach
•Supraclavicular fossae (enlarged nodes)•Lateral chest wall (surgical emphysema)•Under diaphragm (pneumoperitoneum)
How would you summarise this?
“This is an erect chest X-Ray of an adult male. The heart is not enlarged, the mediastinal
contours are normal and the lungs are clear”
Take Home Points
• Be systematic• Review with history and physical
examination in mind